29144 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL - PERMIT NO,
BUILDING DIVISION APPLICATION/PER IT PLUMBING-MECHANICAL. 29144
B (DING PROJECT IDENTIFICATION
BUILDINGADIHtFSS: SANITARY NO. A1PPLICATIONSUBMITTALDATIi
OWNER'S NAME I PHONE: CONIRACTOR'S NAME 'NO: •�
WC CONTROL♦
RCHTTC-UENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BNLDING PERh71T INFO
❑ Consultant Fors Paid by APpfrcant(Initial) _ Ly uG EL-fCl PLUMB SUCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE Flyer FD�Q� /��. LY
I hereby affirm for 1 em licensed nakr provision.sir awl)«9 Rommeneing JOB DESCRIPTION
X02 with Seetion 7000)of Diveresn Jaf Eo Flararres,marlProfesake Code, n Jmy liceme is
F in full forest and effttr. PERMIT ISSUANCE SRESIVEIsMAL '
FW.V�uj1 Lie.CWe Li,NNiv lVL ❑KITCHEN REMODEL
to Qy Duo Curmcmr APPLIANCES-RESIDENTIAL ❑ DITION ❑PLUMBINGRE-PIPE
1„Dr� ARCHITECTS DECLARATION �LTI-UNIT E3 STRUCTURAL
Z 1 uNvqud my PLu shall be owlrc blit words PANES
Z O fu MODIFICATION
OZ.. UP TO IW AMPS
F�F•u�l UeewN PmfeasimW ❑INTERIOR ❑CHIMNEY REPAIR
f'I OWNER-BUILDER DECLARATION IDI-I1000AF1P5 IMPROVEMENT
W '1 hereby ti irm that I w mm
cxcmPL from e Cveclor's License Law fm We OVER 1000AMPS ❑BATH REMODE/RFPAIR [I DEMOLITION
3 a F fol"ing narml.Section 70115.Bxdnese end Prof iaeu Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
F LL C which neguires a pmr,on etanstmn,.Iter,improve,dcntulish,at rclvtir any proem.
r� pro to ire ircumoe.dso rcqulrtetM applinm fm ush Parodi to Bkesipd sumrtou SPEC]ALCIRCUITRAISC. �7 s-
A
} that his,is licenral pmxuent lathe provisitm.afine Comracurr's nse Lew lc
Licehaacr9 l _
�0 (rnmrcrcing with Sxtim]OItO)of DivuianJnf do tlusioeas and Pmfesrims Codcl« TEMP.MEIFR OR POLE INS",
a C mat be is eeemq Ncrtf ai wd me buil fw the e1kgM eaemµ'xn,Any violation of .
t�• I+• Section 7031.5 by ui.y.,linam Gra pcnrit subjnv lhe.pplaramm o civil perky of POWER DEVICES ❑NEWS DD�ON ❑DEMOLITION
F_Z_y not more W
c n Five hundred dollan(g5do). ❑TEUNT. D �Q[]FOOD SERVICE
< I]I,est owmof Je pmpcnty.mmyrniployenwimwegaandwirsnlecompnwtion. SWIMMING POOL ELECTRIC IMPROVEMENT 6
ill do date wurk,und the structure iv outimealclor othred for axk(See T)Ya,Bueinev ❑OTHER ('/l• U
W and Pmfea.sions Cade:The Conuatnnra License IAw Jae.am apply to w awmr of OUTLETS-SWITCHES-FIXTURES
t'm,cny who bui MLs«improve.Joon,aal who nes such wM momelf fir.rough 'v
his own employees.Prnvirl ma such impovemrnm ate not intended or oRaed per NEW RGSIDIdspOl ELECRt SO Fr.
arle.ILhoweser,rhenuiming wimpmvcaml is Wild withinrrrcyearafcampletion,the SQ:FT.FLOOR AREA ,LSO.FT
owner-bonder will hese doe buNcnofpoving that he did oro build or improve for For, N O
of u2 O J 1'
I,a+nwrtcwrcr of rhe prnpeny,.m exclusively crnrrvcting with lino Ummrxtanm
m rrrtdyep.Jnt(Sec.]Iran,Bnerol' aMryw who
vu Code:)Theconmecmle U- .
