29149 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO
xU11.DING DIn951pN AP LICATION/PERMIT PLUMBING-MECHANICAL / Q 1 A Q
BUILDING PROJECT IDENTIFICATION L J 1/� V
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMOTAL DATE
OWNERS NAME L PHONE: CONTRACTOR'S NAME: LIC NO: lip
NIC -� ^// CONTROL;1 RCH11T,Cf/INGINIAR: - WC NO ADDRESS: .❑ f. 4YO
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Tea Paid by Applicant(Initial) BLDG ELECT PLUMB MECiI
1 gyp[ ❑ ❑ ❑
Lm that I CONfItACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I xwfy affirm that I w ldekd imda nit P,nn.um❑wpard my Wcaaing JOB DESCRIPTION
wiNScnion]IMgO n(Dis'isimJnfnhe Husircxs unit l'mfcssitms Cade,wxl my littlae is RFCIDF.NTIAI�
O in full Paas and eRcat. PERMIT ISSUANCE 4 S6
GF.VZ Ej Licem.se Claw Lie.N ❑SFUWL [IKITCHPN REMODEL
NQW Dwc Contractor APPLIANCES-RESIDENTIAL El ADDITION [I PLUMBING RE-PIPE
6
ARCHITECTS DECIARATION O - -
F.'nvt PANELS MUI1UNH' ❑STRUCTURAL
Z p�1 Z 1 noncriminal my Plans shall be excel as public laurel. MODIFICATION
:.f pp UPTOMAMPS ❑INTERIOR
FhI"W Licrnsed Pmfewiovl LII-1000AMPS IMPROVEMENT
�CIIIMNEY REPAIR
SY �
OWN'EmcxcmDER DECLARATION OVER HMAMN ,❑BATA REMODEUREPAIR ❑DEMOLITION
6 1 hewby affirm m, 1 am cacmp form the Co,imi,Coins.
i s.A.,c Lew y or cafor dor
x 3 O FU- which Irequirta a In mm to a tmo.ahcR limp live,f dcmnlish.or acr air 'y struntvcy SIGNS ELECTRICAL DOM
♦ t
LL y «Io ire i.wena,ilso rryuirtedie ap!sliceru forsuehpemliOnflevu =,demrnl U
y e SPCCIAL CIRCUII'IMISC.
'�d�<� nhanheiust.,smaSceuam7NNUmfavisimuofdeComanm'sLicemsetaw(CM1nPwT9
1. (morn is
with Sectian]g10)of Divislanr M,be Busimesserdl'r.Anyi vi la!i.)ar TENIP.METER OR PO ST. OMM R IA r
a d e K that Inc is eaaryt IMcflwn erd Nc basis fir the alleged c.acinptirn.Any violvian of ❑NEW BLDG/ADDITION ❑DEMOLITION
!a• Sanon703 13 by any applicant for a pandit subjccu,ntr appliunl to a civil patulty,of POWER DEVICI'
ran more man five hundred dollvn(5500). ❑TENANT ❑FOODSERVICE
6 1,as owrcr of the Pmpcny.ormy rmploYas wim wgcxddeir rMe comPcmwinn, SWIMMING POOL EliEWY IMPROVEMENT
� � -will do do wok.aml111e strucwre inrolideodW arolemlfor wk(Sic.]DW,Bmi. ❑OTHER
W and Professoriat Conan:The Ccnirsmfs Liernre Lw yrs not apply,to an owner of OUTLETS-SWITCH_ T RLS _
63- proyicary who Wilds mimposes thelnm,and who mcn vmm work Iumaelfanhmugh
his own employees.Provided ihm wch impmvemcnu art Iron inwtuled car offered for NEW RESIDENTIAL ELECTRSQ FT.
sal,.If,however,the Widinmwd a
gorirupposeeen i. within aneyro(comphiiae,the SQ.FT.FLOOR ARG $RQ.FT.
