28960 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES,-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PERMING.
BUILDING DIVISION APPLICATIONIFERMITPLUMBING-MECHANICAL 28960
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DXnM
/06® .4 ,v eft-
OWNERS NAME PHONE CO ACTOR'S NAME: LICNO:
„ vi
NIC CONTROL
` U.EU,UE1IlroNbUIL LIC NO: R K • ❑ -
6W &C
CONTACT: PHONE: 1V�JS Yys C'�I BUILDING PERMIT INFO
Lj Consul [ es Yard by Appllcan,{Initial) BLDG ELECT PLUMB MECH
❑ ❑ �� ❑
LICENSED CONTRACTORS DECLARATION 71' ELECTRIC PERMIT FEE
1 f by mem,that I en,hce,.md under pb,vieinn.of Chanter 9 rrommm,ane ]OB DFSCRIPfION
FWQaZ with Seatlm](00).f DiAtionJof the 9miaa and Pr,feecl«a Code.and mylio.ie RESIDENTIAL:
io full torte aril eR PERMIT ISSUANCE -
%F�Z�ut lacroseCWs - — Ir, Lic'Y LYO Y.o1 _ ❑SPDWL [I KITCHEN REMODEL,
h6� Dare ContractorAPPLIANCPS-NESIUt AL ❑ADDITION KHarMBING RE-PIPE
ARCHITECTS DECLARATION
p,Otn PANELS . ❑MULTIDNIT ❑STRUCTURAL
Z O ZJ. 1 imdcrvaM my phw h shall used!m mx
Public tda MODIIlCAT10N
OZt—'O UP TO No AMI'S [3 INTERIOR ❑CHIMNEY REPAIR
�r!'�LW Liceoed Pmfeaimudi 201-10(IOAAfPS IMPROVEMENT
SSSS OWNER-BURDHR DECLARATION OVER I(Mp AMPS - ❑BATH REMODIif/RBPAIR ❑DIiMQ1.ITIQN
L���dd c w Q 1 hrmhy uRrm that I am exempt fmm the Conutume,Liceme law for the
x1U foilmring trusser,(Satim]0313,Brains am Pmf.aiom Code:Any my m munty SIGNS ELECTRICAL ❑OTHER
til 31r. which raryues is Permit to e.I..Iter,import,dermlisn,«reluir any swcvue
frimmit,iamae.elso...rineslhceppliuom for,,eh .,it m filc.eignW-morm,m SPECIAL CIRCUIT/MISC. -
f Y that Ix is licensed patsuau a be pmviaiau of the m
Cmones Lo,erue Law(Chagcr 9 '
—GAOa (emmrncing with of"'Mob 3 ofthe Ramses.std Pmfe.sions Cak)m TEMP.METER OR POLE INST.' COMMERCIAL
6 e LL IMI he is ucmp therefmm and the basin f«Naullegul vsloO gum.Any violmim of
u. ❑NEW TENAN DG/ADDITION ❑DEMOLITION
Sadon]UJI3 by any epplirmtforeprmit aubjav the.pgiwm mecivilpwlty of POWER DEVICES
—y ❑TENANT ❑FOOD SERVICE
F Z Y Thar mart tNn five hundred dollars($SW),
Q ❑I,mnwnmoftlm pnryeny,«my cmpinyca with wags en their sale campttwtim, SWIMMING POOL ELECTRIC \ IMPROVEMENT
will du the wveV:,and the mrvcmrt u at intcWM m oRmi,not,'S y to Tin om,re ws []OTHER
—� aced Rofe.vms Code:Tle Canuxmh Liceve law doer na apgY to an irwmcr of OUTLETS-SWITCHES-FIXTURES
d 3— his wW Wilds a Provided[
That
and wMt yes rmch work himsclr nr bur
M1ia own e W k!m dw such impo.xmcotn art ax int.....m offend f« NEW RISIDFNML FJECRt SQ FT. r�
nW Yea.Prov
cede.IL Wsvecv,ll I Willing harder
mrntisaaNwiid nurcyaer comge for,the' .FLOOR AREA M.FT.
