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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY 34�_ vlcoq red 14 74-
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUIIDIN ,DIVISION APPLICATIONMERMIT PLUMBING - MECHANICAL
BURA)ING PROJECT 11) lE'IFICATION
HWLDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
l^
O' RSNAM PHONE:
CON CfORS ME / )e �. D
!�7/,�
NIC
CONTROL0
III'fBCIANGINHER: LIC NO
ADDRESS:
i L
CONTACT PHONE
BUILDING PERMIT INFO
❑ GOffAlltan[ F. Paid by Applicant (Initial)
BLDG_ [LEC(' PLUMB ME -
-
L^d"/ LITt LSN CrrJf
LICENSED CONTRACTOR'S DECLARATION
] hereby emrm Nm 1 am Hcemcd uncle' Pmrviritme of Ch.Nrr 9 (ton mercmg
QTY ELECTRIC PERMIT FEE
_
JOB DESCRIPTION
PERMITISSUANCE
wit Section 711)(o of Dlvnbxo of d-Hu.iwm and Profession. Ga]e, end my litems lv
in mn fa amt en
Bene Cluer O1�
Dam Cnmrvno
RESIDENTIAL
W'
❑ShDL ITCHF.'lREMODEL
❑ADDITION 1:1 PLUMBING RIi-PIPE.
APPI,IANCF_S-RESIDENTIAL
ARC] ITTECI'S DECLARAHON
I uMclwM myplans JW be used¢s Publico tU
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
PANELS
UP TO 200 AMPS
[I INTERIOR El CHIMNEY REPAIR
IMPROVEMENT C] SWIMMING POOLS
Q.RKffi REM11ODEflREPA1R ❑DEMGLfDGN
D OTHER
Licensed Pmfcuintal
OWNER BUILDER DECLARATION
I thereby affirm Nat I am cxemN form De Con mr'v License law for We
following mason. (Section 7031.3. Boniness am] Profcuions Cede: Any city Or on,m y
201-110OAMNS
OVER HMIOA S
SIGNS ELECTRICAL
which Ityuiles a Fenmil to caarvct, aIle,, impovc, demolish, or Iemn mY structure,
SPECIAL CIRCUI'IIMISC.
pr6c to its issuamq al.m reeluites the sWiiamt[n each pcnmuo rile a signed] statement
that he Is IiceoN Putauam In the provisions of Be, Cmlranor's Liao,e law (Chapter 9
TEMP. METER OR POLE(NST.
COMMERCIAL'
(waned,., with Seen.T000)of Division 3o1fNe But.. end Prefess. Cme) he
(fat Fe is exempt Ihaefmen ertd ttr basis for the Wlegal escmptiw. Any violation of
0 NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 70315 by any applicant fora Permit wbko, the applicant to a civil Perehy of
not tmmm Then live hunched dollar, (SAX)).
Fl I. ss owner d the property.or my employees wish wages a, their sok co.tpensniart.
will do Oe wort, and t4 strucuve u tta inlemet d aroBercl far sem (See. 70u,I. Boaineu
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
ODU JTS-SWTTCT IGS -FIXTURES
and P oferaioms Code: The Conn ,.", [jet. low Jas nut apply to an ow. of
pro,eny wow W dd, or insprovas thcmw, and who drier wch w,,A himself or Ihmagh
his own employee, pmvWN thud such iml'mvcmcna are not imudel or offered fee
NEW RESIDENTIAL Fi FCTR SQ FT
.FT. FLOOR AREA SIBQ. FT.
are. If. however, the Wilding or irnm rtem ie Bold within acre year e(cvr.pkliun, tW
owtcrbuildn will have be W Iden of pawing Out k did nor Wild or improve for pm-
P^n of ale),
❑ 1, as —,of Nc prop r em eacludvely connxting with keened rwtrmte¢ 10
cwutmct the Prol (S . ]OU. 9usiteue am Professions Cmi The Caaracla(a U-
IsseLaw doew not apply loan ocher On Metoty win Wil& or improves t1twmr, end
QTY.
wW ttmtmctx fmwch projal witha<nntracaxls) lia¢wdpursuantmllo Comin Wx
Liccn.m law.
lamesempfumer See. ,BAPCfmthiso,con
PERMI UANCE Ik
ALTIiR-LIRA Vlaa
4`6WORKER'S
BACK FLOW P . DEVIC
VAL��,UATJJTTON
C.j' CO
r Uate
COMPENSATION DECIARATION
1 be eb, elfirm dlxkr pc rety of perjury one d tk following dttWuima:
D
g] I lose and will maintain• Ccnif to of Comienl to self -insole for Wmrlh's CunIxt
satin., es provide] fee by . inion 37M of be LalXe Cole, for the pcermoretc,, of the
DRAINS- O
STORIES TYPE CONSTRUCTION
wur61'ur which Nin permit ie iuued.
