29135 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL n n 1 3 C
tlUILDING PROJECT IDENTIFICATION L J J
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAM(!; PHONE: CONTRACTOR'S NAM(_ LIC NO:
NIC CONTROLx
�ARCHITEC'VENGINEER: UC NO: ADDRESS; ❑ wGG{{o
tt
CONTACT. PHONE: BUILDWG PELRLMITINFO
❑ ConsWtenl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB' MECH
IJCENSED CONTRACTOR'S DECLARATION v
I herchy.R...hut Ian licensed order prnishns of Coup"9(cmmmealn QTY ELECTRIC PERMIT FEE
Is JOB DESCRIPTION
COpin full tura end car.z dlSmice N00ffecl. i.irn JaftheBminexs.nd Pmfeviom MIT
Cadc,.ndm li¢meix wt y PeRIsSDANCE
RESIDENTIAL
a'We. OSFT)WL ❑KITCHEN REMODEL
N Q anDate
ate C1. Cm _ APPLIANCES-RESIDENTIAL ❑ADDITION OPLUMBINGRE-PIPE
ea Cm mna
L,- ARCHITECTSa,DECLARATION PANELS 11ULTISTRUCTURALO STRUCTURAL
Z O-Z I IUNkrnaM my Elam,hall bt
e rud n Public road, MODIFICATION
OZ-O UP TO 20)AMPSgg ❑INTERIOR ❑CHIMNEY REPAIR
FNt Lkenscd Pmfcssion.l 201-l"CAMPS IMPROVEMENT
x� OWNER-BUILDER DECLARATION
yW 6 1 hereby affirm That 1 am excmp from the Contractor's I.Icemc Law for IO c OVER 1010 AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION
x O6 U following rtawn.(Smear 703 1.5,Busimeu and Profession Code:Any chy orcounty SIGNS ELECTRICAL [I OTHER
which rtyuita'v permit ,,ein,mic4 aper,improve,denwlish,ar re,nt .ny sweturt a P*
F"LLD pnamiu i.,A.
the
.pPlk.nl Tro w,h permit
In fikvadreduvteman SPECIALCIRCUITNIISC.
Qma he is li¢tunna
l puuu to the sims pmviof the Covmcmla Liceeae Law(Chapter 9
u.1Cp0 (rnmrrcming with Section 9(100)of IA vision 3 of the,Buri non and Vr,fcuiom Ca@)nr TEMP.MCFER OR POLE INST. CQ
1 i K that be is exempt thercBom uu and the bfor the alleged exemption.Any violation of 0 NEW B D TI N OLITION
a0 Scainn]0315 hyvny epplicwt faapcmut a itjocoithe upplicwt macivil pcwO
lyof POWER DEVICES f1y��f
ern TEJ;/YI' 9�hDSERVICE
FZY Imllmrt dun fire hu. , ,dtlux(SW).
6wiI,anwncrofdl pnpcny,amycmployas wimwegaamcirwk70m.Rualom SWIMMING POOL FJJ:CTRIC OTPROVEMENT
wBlmthe w.rk,eallne umaa<inmt manam marrer,d n,r weLsa.nw.xaame� []OTHER
"UrCMflrtvrl
Lad Professimu Cod,:The Cmwaorx License low does wt taw".vn owner of OUTLETS-SWITCHES-FIXTURES
prolrny who hadds or improve,thereon,and who does..ch work himse f or from,h
hex own employca,pravoledi that such mr mvemenu ate rear!merd<J or nfftred for NEW RESIDENTIAL E!FCTR SQ FE
vele.If lowest,,the leildingor improvement iv sold sithinova ycvofcumpkuon,the SQ.IT.FLOOR AREA SbQ.PT
nofi ilr dcwill hone Ox burden of proving that he Did not build or imprme for par- ��\
ofwlei
I]Q 1.an nwrty nr the pmlrny..m exewairel nxmttvrg Wim li¢nsed c m mcto x o' e
vua tlx projat(Sec.70,H.Business and Profeviom Code;)The Conv.nor'a U-
cerin law docs tux appy tae.rssnerof pn,er,y who boildsmimpovcs mentum and QT'Y. PLUMBING PERMIT FEE
who coa.fm such fxojms Wim.mammon(.)licen.ed pumuam m the Comr.or"
License law. PERMIT ISSUANCE
0 ImcxemlKu;�See.7 BRPCfmorisrtasm
a� ALTER-DRAIN GVENT-WATER(FA) VALUATION
U WORKERS COMPENSATION DECLARATION
I herehyellirm miler Rnally.1 perjuryone.fibefoll.win,declarations: PACK It/3W PROTECT'.DEVICE q88 (0/A
0,F1IhaveeM wiO nuim.in aCrnifcate ofCmunno¢If-inwrtfa W'Mer'a Canpen- DRAINS-PLOOR,RCORARFA,COND. LM
