28616 TAPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIIDWG-ELECTRICAL PBRMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 28616
BUILDING PROJECT IDENTIFICATION
BUILDINGADURFSS: SANITARY NO. APPLICATIONSUBMI ALDAT.
0"y 02 0
SNAME:MA L
CI ACTOR'S AME: LIC NO:
NC O
AKCHITECUENGINItJb LIC NO: ADDRESS. ❑
GQNTALT: PHONE BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDGELECT PLD MECH
�' �� 11 ❑ ❑
LICENSED CobuRACIORS DECLARATIONQTY ELECTRIC PERMIT FEE
I hcaby elf Thu 1 w hom,cdMer upoviuou of Chapin 9(m ersocr g JOB DESCRIPTION
WoZNSeadon7000)of Division Jnfinmnl
e Hasin ,oProes,imm Cale.and my hcenm is
Foo
in full(oras PERMIT ISSUANCE - RESIDENTIAL
i.Z, Tian l.ic,X FIADWL C PLUMBIKITCHEN G RFPIPI.
�<W� Dae GanllYl« nPPLIANCt3-RFSmFMUL CAUDRION ❑PLUMBING R6PIPE
ARCHITECTS DECLARATION PANELS
❑MULTI-DNR ❑STRUCTURAL
Z O n? I undervand my plans shall h uecd m public records MODIFICATION
oz—
.to UPTO200AMPS E3 INTERIOR ❑CHIMNEY REPAIR
FWD Licrnad l'mfwiarW 201-1000AMPS INIPROVEMFNT a
�Y IQ mat I mn cteri Ron the,RATION OVER I000AMPS C BATH REMODEIJREPAIR El DEMOLITION
y U I hereby.(Bern that 1 am exempt fnrn pr Croons Cod 1,Any c Law forme
u 311 U following mg LI sun.(Nasion 94113.B oinns mpe professions aim,Code:Any city«ca nom SIGNS FlECIRICAL D 0�
which mryirm a pmdt re amwue ober,improve,hammier t «e rash my mment �' A
priirmlu i,suawaalso requires me applicant for wch pcnNuulilc asignd eaamcnl SPECIAL CIRCUIT/MISC.
`�a mat nasi(,wm puauaatmthe povin,i«uwm,c«a,a,mr.I.iccmalaw(Chepnv
�'QO (cvmrrcming wird Scrim T00lHoflBvisitm JuflM1C Buaiticsaond Profcssiona Cadcl« TENIP.METER OR POLE INST. COMMERCIAL-
thin
OMMERCIALdwt he In exempt therefrom end me Fans,for the alleged exemption.Any vioWim of
4X1 4- El NEW BLDCilADDITION 0DF1.10LI770N
Section,7031.5 by any applicant(«.permit tubjesme epplicem toe evil pnWty of POWER DEVICES
y Lar nue than five hundred doll,($NX(P. ❑TENANT ❑FOOD SERVICE
tZ0 I,u owner oflk - IMPROVEMENT
= propry.mmy amploym wim wgmulhcir sok amlpenn,etim, SWIMMING POOL EL ECHOIC
will Jo the work,and do slmeture is not(sanded a offered fur sale(Sao.9fN4,Hus�ncra C OTHER
and Nof sniam Cod,:TJa C«urxtors Littme law docs not appy to no owner of OUTLETS-SWITCHES-FIXTURES
p,anrY who builds or impuves Ihercnn,atd who dour such work himself or through
his own employm,providW that such improvements are not intended m otTeral for NEW RESIDENTIAL EIECfR SQ FT.
one.If.bowever,the Wildin8«improvcmcm(sand within me Year ofcmmpinim,the SQ.FT.FLOOR AREA VSQ Irp.
caner-buidn will h.vc the b«Jen of povin,that he did n«builcor impmva f«Pur-
. pmc Made.).
E]1,es awver of the prnpcny,em cxdusiwly cmnoacd ng wish Ilmwad cumraa mi n, TOTAL: '
amnwixt the project(Si TOu,Business and Profnsmm Cade:)The Ccmvaaor',Li-
eenaLaw loser;not apply to an owner of property who Wilds or im,nows lherean.and QTY. PLUMBING PERMIT FEE
wbu mnlmea fm sucM1 pmjens with a mmnclu(s)lieenad pununnl to tK CmtraelUr,
Bassa law' PERMIT ISSUANCE
❑Fero exam uJc's a. ,E&PCfmdhi,oammn
Owner DamALTER-DRAIN&VENT-WATER TA) VALUAT
WeMKERSCOM13ENSATIONDECLARATION BACK FLOW PROTECT.DEVICE
I ICMy.RrmM
uer penalty ofparlor,aria of Ne fallowing le claratiorn: o d
❑ have and will meimaine Gnificme ofCauent to alGimurt f«Worker',Camper DRAINS-FLOOR.ROOF.AREA,COLT].
