B 3853 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL. PERMIT NO/1j
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICALQ Q [ �J
BUILDING PROJECT IDENTIFII 3 o J J ION
BUILDING ADDRESSJ SANITARY NO. APPLICATION SUBMITTAL DAT
WNEe:S NAME p PHONE; P CONTRACTORS NAME LIC NO:
CONTROL
f OD -0.9,(I/L!7/ [fA SIC
RCHITFCT/ENGINEER: LIC NO: ADDRESS:
9,L-Re La L'r a/� ,5�+•�f.►C/ar+ �� ❑
CONTACT. PHONE: 0,11,V RMITINTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ool ELECT PLUMB MECH
2,10 ❑ ❑ ❑
LICENSED CONI'RACFOR;S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy alnrrtt mal I.rn B[enaed padin provishn....fChapter 9(=antmpnfing JOB DESCRIPTION
MWZ with Sxx,mn700t0ofD.vislnn 3ofihc Bminew ndvrnleaai„nx Code.mdmy liver.L RESIDENTIAL
BI O p PERMIT ISSUANCE
CSF n full force and eRcn ; ������ ❑SFDWL ❑KITCHEN REMODEL
aUU License Class- - Lick APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
ZZ w Uate Chose P 4§ cele L�A.G'
ANCHITECTS DECLARATION [I MULTI-UNIT Dut)Z 1 understand my plans shall he used as public records PANELS MODIFICATION
OLM UP TO 200 AMPS ❑INTIiR10R El CHIMNEY REPAIR
F:?FW Licensed Prfnsiomd 201-1000AMPS IMPROVEMENT ��q.WIMMING POOLS
C W 2 J OWNERBUILDERDECLARATION OVER Ig1UAMY5 ❑BATH REMODEI/REPAIR DEMOLrr10N
of C 1 hereby off...i at mI ant cxnnpl from the Couthetre,License Law for Clic
1131 OF following reasons(Section 7031.5.Buxinexs and Professions Code Any citynrcoumy SIGNS ELECTRICAL ❑OTHER
LL
Out) which rtyuires a petm:l la fonswct.nlcr,imPmax,demolish,ar repair any strerum // 1
prinnnitx issutmac,alsn myuirestM npplicanl for ouch pcmtiuo flc asigneJ smmmcm SPECIAl.CIRCUITIMISC.
fly that he is licensed putsuad to the provision of the Contractors License Law(Chapter 9
lel 0 (commencing with Salton 7IXp)of Division]of the Business and Pmfessinns CodO or TEMP.METER OR POLE INST. COMMERCIAL
L Xe C that he in cnempi therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
In Section 7031.5 by any applicant hire noraf subjecrs theapplicant at a civil penalty of POWER DEVIC17 ❑TIiNANT C1 FOOD SERVICE
n more than five hundred dollars(S5IX). IMPROVEMENT
t=QFI1,as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC []OTHER
F. will it,,the work.and lhcslrcmrms nut Intended pr oBered basals Nice.7094.latrine,
L3 m and Prefcsaions Core:'I he Con meats,Lift en.m law docs nal apply to ret owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
bin own employees,provided that such improvements ort not intended or oRared for NEW RESIDENTIAL ELECTS SQ FT.
sale.H.however.i1whuildingor improvement is sold withinone year fnnmplction,the SQ.FT.FLOOR AREA SISQ.PT.
ner-huilder will have the burden of p oving that he did not Wild or improve for pur.
pose al'stile.).
n 1,as owner of the p,,,,.y,am exclusively commena,wall Incensed oruse, er AL:
instruct the pntjest(Sec.7044.Business and Professions Cade:)The Contractor's Li
-
nssLawdoesnolapplytoanownerofpro,cry who builds or improves thereon,and QTY, PLUMB ING PERM I'1' FEE
whoer bra, orweb pr,,je[a with u rrmmotana(x)licensed pursuant la the Comment,I
License law. PERMIT ISSUANCE
1 am exempt under Site .B&P C for this mama
ALTER-DRAIN&VENT-WATER(EA) VALUATION
D
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE j1 -kk IJ
IM1ertby affirm under rally of ofCon enol lhefollowing
uefor declithatWorkers Co:
51
have and will forty netion 37M of the duo Code.far the Performance
Compero DRAINS-FLUOR.ROOT'.ARBA,COND. STO ES 'TYPE CONSTRUCTION
as provided for by Section J7W of the labor,CWe,for the perfomtance of the
Xw
for which this permit is issued FIXTURES-PER TRAP
1 hove and will maintain Worker's Cama of fthe w akfor chi rte respired by Section
3]U(l of theUWr Code.lin the perfnrmwce of rhe work far which this pemtit is issue]. GAS-EA.SYS'FIiM-1 INCA OUTLETS OCC.GROUP APN
My Wmk1I Com liogqland Policy number ore:
Carrier:lYL h/lla7rtf'Policy Na: GAS-EA.SYSTEWOVER 4IEA)
CERIIFICAFE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(T his section need not be completed if the permit is for one hundred dollars(EIOft ORIASETRAP
nrinsxJ PLANCHECK FT,i?
