00010101 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTTDCAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
BUILDING PROJECT IDENTWICATION'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL LATE
OWNER'S(.'AMI!:
PHONE CNC � LICNO
a' / ✓ u<`N
WC CONTROL# '
RCHITECT/ENGINEER: LIC NO'. ADDRESS: ❑
CONTACT: PHONE: BUILDING PGRMIT INFO_
❑ Consultant Far Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ - ❑
LICENSED CONTRACTOR'S DECLARATION Q-ry F,LECTRIC PERMIT ,FEE
I hereby of firm Incl 1 am Iicrosd anger Provisions of chaffer v(fo,maocing JOB DESCRIPTION
�0Z Ih Sccfion 70AP of Division 3 ofthe lfoninexs o,d Podnslm,Cde,rdlny liar,is�� n'full fora and eRecl. yn, PIiRMITISSUANCF.
RESIDENTIAL
aFVU Liceme Class �' 2-0 tic # 2 "'� �Z FOWL ❑KITCHENREMODEL
NQa Dutc uvctm APPLIANCES-RESIDENTAL ❑ADDITION ❑PLUMBING RE-PIPE
' �-! ARCHITECTS DECIARATI ❑MULTI-UNIT ❑STRUCTURAL
zbp2zm+ I unJersland my plans shell bt used as public rrcorl. PANI!LS MODIFICATION
O Z-�L, UP DONID AMPS
aj factorial
El INTERIOR CHIMNEY REPAIR
1(11-1000 AMPS El
SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IW
TN S BATH REMODFUIREPAIR ❑DEMOLERON
¢ 1 nanny affirm that I am exempt from He Cmtnacl«s License Law for the
follmving rea.s.(S,,aam 91131.5,Bri,iness and Profir rinm Cdo,Any city orc.nnly SIGNS ELECTRICAL. �OTHER p
'3 which rcyuim u orfit ro construct.alter,improv,,droar ish,or rrpai,any madarc _(�
prior to it ivuemx.alum requm,i the applicantfor wach Pool to file a signdttt SaemenSPECIAL CIRCULDNIISC.
C� er
S2 honk is licemsd purwam to the roviaiari N are GCdIY1Cr3 Licanse Law(Chipar9
WCpO (mmmenemg with Soo rimlf](p)of rhvivon J of the Husimess and Pndcssionx Cde)or TEMP M EVER OR POLE INST. COMMERCIAL
d e p[ that he Is.exempt Ihcrefmm and the hiesai for the allc0�cum,dinn.Any violation of E]NEW BLDGIADDUHON ❑DEMOLITION
'^4• Scefion 91131.5 by any,,licmf for.pcmtit subjtt IS IM;aPpllcem loo civil ritually of POWER DEVICES
w ❑MNANT ❑FOOD SERVICE
FZ Y not more than five hundrdol
ed len(S500)
AFD
El 1.u owner of the fm,on,or my empkryees worn wages as their safe T
e compem.ation, SWIMMIN Y IMPROVENVE.
will da t New ando amemre ma ml imadafrd or offers]for sale(tis..](134,Basi OTHER
a3 and Prfcaaimn Coda:The Commchn"a License law rises tta applyfo an own O - _
pn,fty who build,or intpmves tarcon,and wind Jou nmh work himself a tWtr1 !Q\
his own emplgees,provided that with InEc urmn ant rM inmrrdd..Had '1 CrR FT
sane.If.however.the,building"!in wavemem is sand withinomeyearofcomPletion. I1 SQ,FT'FlAOR'AREArT.
owter-luiltkr rill have the Foden of Priori,that he did not build ams rr us,fa Par-
potentials.). u U
L JAN 21 2000
❑ I,ax owner Nie pmpcny,,B cxdusiwly moessi ing v9N h If C.m.l.,s i-
rnwrmt tM pojcCt(.Seca]DM,Bmiruas and Imfcarium CMc:)'llw Cumncmr'n Ib
carte law doer not apply to an owner N lx.pcny who builds or ms,r cs thaean,and QTY. N ;C
who cobweb fa..,.h pojsts with•cmuacorts7liccmcd pusuanl to tK Conan
Lofene law. „ By-
[3 -
Iamexemmi,rderScf. ,H&I'C for!nix real
- -WATER(PA)
Owner Due DRAIN&VNNfVALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2 OO�
1 hereby anion under firmly elty N perjury ane of the foe.wing Jxlwiom:
I have mrd will maintain a Ccnif roof Conwntto ath insure for Worker's Compn- DRAINS-FLOOR,ROOF AREA GOND, STOR ICS TYPE CONSTRUCTION
ration,rax provided tin by Section 9](X1.f fin,Lunar Calc for the Ptr(Dmtmrc of fit
work fm which thix prmif is issued. FIXTURES-PER TRAP
❑ 1 Mss and will Batman Wanes Canpcoaetion Ins...as rryuiml by Serfion
3I10ofde Taboo Carole,to Ne pdr.a.fda,work rawhich Nis eamitn iaaaed. GAS-Ek.SY, f %ill INC.4 OUTLETS UCC GROUP APN
My 74om' p Ion bane,canierad Pnliry nu /�
Carder, o " _PolicP , ' G GAS-FA.SYSfEM-OVER4HEA) 3�Y�� p
C.RI'll' ATE IFtEXiMITONPROM 'ORKIiRS'
COMPENSATION INSURANCE GREASEJINDUSTRL WASTE,,INTERCEPTOR
BUILDING DIVISION FEES
(Thuncaaim rlmlru be canpkfd if Ne permit isfamehun4d mlollualS l01) GREASETRAP
m load PLANCHECK PEE
Icenify tat in the perfammrc"fth,work for which this permit iv iu"til.I shall SEWER-SANITARY-STORM EA.400 PT.