n,a,ioo,u presided fu by te,,oan 3900 of me IaM Calc,for IM perfumarce of the SfORWS TYPE CONSTRUC ION
work for whichthus droit is tamed FXTURIS-PIMTRAP
C 1 have and will maintain Wortrrs Cenlpeasetion Imurulcc,in na,firM by Swim
JT00 of the laMm�adc,far the pefomunecofibew«t for which this pcnmit isissssuad. GAS-IA.SYSTENI-I IjC 401TI.EIS OCC.GROUP APN
MyCarcr era tin %. I0 /��A GAS-EA.SYSTEM-0 ( I/ '
CIJTIVI a OF EXEMPTION FROM WORKERS'
MPENSATION INSURANCE GREASM U RCEPTOR
Mix Lmlinr neral not he completed if ilia permit is f«orc bundml ddaa(3100) BUILDING DMSION FRES
or leo.) GREASE P PLANCHECK FIJI
IcmifYNatinlheperfrmunceuflhewarkfurwhichtHi crmitisissucd.l.shall
not employany scrcan in an mhen.ne sub' t to the Workers Cam SEWER-SA ITARY-STORM EA.200 FT
Y^v^aer su es ycc pm- ENERGY FEE
OZ .urian lawof C.11form.,Das WATER HEATER WNENF(ELECTR
Z Applicant GRADING FEY
aN NOTICE TO APPIJCANT.If,after meting this Camif a of Exemption,you rhouW WATER SYSfE11V1REATING
; ba,ome,vbles,In the Workers C.,..ion ors,im,ofiha lab«Code,you maxi SOILSEEE
fmNwith campy wlmnosh pmvuiore or Nu Kinin stall be barred avali WATER SERVICE
p, Q
DZ CONS'IRUCTIUNLfimI ngaN y NEW RESIDFMIALPLhIB. SQ.FT PAID
LlQIhaebyaffum lhNlhvc isammtreclivnkrdi .) yfu the per(annercc a( One Rm<ipX
IbewnrkC«which this P.rmit is iswM(Sea 3199,Co..CJ
p f•-' Leaders Neva TOTAL:
G Lerdeh Adhvs TOTAL:
1 cealfy mon I have sad Nin,epplissimm mrd....0.1I11e ebova infarrnuioo is BUILDING FEEA h �
N corrm.l egrccmcomply vim ell rity aM mum,arduurnce erd walaw nNuivgm QTY, MECHANICAL PERMIT FEE
U ,Za building cunarucmm,wxl Mrehy numnry<rtpasrntatives ofthi,city wester upon the SEISMIC FEE r Lar
anevemrnlioned popery for impnim W rpven,. PERMIT ISSUANCE
(We)agree m save,iMemnify and Amp Iarntke,Ibc Cory of Cupcnim ogdmt ELE
Iimililie.judgmnlu,costs erd expenses which may in any way acme ageilut Laid City ALTER OR ADD TO MECH. %Y
m
in oaguenm of the ,morimg of this pcmm. PLUMBING FEE
APPLICANT U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,000 CFM)
SOURCE T10NS
r� AIR HANDLING TWIT(OVER IO10.0100CFM) MECHANICALIFFEtfIIIIVU
CONSfRUCTIONTAX
Signmmv ofA n hr D c EXIIAU.STHOOD(W/DUCq HOUSING MITIGATION FFE
HAZARDOUS MATERIALS DISCLOSURE
Will the epplicmt afuture Molding mcupent on,or handle harardoun,and iel HEATING UNIT(TO I IPM)BTU)
as de pnel by the Cuperahm Municipal Cade,Chapter 9.12,sand me Haddo and Safny
Code.Seabee 25532UOP - HEATING UNIT(OVER POLODO BTU)
❑Ya CNo
VFMILATION FAN(SINGLE RESID) PAID
M1p
1 Will the afglicam«(mart building by the nt one ryuipmrnl«devices which BOILER-COMP OHP OR 100,000 BTU) Dale Recci I
emit wNoun,dr c«Wnuwla m defined the Bay Arae Air Q�lily Merugert.:m
,,at,iTOTAL:
CYBOILER-COMP(OVER 100,000 BIL)m CNn
I have cal mi,lwsrmsssmm,rials aquiremt,nls under Chapter 6.95 M me Gni- AIR CONDITIONER
ISSUANCE
D
tomo Ife1m&Stirr Cada Scotian 25NIS,is my end 255Ja.I urakreantl Tor If Thr NEN'RESIDENTIAL MECH. SQ.PT.
buSiJk/lglnJg�/dgou rot awrndY kava a Ieram.IM1nt ittis�my raryvl,iMiiry m ratify the utvpvll
of
ar—
d =onrd I m OL ofaCrniflatc of pxv � TOTAL:
���[/ ISSUED BY:
OFFICE