aelAw JaesnorchMe.n alatiefpropeny weereef .mimpnncemereon,anJ QTY ' PLUMBING PERMIT FEE
whoree"..fm uw'h pmjetts wilt o canuacrur(r)lion W Ixuvaatu ro Je Caaagenr's
I'� raw' PERMIT ISSUANCE
❑Iwo exanq under Se. ,B&I'C for roil renwn
ALTER-DRAIN&VENT-WATE-
A ^ n.. .�_•_��_ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE ^1 aJ
� 0i""'❑ I have and will Ce wofCono,in to for Worker's Campn- GRAM AREACOND. LwL ut
Uli® on u
Sf RIES TYPE CONSTRUCTION
provid o far by Ss sur 7]00 sir IIY I.abar ooh.roc do prfamurce of me
workfar moll roil arrudis issued. ItIXTURES-PER TRAP
❑1 here eLat will mximvn Wontefs Connpuwtia Tru for
a regwrtd by Sn-tian S
My ofmcl�om,emadomlhcprrnce a ort date fmwh which permit is issuW. GAS-IA'.SYSIFAI-1 INC.d OVfI,EIS
OCC.GNOUP -APR
My Warko-'a campmW ion Insurance carrier and 1'No.:nunthcr ate:
Cmier: Policy No.: GAS-E\.SYSI'EMOVFRd(F.\)
GIiR TIFICCOMPE EXEMPTION FROM WORKERS'
COMPENSATION Fa INSURANCE ORPASEIINDUS'IRh N'ASTF.INTERCEPTOR
(This rection mrdMhcnnplaN ifJe(e[rnil ie fmrmc hwdml dmlars(STINT) BUILDING DIVISION MES
or laxJ - OREASii TRAP
PLANCHECK Fl.aE
(certify then in the Is .ofthewmkfor suhj this stand,is cmwCoIshell ^^
not cmgoy any pnnn in any rtanner so ns to M1ecomceun fir.tM Wntkcrt;Com SEWER-SANITARY-SDlRF1 G.1g1 PC .
Z' ..vean Ltwe ofarrmnie.Date i Win- ENeacr FEE � .•+
7� O Applicant WATER HEATER WNENTf ECIR GRADING FEE
Ll y NOTICE TO APPLICANT:IL after making mu Cenificam of Exempian you ebwld WATER SYSTEMOT EATINO
F•' "" becwrc subject b the Workda Compcnsetion povirine N See abm Cade,you must _ SOILS FEE
fmmwim comply with such provisions or this permit Jwll be damn)rn'okeJ. WATER SERVICE
a0
5 z CONSIRUCf10N LENDING AGENCY NEW RISIDIiM AL FILMS SO Fr. PAID
U Ihacny aflinn Juttkrtisucroswninn kMing agency f«pre pv(mrence of IAm Racige
P w
the work for which this Permit is Iwmd .Hl9
(See. ].Civ.C.) -
U Unhls No. _ TOTAL -
� lndehAr...= g
y 1 cmify mat 1 have read Nis apgicelion nrd gat<IM1ar the about infvmtatirw is BUILDING IFF, ' O r
U) cornet.I agrcetocomply with WIcity andcountyardirunceraed mate laws relating m QTY, MECHANICAL PERMIT FEE ' L�
U Z building cmnmsction, nd herebyeudodre rtprcrcnutivn a(miscitymcra,oponlhe SEISMIC FEE K
shove-orma irm�proPmy for inspctian aurpv:e PERMIT ISSUANCE �/�
(We)agree to save,indemnify aM keep lwmleu do City of Cupenira environ EIFCIRIC FEE \7�
liebilitin,judgmenls,<ou end eapem.I.1eh may,in anywnynccrueeguml said City ALTER OR AUUTO MECH. 1
in mnrequence of the grunting of mLc prmil. PLUMBING FEE l
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNH`GU 10.0f1(ICFM) 1 •�..�A
SOURCE REGUTATIONS. MECHANICAL FEE `3�
AIR HANDLING UNIT(OVER Lg000 CPM) CON.SfRUCITON TA%
Signmu.af Apph.a Conlrenor -" Date EXHAUST HOLD(W/DUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DLSCLOSURE
Will Its,Whceat or future building c,cu,am Arne or handle homudae material IIFATING UNIT TO 100,000 BTU)
u defines by Be Cape..hlunicipat Curie.Chepa 9.13,sm1 rhe Halm and Safety
Cade.Section 255911x)1 HEATING UNIT(OVER 100Jg)O BTU)
❑Yet ❑Nn VENTILATION FAIN(SINGLE RESID) PAID
Will the applicant in fuwre molding occupant use t m desica which Dale ReceIR C
eyuprcn BOILER-COME LUIP OR 100.000 BTU)
emir hvadwa est meuminenux n nkfml by Je Bey Arta Au QaalitY Mwgmopt
District?
❑Ya' Fl No BOILER-COME(OVER IW.000 BTU)
I lout read Jac hounkvs nteterials AIR CONDITIONER
requi.nxmis tintta awplm h 95 nT Jo GTI- ISSUANCE DATE
rarni ThWah&Safety Code,Sntioos 3505,25577 atd 25531.1 undrnud mat if dye NEW RFSIDFXfIAL MECH. SO.FT,
building docs rot cwmoly have a tcwnL vain it in my reysnuiblllty m agify the uecupum
of Je nemwemew which must be men Dnior ro uu .L.Cenifcate of(kcupmcy. -
Owner or iuohmiasl.gem Dam ISSUED BY:
OFFICE