99110125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. I PERMIT O.
BUILDING DIVISION APPLICATION/PFRMIT PLUMBING-MEUDi NICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL 1)
0 Q. a /(/- l
OWN'k'S NAME_' PH NE CONT'RACTOR'S NAME: LIC NO'.
S/\ NIC CONTROL a IF
�RCHITECfINGINEER: LtC NO: ADDRESS'. eIJ.G ❑
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant IFm Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
-� ❑ DK. ❑ K
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PFRA1IT FEE
I eby norm em tm ,ovm
this 1 licensed ler pisions a Chaprr 9 oc, mrrcina JOB DESCRIPTION
IQyXZ htt
with Sedian]I000 of Divisinn9of the Bunions atxl Rnfan'inns C,xk.aM mylkcn¢is RFSIDENTIAU
F in full face t. ` PCHMIIISSUANCE
sc.U V liceree Lk.Y ❑A D ITL ❑KITCHEN RE-PI EL
NQC DucConuxta -<•�QQ APYI.IANCES-RESIDEYIInL ❑ADDITION C:)PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MUI,1I-UNIT ❑STRUCTURAL
Z O to Z I undmeww my El...hall be uwd io public os,on, MODIFICATION
OZ�M UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
Littnani Prof.imood 201-1000AMPS IMPROVEMENT SWIMMING POOLS
yf,
OWNER-BUILDER DECLARATION OVER I"AMN ❑BATA REM EUREPAIR [I DEMOLITION
CWC I hcret, worm that I om exempt room the C....mcl is License Law for the (plpl
Pr U following Tcawn.(.Sx nsr 70315.Busirm.0 amt Profcniav Cod,:Any city or county �TIIER R ^lam 1� 41G e.
3 i. SIGNS ELEC TICAL i
0 h which�uvn a pemut to ugutn,m,dttt,impose,demtBN,car repvr erry avumure Lw,.�j\V A C L
-fig po,lons con ¢c.nso rac,irt,not ppl.,for ah paccount Gkesigas!son., SPECIALCIRCUH'IMISC. ��� P I C�
p- that he i,licensd".1 ,,tlmpmuums of m,Gmtnctor,Uccrw Law(Op
wa 9 COMMERCIAL
OQ (cannrtncingwahS¢tinmIXMl)of IN skim 3ofdo,Huninns wd Pmfc ionsCu )a TEMP.METER OR MILE INST.
than he is tempt thuefram oro the bai%fa do niepd esmo tion.Any violmian of ❑NEW BLDGJADDIIION ❑DEMOLITION
Senior 70313 byway aWliuot fora permit subjtct the applicant to a civil peruhy of POWER DEVIf,L'S [I MAW [I FULL,SERVICE
F+ZY not norm than five humbas]dollars.(SSW).
E Oa ❑ I,as a
owr of the prupanor
y, my cma
phIcc.with wages ,Orcompensation,
ir We SWIMMING POOL.ELECTRIC IM VEA1INT
y,- writ Jothcwora,ondthcsuscNrt I,.inRWdoraRuN forselc(S,c.]OY,,Busirc,r
R: ml PANb,..Cock,The Co unnara Lk .Isw don ra apply to an owner of OUTLETS-SWITCHES-FIXTURES
C 3- poprry who hold,or innl*nves thereon,and wM dues such work himself or though
hi,own employee,movided that such impmventem,we not imemld a oRand for NEW RHSI DIEN'UAL ELECIR SQ PT',
.al,If.howcscr.the huikim,or imovcmcntksold within a,c yearofam,plction,the FLOOR AREA SISQ.FT.
t,
ar-huBR,r will have Ne buNen of proving that the did not buiM"'improv,fa pu-
p M ala,).