run employ any paras,in any manner a,n,m bsrwme xuhjccllo tie Workcrd Compo- ENIERCY FEE
Z
Rw'O woos Lu;of California.Date WV-FR BICKER WNENT/I:LECIR GRADING FEE
an
y NOTICE TO APPLICANT.If,after,making Nis Cenilcate N Exerpnm,you duuW WATER SYSTEMITREATNG
a ; berme wsiect to foe Worker,Compcnsatimm Pmvisim of Ile labor Code.you muss SOILS FEE
fidir b comply with aueh Pr isi"m or his femur shall he dctmd revoked. WA'IT;R SERVICE
PAID
= Z CONSTe is.ro NLENDING/aGENCY NEW RFSIDFMIALPCMB. SQ.Ff. Date Rcacip#
U O lnorehyafrrm that there isacm(Sao "It.Crng a.) for The Perfor,ra,asN
u. rime wan tun wnitn mix prmif bi.�,rd(sera 8191.civ.c.)
Q
U Lander',Na. TOTAL:
y U Lander',Address TOTAL'.
yI cenify Nat I love mud Nis appldetim card Bare Thu rime mbuve ioformatim u BUILDNG FEE
N cmrccv.l agree to mmply with all airy ad mudy ndi,uacesand,name laws relatin6 f. QTY. MECHANICAL PERMIT FEE
UZ boildingmnstrucfion.mmd taint,aulM'u,epresenw,i,,cf Niacilymn emerupmtna SEISMIC FEE
aMsveoncntiond"'id,I.,infection Pmpm,c,.
(W,)agora rat save,indemnity and kttp hmod,ce N,City of Cuptninr aquina PERMITISSUANCE ELECTRIC FEE
Iiabilitic,rdtimenL,eau and eapcma which may in any way accmc agaimt said City ALTER OR ADD TO MECH. PLUMBING FEE
in roman ance of dtc granting of Nu permif.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO I0.101 CFM) MECHANICAL FEB
SOURCI!REGULATIONS.
AIR HANDLING UNIT(OVER III1000 CFM) CONSTRUCTION TAX
S1"umof Applica ontmcfa Date EXHAUST FOOD(W/DUCI)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MTIIGATON FISH
Will the applicant-futmc Wilding.,of sore.,hada,mooundm,malerial HEATING UNIT f10 IM,001 BTU)
u dcfnd by the CuPenim Municipal Cak.aa,,,o.12,aha The Hcalln and Safay
Code.Section 25531(W° HFAI'ING UNIT(OVER HX)JXIO HTU)
0ln VVN`HL TON BAN(SINGLE RESID) PAID
Will the applicant a future buiMing occvpam use equipment or Mina which Date Rei Ir
it hvnrdoos air c mmnimmni a,d,Ned by tM Hay Area Air Quality Managn,ent BOILER-COMP(BHP OR IM.000 BTU)
TOTAL:
_ BOILER-COMP(OVER IBB.IBIBT(p � _
Vias Ir//r CX
I have read lTe haaaAott mucoids rryuucrrcnt urmdrt ClmaM h95"rile Cdi- AIR CONDITIONER ISSUANCE DATE
fomia Health&SaBs Code,Sstiat 25515,2553:1 and M534.I understand that if the NEW RFSIDENHAL MECH. SQ.IT.
a thangnunottur:ncly haves.mrum6lhu irk moracootym xlfyta oavlant
N rime rtyuiremmmn which nun be ref foam' nee ofaCmificvtcy(jYeupwvy.
OwnrrmmrNonizd �� Duc TOTAL: ISSUED BY:
OFFICE