scion.ex pmvidal for by Sex i xn]100 of me Iibor Code,fm me perfomlaa<of the STORIES NPE CONSTRUCTION
work fa which this permit is irs.I. FUTURES-PER TRAP
❑I Iuv,and will maintain Worters Conyelssulrn houunrlce,a mpnred by Smiam
37fMlaflhc LahrGd<.tin Ne per[onivae.f me work hr whkh Nix permit,i.ext GAS-EA.SYSTEM-1 INC 4 OUTLETS OCC GROUP APN
My Worker,Canpensalicm 1.in
My Policy number are:
Caner. Palley No.: GAS-G.SYSTEM OVER 4 BIA)
CERTIL CATF.OF IIHNIPr10NFROM WORKERS'
COMPENSATION INSURANCE GNEASE/INDUSTRL WASTE INTERCEPTOR
Ghis section ria not M coniplemd if Ib,Lamin ix for one humoral ddlerx GREASETRAP FE
(51 WE BUILDING DIVISION ES
. area.) PLANCHECK FEE ?4",
Terrify met inde lerGrtn m,rso ithcwM fmwM1ichdns pemlui1,e,'C Ia6n- SEWER-SANITARY-STORM PA.HID ET
rot cmMoY enY perum in enY mannttwambavxrc,wbja'I to the WMeri Compcn- ENERGY FEF, atdr
Z Baum luwa of Cilifania Date WATER HEAIER WNENTIELECTR
z O Applicmn GRADING FEE
N NOTICE TO APPLICANT:If, afire making this Crnificme of Exemption,you slwuhl WATER SYSTEMMEATING
? Rrxrme sub)m to the Worker's labor Coda you roma SOILS FEE Lt2.
� ,.. faNwith comply with ash pmvisimammi.permit shall bedeemed revokM. WATER SERVICE
a �
U0 CONSTRUCTION LENDINGhendid AGENCY NEW RESIUI!NMLPLMB. SQ.FT. PAID
L) I hawhich hith is. uetionkoding egrnryfa the prrfam.n¢M Date RaeiPN
� ^ me wink for which thispermil isivuW lSw.30A,Civ.C.)
UCetera N.me TOTAL
IsMer I AJdrtu
F0. 1 eenify mar 1 have rind i 6appli cmm and nine Ism me Shwa%SMIvtiau is BUILDING FEE 1—
h ron¢slagrtammmply wiN,tidy erd cwaty ordiavuca and sato nae rtlatieg to QTY. MECHANICAL PERMIT FEE
G building conuructim,wxl hereby uulMriec«'prt.¢natives of Nix city roamer upon tM SEISMIC FEE
.Cove-melvianed Pofeny fm impettion pa pome,
(We)agrs In save,indcmnifY and k¢p harmleu due City of Cupenim.geimr PERMIT ISSUANCE FI.ECTRIC FER
Iiebilitin,jWgmena,cans eml exprnso which may in.nywuya,..,m,1 said City AITFRORADUTOMECIL
in cvnacqucn¢of the,panting d This pcmui. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0(k)CFM) MECUANICALFBE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER(0."CFM) CONSTRUCTION TAX -
SlgwlmeofA,1.nVCmlratm Dae FXHAUSTHOODOVIDUCq HOUSING MRICATION FEE
HAZARDOUS MATERIALS DISCLOSURE
"I the,applicworfulurt building occapme stortor hardk haadous maeri.l HEATING UNTT(T0100,000 LOID
a 4fired by the Cuperim Municipal Cede,Charter 9.12,and me Halm imul Safey
Code,Stolon 853NW HEATING UNIT(OVER 1 W,(Xp BTU)
❑Yce ❑No
VENTILATION FAN(SINGLE RESOD) PAID
Due Receipt N
W01 rheait comuafuwrt building by
Iffy
Air Qu adcvimwfikh BOILER-COMP(31 IP OR IW.WI)BTU) `
,mil harardtu ver cvnamir,enta a def red hY the IIaY Amo Air Quality Mwugeoent Tn J
Diatncl?
DYer No
BOILER-COMP(OVER 1 W."BTU)
O
1 hive(rad the hamdUa nurerials ot,,imatrnu u Wer CFmper 6.95 a the Cali- AIR CONDITIONER
ISSUANCE DATE
forme IkeW& eii,o Cale.Smima-flat i,8533 end 25534.1 undersand IMI if de NEW RESIDENTIAL MECH. SQ.FT,
buildingdoenciau which
most aarl.N.(heto i.mytewaruiuert munify me rctlpanl
of the m9uirtlrcluu wM1ich oust be met prier m iaravee of v Cenilkwe of Osupercy.
Owner m wthoneM.grnl
Date I.SSUIJ>BY:
OFFIC