30884APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING ELECTRICAL
PERMITNO. /X 8 w
BUILDING DIVISION APPIACATION/PF,RMIT PLUMBING. MECHANICAL
X(/ 0 8 4
lXISlJ
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DAT(
Y46
NERS NAME ONE:COYI1tA
NAA1 WC NO�
NA
El
CONTR
v YL
ARCHITECT/ENGINEER:LIC NO:
aa ile N
ADDRESS:
I/ILm
ISTAC : PHONE
X
BUILDING PERMIT INFO
❑ Conwltant Fees Paid by Applicant (Initial)
BLDG ELECT PLU MEC
LICENSED CONTRACTOR'S DECLARATION
I thereby affirm Thin 1 ata IiccwN under poo,oarsi of Chapter 9 (cammcrcits6
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION -
winhSmbn T000I of DiviumJof the Busircu rrtd PvfnsoaCndc. end my licrnuis
m full foil, ob eB /
License Chis Loc.X or L Z'S�IL
Da, Crmtuux
FSIR �FNTIAI'
❑ KITCHEN REMODEL
N [I PLUMBING RB -PIPE
❑STRUC URAL
MODIFICATION
1M."T""O"NIT
PERMIT ISSUANCE
� APPLIANCES-RESIDEM'IAL
ARCHTIHCT'S DECLARATION
I onleratead my plan shall he used v Public Mond
PANELS
UP'IO SWAMPS
RIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELflRFPAIR [I DEMOLITION
❑OTHER
Lics'u°d Pmfuaiunal
thmOWNER-BUILDERI ,teroDECLARATION CaATION
1 hereby aR� that 1 am,Bump (nate the Cotunct«s e: Any a Isw far the
whichfollowngreum,lSminn'comar.Busiteverd Refusions Code:Anyany momy
a permit comtruct, oxer, improve, demolish,
which ti.
repab w! atrc.,
301-ItVlll AMPS
OVER 1000AMPS
SIGNS ELECfRICAI.
SPECIAL. CIRCU I
vats o th "It., ficirisikk—,the mch fi
Gr
doprirheitlie,cc!p.Uurto,he Ctourum',tofleeugrcdueunlrnt
that he is linen 1purswmm Liana law (ChepmrV
TEAIP.M O (NST
(.to,empt Subornn ) aDisinnii 3,ftbe B.Ticmut
iaiiian J our Busi"empt PmlAny Codc)of
and be th
that he is exempt thaefmm and the basis for the dlegM exemption. Any vbiatian of
❑ Nlik l/1apyC,/ADDIA0 LH'ION
PO E EVI
S,efion70311 hymy applicant fora permit subjecu theaWfic-.tnt toocivil ptultya
out come flue file hurdml dollen (SM00).
❑Lax mmefofthe l'topeny. or mY employees with wugnu bomolecampenmtlon.
will do the work.ml thenrimun is on. intended orefl for tale (S .]DLd. Boaircas
EITENAN'1' Lf�• SERVICE
ft
IMPROVG1E rL1U/•-,
❑OTHFJi ilAap
MI GPOOL ELECTRIC
ICZ
end Pvfanmu Cak: The CmtracmM1 have haat' docs fin apply to an weer of
UTLETS-SWITCHES-FIXTURES
e,d who docs of thrmgh
y wMt build' po Intpvves thmch
Ifo, u
hie own employtta, building car
i cornu enc m infeeticd w Ufeml for
e not
mere
NE RESIDFNHAL' EI.ECIR SQ FT.
itis m, is
WalLhowcr will Int, idirgner of mocnt asold withinon ildor ieompletfor the
mer -builder will have thebwo of pvving loot he did not boildaiftpmve for wr-
pore of Wen.
SQ. Pf. FLOOR REA
�� y{a
LSQ.f4.
L
❑Lin; owner of the popeny. inBosun uxivdy mnrveting with l comncun
censuuct the pojar (Sec. ms Code:) The C -
Brce.fa and I :) The V-
o rm y h,r th.,-.s
avcomomsfU. clrsa� rmapperniwithce pmodi)becosed, mimtro
QTY. PLUMBING PERMIT, FEE
ft Ce,mnurd
who cmtrrra for such pmjecu with a avuncta(.) 0rcnscd punttart to tK Cwnncttds
PERMIT ISSUANCE
Licrnsc taw.
I am excmp ufu4, Sx. . B & P C for This uawn,
ALTER - DRAIN & VENT - WATER (EA)
Orvrtcr Dem
VALUATION
BACK FLOW PROTEGE DEVICE
WORKERS COMPENSATION DECLARATION
`�p
I leri aft un,ler penalty of perjury ane of the following declmntims:
I�
VY, 1 ^.