❑L as owncr of tha pmpny,am,talusivcly contracting with licensed cnnnnck,to TOTAL:
m,wn the pmjcct(Sea.7(),44,Bmiacs and Profeaio,n Corn:)'ILc Conunnnr's It-
aLaw dan'm,tapply to an owQr of l+ol,crty who,builds or impcoe%ihnon aM QTY, PLUMBING PERMIT FEE
wMr,novact faouch pojecu with e,anuacta(s)licrnsd pursuant tothe Cnnt tars
Liccn.x law. ` PERMIT ISSUANCE 2
C] I an exmnpi under Sec. .B R P C for thi.owwn
0,." Dem ALTER-DRAIN R VENT-WATER(EA) VALUATION
W'ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I bcrtby u0imt unser penalty of Esdon,nuc of the follow;na dcclantials: �-
Ilwucwdwillmniniano.CenlEcmu
e of Con¢no.elbin,um for Wmker',Compel- DRAINS-FLOOR.ROOF,ARBA COND. STORIES - TYPE CONSTRUCTION
,aim a povi,kd for by Section 37W of do Lshv Cd,,for N,pdoruuxe of ttc
9k for which this permit is ioud. DXTURES-PER TRAP
1 have ad will mwmm.Tokens Compmminn Insunnc,,m uen
us imd by Semi
9f01of the Lalmr Gxk,fm tic perform.cof tic work fawhkh thl,Ktun,k mwd GAS-EA.SYS]ILM-I INC.C OUTLETS OCC.GROUP APN
MyW h olnP�Pq 1����+ aaM Policy Pu^ {e -
(irricr�l \t.ytr ``[Nnr�cem Pdwy No.: `p NTS RmG GAS-HA.S1'S1PAf.OVERIKA) 'As //��
CERTIFICATE OF EXEMPTION FROM WORKERS' (��"Y
COSIPENSAI'ION INSURANCE GREASIYINDUSTRI.WASTE 1NI'ERCEPIOR
BUILDING DIVISION FEES
(Thusectinn meed axhc(mpletd it Ne permit in fa m,hurdrN ddlon(SIM) GREASE TRAP a h,.l PLANCHECK IFF,
I canify Natio Ne Pcmwmuce ofthe wak fmwhich this permitktoted.lshnl SEWER-SANITARY-STORM m . nan EA.20(11'0,
mg employ any p, anyncr sons,,N,rc c.ubject n the Wakcn'Compel- IE
ENERGY E
z O sanio.ant La.sof Culit�ombc Data WATER
WATER HEATER WIVEWMLF.CTR DINb ^ r\
h NOTICE TO APPJCAND IL after making this Cm f to of Exemption,you should WATER SYSTENMEATTNG 1 r
�\bacmm whjcau,N,Worker.Compcnsmum provision,of lin,Iatxr Cd,,Pun moa �OI FI?E( I_I I 11
Q forthwith,amply with such provi.siona a Nis pemut"]I h d-riul mvokd. WATER SERVICE
7 z CONSTRUCTION[.ENDING AGENCY NEW RESIDENTTALPLMB. SO,ET AID a.kgyL A
LAC) Ihereby affirm thuthu,kamnstmction lending it"rcy for R
P is work for which Iia roil,isw,d(S,c.3(P)9,Cie C.) -
U t o&r'n Name TOTAL:
Imkr,AcLi TOTAL
y I cxnif,that 1 have nd rhi,application utE,tma Ill Jc above infomntion is UED NC -
N ,noncan. egrtc m um,ply with oil city tuns caumy ordinorcn arW smm lows renting to QTY. MECHANICAL PERMIT '-
U Z M1uiwing catwct:m,end MrsFy vuNaim rcptcscntutivc'of thin city meaty upmth SEISMIC FEE
aMv,ra,uwcd Pori for impctiron Im,ot,, PERMITISSUANCE.
(We).,BS,to aevc,irdennnify end keep harmless d,c City of Cupertino against ECTtIC FT2
liabilities,judgment.cost wA expenses which may i n any way accrue agai na msl City ALTER OR ADD TO MECH.
rcyucnre of the granting ar this pmnil. LUMBING F
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO W."CFhp
REGULATIONS. ECHANICAL FE
SOl F.
0'.) AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
S,gnamn ofA,licanw.r.no, D. EXHAUST HOOD(WNUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE,
Will the applicmt a futurt lvildin6 uccvFant snort or hu,dle hassNous material HEATING UNIT(TO 100.001 BTU)
as dcOnd by the Cupenitc Mar,,,cl Coda,ChaP¢r 9,12,turd the I[-In anI Sub,, 1;13 0
codc,Scction 25532fa):' HEATING UNIT(OVER 100.000 BTU)
C]Y, PAID
VENTILATION FAN(SINGLERFSID) Data Rttcip0
Will 0c ep,licam or Winn,huilding acvpan(six rym,n,m ar devices which BOILER COMP(JHI'OR IfX1.IXX1 B'N)
rml hE
udous air ninunmwn,t,defined by tM Buy Ama An Quality Mamr,
nagc - L
District^ L.larO BOILER-COME(OVER 100,000 BTU)
DY,
1 AIR CONDITIONER
I,tith S,ifa'hvanlrc,nom;1555.u 52crom Sc Iunafi45ofhan ittli ` ISSUANCE
DATE
forma Ilcnth R Safety Coda.,.on�,25505,25533 mtJ utabil I umfaumn that it tic ,NEW RESIDENTIAL,MECH. SQ.FT.
build'y�Jou m,vrrtndy have lb te9eul chain it H my mporuibilnty to m,ufY Oc acupmn 9
of JscYypnimm�tl�wII thou lc ma pion to is.wTnx rota C Icyanf —9\
pwntt sir umhTycnt sic TOTAL: ISSUEDBY: ZZ
OFFICE