owrcn W ilder will hove do Maden of proving dust he did axon build ur improve for pur- 1
qne of sdcJ. ,L r�
1,nomepoTthe Scec ,emeja_ant caressimeg Cushlittoralrnnnawasw TOTAL n,
ewautwt dor pnjan fSa.'IfW,Nusinar eW Pmfeceipu CWe:1'Ih Cmurro's Li- L� B i�
e m Lawdaew no apply to on owmerofpmpedY who Wildso ilrmrmvm themm.mw QTY. PLUMBING PERMIT FEE J/,�
who comracks R.such projaiswide•cimovemoN)licensedfumuom nu the Cummicu s V
Uttar law. - PERMIT ISSUANCE • C��(l` 1g9P
❑1 w cacmp only Sec. .H&P C tar this aeuml
ALTER-DRAIN&VENT-WATER(EA)
Ow Dew ` N VL�'ALUATION
WORKER COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / 1 ,,vv
ashy eDinn under picalty a peviery one of do following dedaramm, (� 1 `
l have"will maintains Ccnifwae of Consrnt toself-imm,fur WoAcr's Compcn- DRAINS-FLOOR.ROOF.AREA.COND. - yTpIUpS' TYPECONSTRUC ON
ration,as povidcd for by Senior 31(1(1 of elle Lahr Conk,for do perfmmn'e of nbe
work fa which this Pc r it is i—od. FIXTURES-PER TRAP
1 have and will relation W.A."Compcana.Imuwwq m wyuiaul by Section
J](Xl of Nc labor Cods.for Ux,prrt.ofthewort for wiich his permit is iwucd. GAS-EA:SYSTEM-I INC 4OO ,S
My Workels Conycnudion lmwmee cearicrend Policy namHaraae. OCC.GROUP APN
C'¢ Polar Na: GAS-EA.SYSTEM-OVER a(EA)
CERTIFICATE OF EXHMT PEON FROM WORKERS'
COMPENSATION INSURANCE GREASrAN'DUS7RL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This--rced tort be compland'IPdcicmlit is for meM1undr ddull:un(SIM) GREASETRAI'
°f ) PIANCFiECK TEE
Icedify that in lh Perfoxwnceofine oral for which mi.PermitisivuN.l shell SEWER-SANITARY-STORM EA,2W FT
rM employ anyprnmin vny lvnrcr.�u es rah Inc aubjen to do Workm'Cemprn- ENERGY IEE
Q Z nation laws MCalifornia.Duct, WATER HEATER WNESUDELF,C R
Z O Armliwm GRADING FEE
rq NOTICE TO APPLICANT:IL eller molding this Cenifiaw of Exemption,you Jnuld WATER SYSTE V RENTING
becmme subject t.the Work,aComp,mation povisioi,of do,labor Cede,you muu SOILS FEE
[
forthwith cmnpl,with such provisions or Nis permit sWU be deerlled revoked. WATER SERVICE �
a A
= z CONSTRUCTION LENDING AGENCY NEW RFSIDENTIAI.PLN R. SQ.FC PAID
IJQ kforwieh rdWdlne uaml(Scs-nkrd!ng agency for the pcdornnme of Data HeeipN
� .. dss wuh for which Nu pcnnit isissuM(Sa.JW],Civ,C.)
C) E"' Ixeder'a Nanc - TOTAL
W I.eaNkPn Addams TOTAL
0. I cenify rhdl I have red Nis.pplicerian noel awe Nat lhe.Wve infirmnrim is - BUILDING FEE
N cur.L 1it,ca wcomply with ad city and,curry onfirem s mrd sone lewa od.ing to QTY MECHANICAL PERM IT FEE
V Z building construction,vnd Meby summisc wpesematives of Nis city to enter uPan the SEISMIC FEE
'-' alsmve mrntlncsl proPcoy for ialp[niml pm c cs.
(We)tarts to ssvaimfcmmfy and keep harmlcw the City of Cupcni.oagnlw PERMIT ISSUANCE ELECTRIC FEE �V
r rnme cyifucnscnunre mcnw,cans and capemsca which mar in any ray emus agvinn aid city
of dor grunting of W s poorer. ACIER OR ADD TO MECH' PLUMBING IyiE
APPLICAM'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,[100 CIN)
SOURCE REGULATIONS. MECHANICAL FEE'
AIR I IANDLING UNIT(OVER I0,00)CFM) CONSTRUCUON TAX
Siputurc of ApplicimUCormaror Dwc EXHAUST HOOD(WMUCT HOUSING MITIGATION FEE
I IAZSRDOUS MATERIALS DISCLOSURE
Will Neepplieew mfutum luiliinll wirers handle hiaamlaun maseial HEATING UNTf(To 100.0sd BTU)
as dile 1 by the Cupc tin,Municipal Code,Chapter 9,12,unit rhe Hcalth soft Safny
CMe,Sceu en 255TUaD HEATING UNIT(OVER 100d"BTU)
El Yen C3 No
VhN'TIIAT'ION FAN(SINGLE RFSID) PAID
WIII me� acofmuw Wilding u se sos deviceswhich
Date RaipY
ephair ermhumiwna an dfrcd by me Bey Arta Air Quality Awgemrnn BOILER-COMP JHP OR IdIMUN)
Dnmicut TO
DUILBR-COMP(OVER RpJxq BTU)
❑Yes ❑Nn ,
I lave wW the hamrmw oulerials reyuimnrnss under Chaeta 635 M Ne Cali- AIR CONDITIONIJI ISSUANCE BATE
forme HUIN&Safety Cock,Savnm 255n!i.25533 and 235U.1 Ymd[astmJ mat if do NEW RESIDENTIAL MECH. SQ.FT.
Wilditlg dun n
not cvemlemma,ly hove a ry the,it ut my wspraht y to notifydnvrynt
or o
ofIic mmimlrmrs which mum Icapact pxor to ivsuance oft Ccnificmc M oc Tmocy.
Owner a vumorired agent Date TOTAL: ISSUED BY:
OFFICE