29147 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION PLICATIONIPERMIT •PLUMBING-MECIANI"I. 29147
BUILDING PROJECT IDENTIFICATION
BUIIDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DA
OWNERS NAME PHONE CONfRACi'OR'S NAME LIC NO:
NIC CONTROL#
4RCHITECT/ENGINEFR: LIC NO: ADDRESS: LD -717 OL-ks
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Feed;Paid by.Appllcant(Initial) BLDG F E PLUMB MECH
LICENSED CONIRACfOR'S DECLARATION
I trinity effvm duff 1 am licensed under pmstriom of CM1nper 9(comnemin QTY ELECTRIC PERMIT FEE
g JOB DESCRIPTION
��Z 'N Sectiun]IXXI)at lHviri�m3af de Husinesn and Prufecvion•CnJe.^M mY lianuu •
ADO v� PERMIT ISSUANCE 0SFDW RESIDENTIAL
F� nfunse WeBm. ❑SFIJWL [I KITCHEN REh10DE1,
line Cl.CLC., APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE.
�Za Dela CamrEC
O ARsBall h CTS Df:C1ARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL'
Z Z 1 unhratnd mY Pima Jull be usN u I MODIFICATION
0z r UP TO}-0o Ah1P5 ❑INTERIOR ❑CHIMNEY REPAIR
F� _1 Licensed Professional 201-IMAMPS - IMPROVF'.MFN1'
OWNER-BUILDER DECLARATION
dW¢ I Inertly affirm the,1 un exempt f.the Con.at'i,Lt..Law for Ne OVER 1000 AMPS' BATH REMODEUREPAIR DEh10LR10N
pe 3 L V fallowing. (Sn'tion TRI 1,BLelnca and P ofn,nons CNG:Any city or county SIGNS ELECTRICAL DOTHER
4411 u.{'_ which nef,irn a permit to avtstruct,cher,improve,demolish,or repnir any nmetum
0 prior to its LuuvKe,dso«quirts the yrylicnm f«such Permit to file a sig«d umcerent SPECIAL CIRCUIT/MISC.
Ic,H� that he is licensed pursuant to 0x:provisianr of the Corinni's License Law(Chastener 9
(.ommcncing wah Section](XIO)of Division 3 oflhc BusitcssLN Pofcsoon.Gdc)or TEMP.METER OR POLE INST.
m a e K thu he la esemq Ihrefmm md'de,haus for the alleges exempwm.Any s'ioluien M
,Seclinn]0313 by any applirentf«•peaadl wbjecu 0te epplkanl loecivil pcmltyM POWER DEVICES FIN BLDG/ADDITION ❑DEMOLITION
co Tlla'ANT FOOD SERVICE'
FZY n
m ems,than fere s, ere d.11an y($500)
empi IMPROVES!
6 p l,naw.te,wo o,Ne leopeny.«my cmpbycm wind wa6c• nasi, raleco LBurntim, SWIMMING POOL EIJ;CIRIC
will Professions
CocV he C onfoseeNimmdd«.w dfm•ak(Sec.]Oaa,Bminms ❑OTHER
-� and erty who
Code:,The Canwcmr's License law Jan ml apply m if owner of OVILETS-SWITCHES-FIXTURES /A Is
aa^
his..a
whobuildsaimprovestsoccn,endwho Jan such reware:himself«Nmugh �—
huowoemployers, boilhod rmsncM1own,i, niwtae nm imerdcd«oBerd for NEW RFSIDFNfIALEIFCfR SQFT '
wale.If.M�wbvcr.these,Uineorimpnnemenl isaoldwiddnooe YearofmmMetinn,dr SQ.FT.Fl,OORARFA 55Q.Pr.
me.f s;aIder wiu h.ve IM tunic of Ensuing nal to ria ml bmld m imprnvc r«Aur-
,Seae
.
as ow r of cn Pmp,tY.ani sine exclusively contracting Cwithod I[cereed.rantramr.x i_ gal 16
7 J
' c trocsesm (Sec.otur Buxirc.as.nd Professions CNr:(Tore es therhiia I.i- 1/•� O
c lawdonrsi app jms with
a ennpoperry whoboildsrrientnova Canon.and QTY. PLUMBING PERMIT PEE
who Canlm[Lr for such pmjenx wiNtcunvacmrtsl licemcd Puntunt to Ne Conu.cmis JULLiters.law. N 16
❑Iamexcreppurder^. ,B&PCf«Nisrmmn PERMIT ISSUANCE: rh 1996
Own Ila¢ • • ALTER-DRAIN&VENT-WATER(G) - • ' Vt (f1a VALUATION
WORKER'S COMPENSATION DECLARATION 2 /y�If rrn/�g'O
b aBirtnLNcn HACK FLOW PROTECT.DEVICE _V Q ��
ima:
re y pcmllY of pcejwy o^e of de fnlW.vity dzlmat
❑ Ihorc and will nuimain.Cenifum ofC«aemmmlf-ecce fa WcvkQs Compcn- DRAINS-FLOOR ROOF,AREA,COND.
