S 2576APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMI'I'PLUMBING-MECHANICAL
BUILDING -ELECTRICAL
BUILDING 1'ROJF.C'T IIIENPIF'ICATION
PERMITNO.
S 2576
BUILDING ADDRESS:
SANITARY No.
APPLICATION SUBMITTAL. DATE
o
S
� 'D
Z — 22 -y
OWNER Mli:I I` I' ryE: " FnU)NI'
\\
CI )NS NAME: LI NO:
NIC
CONTROL#
❑
ARCHITE41'/I7NGINEER: LIC NO:
)D
CONTACT. PHONE:BU[LDING
PERMIT INFO
❑ co sultan( Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MICH
�e�`���j
/ 1(7
E] ❑ ❑
LICENSED CON'RACTOR'S VCLARATION
I herchy atflrm that I am licensed ower prlmvia x tf Chapter 9 (umanancin
Inn
QTY
ELECTRIC PERM IT
FEE
JOB DESCRIPTION
I'L•NMIT ISSUANCE
with Section 7111gB oftlivision 3 nl'Ihc Buninees and i'mfessiens Cole, anA my I'menne v
'n full force and effect. S1
RESIDENTIAL:
❑SIUWL
APPLInNCES-R[SNF.hT1Al.
-icer mss V hie.#
hale Contractor
s�_ ARC ITECT'S DECLAR 1st
1 undenwnd Iny plana CAIT be n.ceA a. Public rec"Ns
ElPLUM IN RF -PIPE
❑ADDITION El PLUMBING RE -PIPE
❑ MULTI -UNIT ❑STRUC URAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMI,N'T OSWIMMING POOLS
PANELS
IJPTO200AMPS
Licensed l'ndcssional
]III-1(00AMI'S
OW'NIiR-BUILDER DECLARATION
1 herchy affirm that 1 am e¢mpt from the Collimators License law far the
following reason. (Section 703 1.3, Business and Pmfcasamn Care: Any city or county
ClBATIi REMOU'/REPAIR ❑DIiMOLITION
❑OTHER
OVER I(NIOAMI'S
SIGNS ELECTRICAL
which requires it permit to construct. slier, improve, demolish, or repair any sdaemre
SPECIAL Cl RCUIT/M ISC.
prior o hs Issuance, also require, thonpplicams for wall permit to file u signed statement
lbw lure htenxeJ pursuant m the prov l pions of the Cnmmcnm's License law (Chapter 9
(enmmenci ng with Section AXXq of Di vision 3 of the ]business and Par esxinnx CNo) or
That he is cxempd mhercfram and the basis for the alleged esemp,ion. Any violation of
TEMP. METER OR POLE INST..
'I' AL1
❑ NEW BLDNADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
POWER DEVICES
[I TENANT ❑ FOOD SERVICE
Bat ...,ban five hundred doll... (5500.
❑I, as owner of the properly, or my employees with wages as their sole compensation.
will do the work, and the smear Is nom emended orot'ered rnr sale (Sec. 71,14, Business
IMPROVEMENT
C3 OTHER
SWIMMING POOL ELECTRIC
mid Profession, Code: The Cn dranor'x License Law dues not apply to an owner of
la
OUTLETS - SW I'I'Cl PIS - FIXTURES
NEW RESIDEWIAL ELECTR SQ FT.
progeny who builds or imprnvea thereon, and who docs such work himself or Through
his awn employcea provided (bat ouch Improvereres are Bol intended or offered for
rale. IL however, she building orimpmvemcm ix sold wdhidone yearnfcnnmpleama,the
SQ. ET. FLOOR AREA
SISQ, f. -n
-builder will have the burden o(pmving that he did nos build ur improve farina.
puser
ce of sale.),
nsed coets
L us ancr of rhe pmpeny, am cxelmively con0aatimg with licemmmm
Flw
OT '
O
o..I... I the pu vo (Sec. 7(A4, Ilu.inma and Professions Code:)'G e Contractor', Li
law does not apply to an owner of properly who builds or improves thereon, and
QTV.
PLUMBING PERMIT
FEE
wn,e
ho cnnmues for such projects with a commends) licensed pursuant to he common..
PERMIT ISSUANCE
License law.
1 am exempt under Sec. . B & P C for this reason
Owner Date
ALTER -DRAIN & VENT - WATHR (EA)
VALUATION
BACK FLOW PROTECT'. DEVICE
WORKER'S COMPENSATION DECLARATION
I herchy affirm under penally of perjury octal the following dcclaaiminms:
❑ I have and will maintain a Cenifcnd ofConsennn aelf-insure for Workers Comped-
DRAINS- FLOOR, ROOF, ARBA. CORD.
TYI'li CONSTRUCTION
motion, az provided for by is mat 37110 of the W Mm CNet for the performance of the
work for which shin .it is issued.
_
FIXTURES -1'T:R TRAP
0
1 have and will .mono,, let cr n am,c, o a [in w rk I., hi as required it Section
1700 of IM1e mambo. Coda far lite perlbrnnnnw of the work for which this Dench m. issuN.
OCC.
U
APN
GAS -EA, SYS'I'I1M-I INCA OUTLETS
-
Carrier:rkmop naafi I� r,NeicYolicYmNo," r
2 1999
GAS-EA.SYS'I'EM-OVI3R 411iA) {
PER 2
�""�`r
CERTIFI( THOF TIRE IP1HONFROMW K RS'
COMPENSATION INSURANCE IYaFv7 4 \
ING DIVISION
FErS
GREgSP/INUUti TRL WASTE INTERCEPTOR
(This simian nceA no, he conmpineJ ifshe permit is funme JJollars (EI 1
or less.)
