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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING- ELECTRIC L
BUILDING: DIVISION APPLICA'T'ION/I%ERMIT PLUMBING- MECHANICAL
BUILDING 1'RGq E:Cr IDEN HIFICA'1'ION
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J 1492
BUILDING ADDRESS:
0545 06�Antw�,^,
SANITARY NO,
APPLICA' I' ION SURMIFI'AT. USE
OK'NIiR;S NAMIi; I IN{.�'
C71 2 1 R'We{ 1F� LOO: 47
NIC
COST ROI.4
A HCH II'ECI'/EN. I NEER: LICNO''
7tb CI qqy-rS-sem
CONINCT. PHONE
BUILDING PERMIT INTO
REMO EI.FCT PLUMB MECII
❑ EJ/ ❑ 6/
p�I_�PFFr�SCs X79 0� 2
❑ Consultant Fees Paid by Applicant (Initial)
Applicant
LICENSED CON'1'RACTOR:S DECLARATION
I hereby al firm Thal I am located node, mwi,jow of Chapter 9 (commenting
with Section 900) If Division 30 the Dust.... and Pnd1cw`lon, Code ;"it all burse is
to mll6rcc and eRccr- �
�T ��
QTY. ELECTRIC PERMIT I FETE
/
JOB DESCRIPTION
RESIDENTIAL
❑ShDWI. ❑KITCHEN HI'.MDDEI.
,[�
PERMIT ISSUANCIi J
r
APPLIANCES-RESIDEN'ITAI,
Llamw Cln Lie.N
Dam - Conuaanr
❑ADDITION ❑PLUMBING RF: -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIIECAI'ION
El INTERIOR CCHIMNEY KEPAIR
IMPROVEMENT' 0SWIMMINGPOOIS
ARCH( "IEC'S DECLARATION
I undcrcwnJ my plans shall he utcd a,,mhllc recmd.
PANEIS
UI"TU 200 AMPS
Llc,nwd l'rnfe,vinnal
2211-1000 AMPS
OWNER -BUILDER DIECLARA'TION
1 hemby affirm that I am etempl from The Contracho, License, law for the
folawiog....... (Sect ton 7031.5. Business and Profession, Code m Any city or unity
�I{ATII I2EMOOELIREPAIR CD17MOLI'I'ION
❑ G1fHF:R LL
A C- 14
OVER IIXO AMT'S
SIGNS ELECTRICAL
which require%a permit to conswCL alar, improve, demolish, or repair any dreclure
prinnmh,issuance. also requires the applicant for such permit file a signed statement
etaln Ip II n 1 on, fn e I I r'xl 1 (ennntero
Innnm c B 'ThS i n9(XX01 fU ' ianl 0th H n.sa dPr f -.' .Cif
cdc)I,
hes roc nI Thcrtl d til h u, f the rat pt Any 'almioa If
Section 90315 by any applicant for a lwr Ivmjats lire appllcouuo a tivi l penally of
SPECIAL 'TIN 'C. f
a
T[ '. IEHO 1.
U'
COMMCRCIAI: ,�NR.I% uP6 Kim
-
C NEW BLDG/ADDITION C DEMOLI'f1ON
CTC ANT El FOOT) SERVICI:
rot ntorc Than five hundred dollars ($50 0).
]I, ux owner nfmc pmpcny,nnny nnployu%•, with wages nx lhcirwdc connnnt
will do the work, and the fortune is not intended oroficred for sale(S, 1 v
and Pmfn,inm C de:'Ihe Cnrmilho'I License law dal% nn f
5 M 'G (11, E.I. R
'11-M. S HITS -FC(I ORES
IMPROVEMENT
❑OTIIISR
I!W RESIDENI'ME. ELIECT'R SV Irl'.
pmpany who build or Improves thcrcon. anti who duct such loon th on Ih
his awn employees, provided that such impmvemems are not adcd o d[orcd 1
sale. IL hnwever,ihch:mdingar impmvmttentiftaldwiducto urian.
SQ. FT. FLOOR AREA
S/SQ. PI'.
sv-
er.hnilder will have the burden oflo iag that he did not nail novella,
TOTAL: Z
t
"walxnluf
❑I,mownvT It the pngtmy. tin caolufively emmmin, with liven. c e+
consumer me pngeet (Sec. 70Ti. Business and mnfcs ion, GdC:) The o tor, Li-
wLaw cuts nor apply a) an owner or progeny who build or imprn%eS thea and
QTY. PLUMBING PERMIT' FEE
who color%, Int' inch pr,,jcvl, wilt n contractions) breased pursuant mo m, Contmtor.
License Law,
PERMIT ISSUANCE
❑ au,scrip. under Sue. . B& P C for this mason
AI fI HR - DRAIN & V I[Nrl'- WA(ER (BA)
VA LUA'1'[ON
_
Date
Owner
WORKER'S' COMPENSAIION DECLARATION
HACK PLOW PROTECT'. DEVICE
1 hereby anion under penalty of perjury one of The following declarations:
I C] I havcand will maintains Ccnific:nc of Cnnscnt nndGinwre for Workce,Compen-
DRAINS- I'll ROOK AREA. COND.