Wines,Is ryovid 1 far by Section 3900 of he Isbnr Code,f«dic r nfamwnce of the STORI> TYPE CONSfRUCUON
wort for which this pencil u inuril. MXTURES-PGRTRAP
❑ 1 have and will m.intain Worke ,,Compere Gym Insurance,Is rtgwml by Scctimt -
3100ofthe laMr Code,fer the pvGmmancs,nfthe wort for which this pemtit is i.uud. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Warter's Cous,cmaticn Insurance internist sod aPol"rums ate' IR'C'GROUP APN
Cinim- Policy No.: GAS-EA.SYSFEM-OVER.(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRE\SPANDUSTRLWASIL INTERCEPTOR
(ITIS section need ant N compMal if Ne Pcmdt is(mon,M1urdm'IJdlan(SIM) BUILDING DIVISION PEPS
«Ins.) GNIASETRAP - PLANCTIECKFEE O
1.,tiny Thu or 1.puforwna,f st workfnewhist Nor phenoliei 'C.IvhAl
n«employ any pertoo to any nmty sommavme wqm to Be Workear:Cn SEWER-SANITARY-STORFt FA.200 FT.
,Z, svim law of Cehtomia[)Mc mpcm. ENERGY FEE ^Z
z WATER HEATER WNFM/I;LElTR
O NOTICE
GRADING FEE'
U7) NOTNOTICETOAPPLICANT.If,doerrenting Thu Cons o of[Ulloor Coo ywshould WATER SYSTEM/fRPATING
a ce wajre to Its Wurtefs Compea•Ink lieravuions of the lobar Cnk,you mLu SOILS EEE
4 Q fonhwiN camPly with ouch PmvisMms«This Pcrtnn atilt tri dccmd rtvokel. WATER SERVICE
oz CONSTRUCTION UNDING AGENCY NEW RESIDENTIAL PI-MB, SQ.PT. s PAID
uC) I aebyeffirm then there is acunxlwcti(Xl lendingagercy larthe perf..e.f Due Rcaipg
IL �--� the wart for which Nis peroin is issixd(Sce.3097,Civ.C.)
OV Lender's Nva �. TOTAL:
Id Lender's Address tel:
yI certify bu I hose tried Nis a plintio.ud ave nal the efnve iof.cadon is BUILDING FEE
y conmr lagmmcomPlywith illeityaadcwmymditenccsaN clawxmlvingw QTY. MECHANICAL PERMIT FEE
UZ buiming e«istri and heorby6ulhorlm mprtumvivcsaflhis city mender oleo lbe SEISMIC HE
above-mentiosud PropcnY for inspection par Boors, .
(We)al I.save,inlemnify and keep hvmldss de City of Cupnum agaitw PERMIT ISSUANCE ELECTRIC PEE
Ii.hilitc,juJg�ncnt..cmu.nde,,.which may in any way accrueagainst said City ALTER OR ADD TO MECII.
N conuquence of Ns,granting of Nis pemtit. PLUMBING FEE Z
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR IIANGLING UNIT(f010J100 cESE MECHANICAL FEE 2
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,00)CIT) CONSTRUCTION TAX
Sigwlmc of ApPlicvlJCtmu.cmr - Due EXHAUST HOLD(WMUCO HOUSING MITIGATION FEB
I IALARDOUS MATERIALS DISCLOSURE
Will Use,alq[icea.«furore fielding occuWnt store or handle bvarothms material HEATING UNIT(R)10(for)(1 HTV)
Is alefnesi by Ne Cate nuro Mannicipal Cade.Chapter 9]3,and One Health and Safety
• CNo.Scrim 25534(.)7 HOSTING UNIT(OVER JOB."BTU)
�Yn ❑No VENTILATION PAN(SINGLE RFSID) PAID
} Will Ihri ti'licanl«furore building rccopant axe equipnem«dcvim which Date Rcccip
emit hiscardicamid,cmleminvnu as defircJ by Ne Bay Ater Air Quality Mvugane^I BOILER-COMP(3HP OR[00.000 B'Tit
A :
I
District? t
❑Ya ❑No BOILER-COMP(OVER I W.000 BTU)
J ,
I buss,mail roc he nudsus nmCdals AIR CONDITIONER
rt,2553enni d5 Chatter 0.95 of Cdi ISSUANCE DATE
Tomer,ch.Health& curreefifyncy
Code,Saliwv 25505,is ru,and 25511.1 tsdnsfud Nu if de NEW RESIDENTIAL MECH. SQ.FT.
huMelonNesrestcmhiehhave arec,pNuh ismy a.Cilirymmtifydecttimw
of the,rtqui¢mrnts which lm4tri mel prier to MuCrndicwc M(khvlicency,
6•vuameudsodaeJ.gem
BIB, • - ISSUED BY.
OFFICE
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