,cme.f uilda will have the W Nen of goving thnt he did not mild«impmve for put- _
pre.osmame
❑I.a Ue Po(the persur,' ely auauour,whh:)The Cevmr.ctanm TOTAL
c«mrun the t(Sec.]W4,Business end Pmfcxlmn Coiled The ContructMs V- � V�
pmja 1
cease law Jaeeora apply manohitofpmprrry who Wildsnrimgovec Contra andof QTY. PLUMBING PERMIT FEE /\
who rwnan.f«such pm}eca wiN•cmvanor(s)liemsed pwsuant m the Cmivectvrs
License
❑ lemuemq uNm Sa. .BKPG(«thL rtasear I'ERMff ISSUANCE
Owar Dem
ALTER-DRAIN&VENT-WATER TEA) - V e�r�sr
� _ . '/G"\.`
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I naxsy eft oma pwtyMprjury a.e of uta ronawmg dccluarimu: � J�
❑have a,d willuminain sCmtifiwett C«ucnt to Tel(-imurefm N'wkcrs Cvman- DRAINS-Fl-OOIC ROOF.AREA,GOND. STORIES `TYPECONSTRUCHON
wdon,a provid W for by Swoon 37(X)of the LM ,e Cost fm the pae'om o.of the _
wak fa which this Perri is ismni FIXTURES-PER TRAP Q �'
I have surd will maimun Woheis Cmnpmatim Insurance,as requum by Sation
37W of the Lalrur Cade,for dao prlaoori ofthc work fw which thin l mrnit'is issued. (IAS-HA SYSTEM-I INC.4 OUILEfS OCG GROUP APN
MY WakcYn Compawtim Inuvarce cerricr and path Y number are: '
Carats PMiq Ni, GAS-EA.SYSTEMOVER4IEA)
CENTIF'ICATF,OF IMEMPI'ION MOM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
Thin uetion need bast be mmplew ifthe parrot is f««e hundred dolub-T$W) BUILDING DIVISION FEES
or Inc,) - - GREASETRAP PLANCHECK THE
leenifythet in fc,,eformarceoflhewmk mrwhich Nu,enot u issued,I shall SEWER-gANITARV-STORM EA.200 FT.
,Z, Faandianfla,an persomiain,Det��w sa to become wb*t to Ota Wmkas'Comment- ENERGY THE
C WATER IMAI'ER WNIN'OELECI'R
Z O Apqicam GRADING FEE
vY NOTICE TO APPLICANT.If,after making this Certifate of Exemption,you should WATER SYSTEM/IRFATNG
aL bei uhjcd m the Workers Compn.wlion Provisions of the Lab v C de,you mum - SOILS PEE
131 fonhwith comply with Ob osisi.or this permit ahul he deems revoked. WATERSERVICB
Z PAID
7z CONSTRUCTION
m.mLENDING AGENCY NF.W RIiSIDENTIALP1510. SQ,PT.
C.)r Thor hish dothmdert issed(Somim len ding egerey forth.perfo 'e of _ Date Recelq♦
U the work f«whicM1 Wu pvnut n issued ISR.309].Civ,C.)
O I" Lenders NTOTAL'
� N.Ienicls Mhbaa TOTAL: i
a„ Icertify than lww<Tad this.pplicarion and orate than the shove mousua im u BUILDING FFP.
ti harm.I egta m comply with ml city evil canry'urdinences and sham Incas rdoting to QTY, MECHANICAL PERMIT FEE
Wilding croswcliun.and hereby amh«iuregeaenwives urlhiscitym emerupan the SEISMIC FEE
above-mmtiooed
Property Tae inspectim purpose, PERMIT ISSUANCE(We)nice m ave,Indemnify end keep harmlessthe City of Cuprnino ag.ivu ELECTRIC FlE
IinMlitin,judgnrtn4 unb and cx,,mms which may in any Sony ecmuc against said City gLTER OR ADD TO MECH.
consegianceof the graruing of thla pexmu. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(II)I(U0y)CFM) I'
MECHANICAL FEE
SOURULATIONS, �b
AIR HANDLING UNIT(OVER IO.Otp CFM) CONSTRUCTION TAX
Sigua1XfApplicma Comran« Dmc EXHAUST HOOD IWMUCU HOUSING MITIGATION FEE
HAZARDOUS MA DISCLOSURE
Will tneepplicant m future buildingomWt store or baiforerrdwa maternal HEATING UNIT TO 100,00a)BTU)
u refinW by the Cu,smno Municij(al Code,Chanter 9.[2,and due Heroin end Surety
Code,Savoa2553Na)° HEATING UNIT OVER 100,00(l BTU) PAI D
❑Yes El No
VINUIIATION FAN(SINGLERESID) PAID
Will dte.ppliumi Or future Wilding aeupant use e,uipmrnr«devices which One Raeiq 0
t hamrdaui air conuminams u defmcd by the Bay Arta Air Qamity Man i'mvt BOILER-COMP CUP OR 100,000 BTU)
�DimrimR
DEC ! i ME
Ely. ❑Nn ILBOER-COMP(OVER IW.000 BTU)
AIR CONDITIONER '1 s
Iheve ctrl de htvarJtms twmdaln tnryirtnrntn under Chatter b.lS MtM1c Cali- - ISSUANCE DA E
fmnu Lend,&Smmy Cole.Sections 3501.25533 and 255}1,I ondentatd that if the NEW RESIDENTIAL MECH. SQ.FT.
W il,mg does d.mat bass a trn.nl.thm it is my repomiddliry m«airy the occupant
Min,"mromcnls which must W ial P^«to ivuarcc of a Ceri Bcem of Ok U,say.
OwrtameutMrrir ingcm,
Data TOTAL:
ISSUED BY: •e'er--'
OFFICE