I certify thm in die nerfunnanceof the work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become subje[s m the Workers'Compen- ENERGY FEE 3 / 0
OZ union Laws of California,Date WAFER HEATER WIVENT/ELECTR GRADING NE
Z Q Applicant
NOTICE PO APPLICANT;If,after making this Cemihcate of Exemption.you should WATER SYSTEMfTREATING
F; Iwcomc.wbject at be W..kcr's Compensation previsions of the[.shot Code,you mush SOILS FEE 0
forthwith comply with web provisions or this peon h.11W deemed revoked WAI ER SERVICE
a �
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ,FT, PAID
UO I herebyafirm that thahere' en
is u commotion lending agency lm
for the performance(if
me HeeciplM
U. r- the work for which this permit is issaed(Sec.3097.Cie.C.) TOTAL:
C) U Lender's Name
l.enoer's Address TOTA1,; t
6. I fenify that 1 have read this application and state that the above information is BU DIN FEE
mF-m fn correct.l agree to comply with all city and county ordinances and stale laws retaingm QTY. MECHANICAL PI7RMIT FEE
U building constnmtion.;md Wmby andthi......esenntivesafdo,city Incineration the SEISM FEE
a1mvcmentioncd property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify wd keep harmlexs the City of C.,nin.against ELE.TRIC F[B
iabilities,judgments,esus and expenses which may in any wayaccrue againslsaid City ALT ER OR ADD TO MECH,
P MBING Bili
in wCANTe of the RSTA g of this permit.
SOURCE
REGULATIONS AND WILL COMPLY WITH ALL NON-MINT q1µHANDLING UNI T(TO In,(Np CPM) M HANICALFTE
SOURCE REGUI-ATIONS.
\ a. � �`//� AIR HANDLING UNI'I'(OVER IO,gy)CFM) CONSRUCTION TAX
Signature o ApplicunVContrachm Dater EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
IIAZARDOUS MATERIALS DISCLOSURE
Will the spplicamor furore Emitting nceapanlsavcor handle aromatic,material HEAT INC,UNIT TRI I(Nl,1g101{'IU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Sactian 25532(.)'! HEATING UNIT(OVER 1 WIX. q BTU)
❑Yes [Q No PAID
VENTILATION FAN(SINGLE RESID) Date ReceiptM
Will the.,,Ii[ant ar future Wilding occupanl use cyuipmetn or devices which BOiI IiR_COMP(311P OR IIXI,fXNI BTU)
,ml haaafdmus air commninan,ax defied by the Bay Area Air Quality Management )Tiff,;
.nWctT � BOILER-COMP(OVER 100,000 BTU)
❑Yea E/N.
I have read the hacerdm,reactors myuitemenls under Chapter 6.95 of the Celi AIR CONDIT TONER ISSUANC/Er DATE
!aria Health&Safety Code.Sections 8505,25533 and 255]4.1 understand ural if the NEW RESIDE(TIAL MECH. SQ.pp. �7 (iso
building does not currently have a nt
lmta .thin it is my responsibility to muilythc occupant !, E' I
of the mq�mna whiab nmsl W nrel prior m issmmcc of.Ccnihcatc nt Occvpanc
le I
owncr or aumarucd ager Uat2 TOTAL: ISSUEU BY:
OFFICE
_`1 P
4
ADDITIONAL PERMIT FEES I93- 1
BUILDING PROJECT I DENTI FICATION VALUATION
BUIIOING
PDOFE55 }\
V
GwMER s /J FEE SUMMARY
/�r/T�
2 � ' ✓^ONE
CONTRACTtTP 5
/J BUILDING
ME (b
uc,NO PLAN CHECK
CONTRACTORS FEE
ADOREss
RHONE SEISMIC FEE
_ QTY ELECTRIC PERMIT FE
UTLETS-SWITCHES-RECEP ELECTRIC 3
LIGHTING FIXTURES PLUMBING
APPLIANCES-RESIDENTIAL
PANELS MECHANICAL
QJ
IGNS TOTAL oD
SIGNS TRANS.
SPECIAL CIRCUIT PERMIT VALIDATION
EMP.METER OR POLE INS.
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Zo TOTAL
I = T ISSRANCE DATE
LU > QTY, PLUMBING PERMIT FEE e�Dc. ELECT. Pw. MECH.
CL O ❑ ❑ ❑ ❑
CL Z ALTER DRAIN&VENT-WATER(EA.)
U0 BACK FLOW PROTECT.DEVICE
O W DRAINS-FLOOR.ROOF,AREA,COND.
PER
a FIXTURES� AP �/Z GAS-EA.SV STEMSTEM-11NC.40UTLETS
U GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B. Y ��
_ LAWN SPRINKLERS-OVER 5MA.) //
/G �
SEWER-SANITARY-STORM EA.200III
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TOIAL
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
i
AIR HANDLING UNIT(T0 10p00 GF.M.1
AIR HANDLING UNIT OVER 10MC.F.M.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN (SINGLE)
BOILER COMP(3 H.P.Dr 100,000 B.T.U.)
BOILER COMP 1.—10000-Rnn SEE FEE Sot.
TOTAL