FIXIURF_S
❑ ] bare and will maimdn Worker', Corepen,ukn Inion.. v ou,mod by Senimn
3]00dfIle,LyaWr CcCcme,yfmmtlepef.d Orwut f�{wuryxbhiucch/tt1 is pemdt is usonl.
GAS -EA.S Wt -I INC. J OUTLET'S
OCC, GROUP APN
�Ei[_P/l/ ccanivruMy
C{YW on cr 1,17'm SG9
. GAS - EA. SYSTTM-0VER4TA)
CERIIFlG\TF. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(THu seetism mrxtic completer] if the permit is for moa hutdrNdnllarr lSl00)
ee leo]
GREASEIIINDUSTRLWASTEINTERCEPTOR
BURRING DIVISION FEES
GRLASI: TRAY
PLANCHECK IEE
SEH'ER- SANITARY - S'BIRM EA.200 FT.
reeify That in the prHmmame of the work fm which this Permit is i.uuee.I shall
not employ arev telxm in any rammu, to Our to become,suFjecl to the Workers'Compco
ENERGY FEE
WATERHEATER WNGYI'/[LECfR
union laws of Califyrnin Date
Applicant
GRADING FEB
NOl ICE TO API'LICANT: If. Wier making this CcnifieWc of Eannpriun, yw eM1nulJ
becutre wbjecl to the Wacker'. Cmnpereadon pmvi mo of the Lbnr Code you mud
WATER SYSTLNMEATNG
SOILS FEE
farhwith romply with such lem,ncorm in, pemJt shill be darned «waked.
WATER SERVICH
NEW RESIDENT IAL PLMB. SQ, FT
CONSI RUCTION LENDING AGENCY
I Iamb, atfrm thathereis a coniuuctim lendinti,ency for thepevfo.cof
PAID
Date Rcho,0
Oe work fee which Nis permll is toured (Sea JO91. Ci, CJ
Lenders Name
TOTAL:
lead,', Addmsa
TOTAL:
1 cenify thin 1 hose read This application sed.tam thin the aMrvc ite—ow i,
BUILDING FEE
curt.la tocwplywitha]LCryamlcmnlyadimmKesardsplclawsmWinglo
buildingcon..c and heteM authodoe hTo e.uivcsofthis city tocorn upon tle
QTY. MECHANICAL PERMIT FEF,
SEISMICFEE
obcwc-recntiomed omPeny for impeclimm purposes.
(We) ultra to save. Indemnify it k q harooku, Ore Cil, of CuFom.. against
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBINGFEC
IiabililictjuJgtrcnu, toga aid espeme which trey in any way...,truta said City
in ceasequenee M the graadir, of this pemuf.
AIR HANDLING UNIT(TO IO,(MCFM)
MECHANICAL ITE
APPLI . T' DERSTAND . y WILL COMPLY WITH ALL N POINT
SOU CP. REGUTA'TIONS.
AIR HANDLING UNIT (OVER IO.WOUM)
CONSTRUCIIONTAC
9a��
Si of Applicam✓ x Date
ifk JUS MATERDISCLOSURE
C1Jl
EXHAUST HOOD( WIDUCTI
HOUSING MITIGATION FEE
HEAPING UNIT O O 100,000 BTU)
thelt,licomor run. oldin,ccuthundoncor Mmlk baemd.as trumrid
to defiltM by Oe Cupcnirw Municipal Cade. C]aprer 9. E2. am the Hedhth and Safety
Codc.Sect 25532(.)"
HEATING UNIT(OVER IO0.000 BTU)
0Yes (]No
Will hethout, epPlicsnt or Toluca Wilding by do, ny Acquin Ota eedMarnwhich
'aaardwe air rnnleminanta ss dcfireJ try Jtc Hay Arte An QuelifY Managctrcnt
❑Yes 0 N
PND
Du R ti
T
VENTILATION FAN (SINGLE RESID)
BOILER- COMP THP OR 1(X1,000 BTU)
BOILER - COMP (OVER Igl,(lgl B'PU)
AIR CONDI'DONIJt
1 have red ft haamell materials tryLi533 an drab . I can ers mf Cali-
forma cel 5r Safety Ctdc, Sccliau 25Asf. 2553] and 2550. 1 utakrstattl that if Oe
t,Oa Y eu t
-baatbtttJJy
pruutt
ikll dewus�t
y
^ i$$'NCE
�
NEW RISIDFNTIAL MFC{, SQ.FF
mheow tenm etno-vt tmeexdalf
ooWft 6riiedswsmuuayrKtreceeeaa a¢Dauumtppcyy.
ISSUEDY:pg ✓�F�
MrornxticmuJmomfO
TOTAL.
OFFICE