STORIES
TYPE CONSTRUCIO'.
.cation, as provided for by Section 3900 of the Inbar Code, kit the pettan ianw of tilt
work for which This permit is issued.
FIXTURES - PER TRAP
GAS - EA. SYSTEM- I I NC. 4 OUT Jf I'S
1 have and will main II Workc,, Compdnsxlnn Insurance as cuyuireJ by Section
1910 of the Labor Code, for performance of the work for which(his permit is issued.
OCC. GROUT'
APN
GAS -ISA SY59'IiMs)VLR4(IiA)
My Worker's CouTionsation Insurance carrier and Policy nu1mbeT me
Comer: - -' dicy Nn.: Fy.y�-ate
NATE
GRPASI%INDUS' TRI. WASTE INTERCEPPOR
CEtTI (IF IiX :M ON FROM WORKERS
COMPENSATION INSURANCE
BUILDING DIVISION RSILS
GREASE'I RAI' '
I'IANCIIECK 19iE
fl'hu.edion nccdnol be complc.cd i t thepoli% I, I, enc fondrtl doll.. IS I WI
of
Iconily maTin.Lc perlornmors"lryc,vork
Necom whichmit peeno issued, lshelf
nut employ any pcnnn in any rumors" as m h<nmc sublet. In the Worker' Cam�wry
SIiWER- SANrD\RV- Slx)RM EA. 200 FI'.
IENIiRGV ITE
WATER TEXT 17R WNENITIELLCTR
GRADING Plili
cation laws of Codinnia. Date
Applicant
NOTICE TO APPLICANT: IL after making This Ccnificam of E,anption. You should
hccmnc .bjc,I to the WorkcLs Coon,nsmion pmvixianl of the IaMm Code, you meq
forthwith comply with such provisions or this perant died be deenmd rooked.
WATER SYSTEN1/TREATING
SOII S FEE
WATER SERVICE
CONS I isC',IONolu LENDINGAGENCY
IMreby affirm that There, is aconswtion lording agency for the perlimnsncc of
work for wjo,hoi, permit is Posit(Sec. 1099, Civ. C.)
PAID
Uu Receipt
NLW RIiSID1EN'TInL I'LM1iH, SQ, FC
TOTAL
'ISrrAI.:
I.cater', Name
Dumbats Addrus,
p
BUIhDIN r it
cer.ity that I Lave need misapplication and state than The aMwe infonnntion is
correct. l agree to comply with all city and county ordinance, and state lawerelaimg m
Emitting en..tow6on. and hereby amhnrow opmfemlool,ofmi, city to road,upon the
a drug-nwnlinned properly l in Inspdt'wn pnrp^fes
(We) agree m are. indemnity and keep hannlcss the Clout Cupertino againat
Iiuhiliticajudgmcns. costs and capcwe, which may many wayaccmc,9mrN-1d City
QTY. MECIIANICAI. PERMIT PF;E
C ;1;
ELECTRIC FIT - O
I'IiRMI'I' ISSUANCE
ALTER OR At)]) TO MECH, t
pl. ti1111NG 'I:
r '
in wequence of .he gram'o, of,hk permit.
APPLICANTUNDIiRSTANOS AND WILT. COMPLY WE I'IT ALL NON -POINT
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE Y,:30
SOURCE REGULATIONS.
AIR HANDLING UNIT I'(OVER 111.000 CFM)
CONS' I'RUCI'ION TAX
S,maoumofApplicunt/Con"I'llor ION
EXHAUST HOOD(W0)UCO
HOUSING MITIGATION FETE
IIA➢ARDOUS MATERIALS DISCLOSURE
W01 the uppliceoto, finure building oetupantmmd or handle hmallon, mmadal
as defined by The Cupcnino Mallicipal Cede Chapter 9.12, and the Htd.h :rid Salcty
Cade, Section 25532019
/7
HEATING UNIT IT 0110.00 BTU) I F�
[TEXT ING UNIT (OVER 100,00 BTU)
_
IAI'ION CAN (SINGLE REFS I Of
❑VcsVENTI
PAID Ilam Rac,ipal
Will the applicant ,, more beiWing oc,upaoa use equipment or devices which I
omit hu'mnluu. air comic inan1, a, do1'med by Ile Tiny Arca At Quality Managuareat
BOILER -COMP (3EPOR 110.0011'N)
TOTAL:
HOILER- COMP (OVER 100.000 111
Disuic"
❑ Vcs [fiNn
erial, rrquorname, der Copier 695of 'be Cali-
I have cladthchavaahownsmun
lismiu Ihalt, & Slaty Coda Section, 25505, 25511 and 25,534. I unduaanW that if the
AIR CfINDi'1'lI1NiHt
ISSUANCE. DA'Pli
G
NEW RESIDENTIAL MIKE, SQ�F1l
building does not currently have Oanant. that it is my muptmsibility to notify.heaaeupaot
—1 [�—
nftil,aqui .coax which meq %ren rmiourrice oft Cenihcmcn lkcu mey�
,�)/��-y/Jn Tr(�
ISSUISU ItY: " " ` ' ` r v
Owner or uw omnd agent Pale'Int
OFFICE