GREASE9'RAP
PLANCHECK FEE
SEWP.R-SANI'I'AkY-STOIIM IIA.2tlfl Ff.
1 ccrllfy Ihu(in she pal Elnnnnrut the worn far which dmi, pencil it ixnued. l shell
Jj�'( Worker.' Counp en-
Basemploylnry Depwn In any morder.n asm a, omy`.k her
�•/�"r�
MERGY FEE
WATER HEATER WNEN'IMLECIR
GRADING FEE
i
sodium laws of form. Date
Applicant ¢
NOTICE COM I AW: ,eller ma -n6 t is CeniO me of Exemption, yuu should
become subject m (he Worker's Compensation pravWoae of the L.Mn Cade, you most
WATER SYSTEMOREATING
SOILS FEE
tbrthwi fi almply with such previsions or This permit shall be Deemed revoked.
WATER SERVICE
NEW RESIDENTIAL PLMU. SQ, ET.
CONST'RUCT'ION LENDING AGENCY
I herchy affirm them Them is o c...ducdon lending agency for he Performance of
PAID
--Y
Receipt #
the work for which the, permit is icwN (See. 3(197, Civ. C.)
Lenders NameTOTAL:
TOTAL'
Lender. Address
BIJILDIN �R
I certify that 1 have mad chin applicalum and state that the above iatermmion is
correct. lugree to cammply with all eityand county ordinances and slate laws mla,ing to
building con.amctiun, and herchy unmhuliae reprexen(utive. of this ciD dm enter upon Ne
QTY,
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC FE
A /
v
aeoveancatinnnl pmpany for inspection purposes.
(We) agree m save, indemnify and ken, heNcs. ,he City of Cupcnino against
ALTER OR ADI) TO MECH.
PLUMBINGF I:
liabilisics,jndgmenn, costs ani upenrea which may in any wuyocerre.,instsaid City
In consequence ^find painting of this permit.
AIR HANDLING UNIT (TO 1I,000 CENT)
MECHANICAL PE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AT.I, NON -POINT
SOURCE " iU1.A'TIONS, '-'
AIR HANDLING UNIT (OVER I0,000 CFM)
CONSTRUCTION TAX
Signameof App ora Compactor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSINGMITIGATION FEE
HEATING UNIT (TO 100.(0X) B 1' Of
Will the applicant or Ed Takata, mlpleam.ssoreor handle h..akma .!t/,
is defined by the Cepenind Municipal Code, Chapter 9.12, and the He flih and Safety
Code, Sccdon 2553^_007s(/,'
HEATING UNIT OVER RiujXXI BIT)
VENTILATION FAN (SINGLE RESID)
E] Yes C(No
PAID
Dale Receipt #
Will the air m tm nr al, a building occupant use e. Air Q l or devices which
emit hueuNnus air conmmimm�r Its AeOned thy the Buy Arm Air Quality Management
BOILER -COMP (3HP OR LIIfIJXX) BTU)
T(YI'AI .
HOTLER- COM P(OVER IIXI j), IT] U)
Dinrim4- ,r.
El Yes D6-1
AIR CONDIT, TONER
I have mwl the haeardnusm0erlah, tr under Chapter 6.95of the Cali.
Poria Health & Scurry CNet 2E5in 25533 and 255Jity uddersmN that if amt
ISSUANCE DATE
NEW RESIDENT Al. MECH. SQ. IT.
eaten i
building Jcesnrn currently havca¢nam,,has it is my responsibility b. notify, the stupor
/� r y
of(heregnir which moat he mm pnonn Lssu mfu Cenifiea,e of p�u�n/pyq./
�+
I.S'SUED9Y:
TOTAL.
Owne'rn Ihodoed aTat hate t-
/ OFFICE
0
Z_z
0
[C -
LU
1 0
Z) z
00
LL
0 w
Y z
A
ADDITIONAL PERMIT FEES
BUILDING PROJECTIDENTeP(CATION
VALUATION
�D D a a
monlssO
-:n �/ N V�
ONNENS
ME
�.) 'Z
orvE L
FEE SUMMARY
mNSAcrons
uc NO % / V ,
BUILDING
PLAN CHECK
FEE
C r crops
RAess /'' ��{,Qp / Q
t (,.C/n� /jWNONE "'O`i
SEISMIC FEE S�
QTY. ECTR91RMIT FEE
UTLETS- SWITCHES -RECEP
FIXTURESPPLIANCES.
AELECTRICLIGHTING
RESIDENTIALPANELS
SIGNS
Lj
SIGNS TRANS.
SPECIAL CIRCUIT
'
EMP. METER OR POLE INS.
PERMO VAL OATION
IUANCE OATS
SS
MOTORS SEE FEE SCH.
SERVICE CHANGE
TOTAL
DTV. PLUMBING PERMIT FEE
SLOG
❑
ELECT.
❑
PLO,
❑
MEOH.
❑
ALTER -DRAIN & VENT -WATER (EA.) -
BACK FLOW PROTECT. DEVICE
` E,
\\J/C/
I
DRAINS -FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM - I INC.4 OUTLETS
GAS - EA. SYSTEM - OVER 4 (EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS - 1 INC 5 V.B.
LAWN SPRINKLERS - OVER 5(EA.)
SEWER -SANITARY -STORM EA.200ft/�
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOTAI
QTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT (TO 10JA0
AIR HANDLING UNIT (OVER 10=C.F.M)
EXHAUST HOOD (WITH DUCT)
HEATING UNIT (TO 100,000
HEATING UNIT (OVER 100,000
VENTILATION FAN (SINGLE)
BOILER - COW (3 H.P. of 100,000 B.T.U.)
BOILER -COMP 10w, 100,000 BTU) SEE FEE SCH.
TOTAL