DRAIN'S- FLOOR ROOF AREA, CONE),
IMve nal will muimeineCenllkme ufCm.cnt mad,-nuurc far W�wY 'a Cumpam
atom to posided for by Sectiwl 37W of the Iaboe Cade, hour the perfomurcx of the
STORIESJ TYPE CONSTRUCTION
wa4 fur which thin pemdl is iuuN.
FIXTURES - PER TRAI'
❑ I Mve vol rill mvnnin Waheh Cumpmurim msauence, u required by Sectiw
JlW of the Mbar Code,fa the perfamerce oftk wak Rr which thio tawit is iuuN.
My WA Cpt�yTA�ytiunlpqurync (Policy numlkr
GAS - PA.SYSfEM-I INC.a Of1TIJ.'fS
OCC. GROUP APN
Comm y Nb.;
GAS - EA. SYSTEM -OVER 4 (FA)
CERTIFICATEOPEXFMITXfSI FROMWORKERS'
COMPENSATION INSURANCE
orinn.)(Ihis recmn need! ma ifdeperndf is formehwdml dollate($I WI
GREASMNDUSTRL WASTE INTERCEPTOR
BUI (VISION FEES
GREASE TRA('
PLANCHECK �^
SEWER-SANITARY-STORMEA.100P1'.
Doan
(unify Guaothe my mmnc<ofs toofkfm which Nu dit,Woker, C o'r..
m employ any person in any franrcrso as to become xuhjem mthe Worken'Compem
ENERGY E
WATER HEAVER WNENT/ELECIR
wino laws of Califorri Date
Ap dem,
GRADI HE
NOTICE 11) APPLICANT: If, after muklmg this Certificate of Exemption, you should
ttemnrtc eubjm m the Nbnkch Campenwtim pauvuioms of 1M labs Cod, you moat
WATER SYSTEMIIREATING
SOILS
forthwith comply with wch povkimci m this permit small N, deemed mvAcd.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that ix a construction lending agency for the pMomtwce of
NEW RESIDENtTAL PLMB, Sp. FT.
PAID
ate Raeiptl
The wart for which this permit is iuted (Sec. 3041, Civ. C.)
lender's NameTOTAL:
I cedifY thm 1 have teed this application erd'teu that the ebov, infamtm or is
-
BUILD( G m, 4-7
QTY MECHANICAL PERMIT FEE
correct. 1 agree to comply with all city" county tmllnmrea end state laws relating to
building cmimuciiw, and hereby authmiac npnsenwivn aThio myna amen rpm tk
SE[SNjCFEE
abose- n,suimed perilterty for inspcmo pm,,es.
(We) agre, to aavc, indemnify Tuna keep harmless the City of Cup,mrtu again4
PI;RM11' ISSUANCE
F, Ecingic EEE (14
Iubildim.jutipoa , comOnd cspetsses which mayor any way a a'vc egeiw iuid City
e of The grain ingot Chia p
in meequegraincrout.
ALTER OR ADD TO MECH. -
PLUMB EE
AIR HANDLING UNIT(TO IO.OW ChM)
MECHANICAL '
'
APPLICANT UND"STANDS AND WILL CO (PLY WIT ALL NOH-POINTAND WILL CO (PLY WR ALL NON -POINT
SOU :REG - JNS.
AIR HANDLING UNIT (OVER IO,OOOCFM)
' O
CONMUCI'IONTAX
EXHAUST HOOD(WIDUCq
Slgatumo Alrylicar"Cu itruc at,
HAZSR U. M ERIALS DISCLOSURE
HOUSING MITIGATION
HEAHNGUNIT(TO I00.000BTU)
Will the ep,licart come ing mculunt fnorem MnJle Murdms material
Tor def nM by The CupmT o Mwicip d Code. CMpur 9.12, unit the Health end Safety
Code, Sato 25532(a)I
HEATING UNIT (OVER TOO." BTU)
,
❑Yes ❑No
Will a
l tpplicant a forme building n¢aMot use equipment or Jevicn which (
:mit bararcom, air coatuninwts ea defined by the Bay Ata Ali Quality Mevgxrunt
Dismct
❑Ycn No
PAID
Dau Rcccip Y
VENTILATION TAN (SINGLE RMID)
BOILER - COMP (STOP OR 100.000 BTU)
TOTAL:
BOILER- COMP (OVER 100jaO BTI)
AIR CONDITIONER
1 Mme read the MzaN•ws mmcrinlx nquirttrcnB rode, Owpur n 95 of the Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
Tunica Hemb & Safety Code. Swims 25305. 25513 and 1PG4. 1 tmdenteed loaf if the
btdMin{ docs m,woody Mve a feTmt4 Out if A mY respimaibility to milt flu ucrvprrn
'
oflo m,mr,mms whicho.,b,tm pnmm oormaet a Cendle. ofO,,aWcy.
ISSUED BY.
Oumenr autMxizcJ rgend Hata
OFFICE