29137 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMR NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL I 29137
CT DENTIFICATION
BUILDING ADDRESS: BUILDING PROJESANITARY NO. APPLICATION SUBMITTAL DAH
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
NIC - /k CONTROL♦
RCHRECTIENGINEER: LIC NO: ADDRESS: El
VO
CONTACT: - PHONE BUILDING PERMIT INFO
n ❑ Consultant Fees Paid by Applicant(Initial) Iy UMB , M�ECII
LICFNSED CONTRACTOR'S DIC ]ON QT-Y ELECTRIC PERMIT FEE I�fAa(a JOB DESCRIPTION 1J�y��
I Ieneby arum Inv 1 ant Iken,ea alldv pavmiam air L 9(awmlmnring
°az ,„mss,;a„npo)nrrh.i.amlJnrll<Bu=i�..Iw Plaresum.cnde,,lle mrlian.�i.
F
rRMITISSUAN3 RESIDENTIAL
'W= m ❑SFDWL ❑ -
KITCHEN RG0DF1UULicmCleo lic.x
N<L Dam ' Can." _ APPLIANCES-RESIDENTIAL ❑ADDRION [I PLUMBING RE-PIPE
I- ARCHTDCi-S DECLARATION PANELS IULTI-UNR El STRUCTURAL
M�Z I uMctwrst my slam shill be nasi as public«cords MODIFICATION
UP TO 20h AMPS ❑INTERIOR 11 CHIMNEY REPAIR
F E-'u] Lic sM Pmf.ionvl 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION OVI7R laa)AMPS BATH REMODEIJREPAIR ❑DEMOLITION
6 1 herchy offrm,hest 1 em eamnpt from the Com ierl-s Liacme Low for the
xd
f+l LLC1 U following mann.(Section 7031 S.BmI'ess nosh Profasipn Cole:Any city m county SIGNS ELECTRICAL [I OTHER
O�a which ruaire a pmrmit Int enmi et,.her,improve,demolish,cenepior any umewm _
vlmJ Frimmiu icsuunm,nitro neyuirma the oppliwnl RK such pemtino file n.igled,Wmmenl- SPECIALICIRCUITMISC.
2( that he is Hemmed In.to the pov.M Oe Contractor's license L&W C Wig
W apo (mntmaeing with Section 7000)of Di som3ofdoe Ba,inus raid Pmfessimu Coale)., TEAL P.MEfER ORPOLEINST COMMERCIAL
apx�e a Nal he is cocoons bemfmm ei me lu es fv the allegsJ eivanar n:My viowiun of ❑NEW BLDCJADDiTON ❑DFbfOLfDON
W�H Scclkn]0315 by any applicau f«aresnail wbjcaslte epplkun toacitil perWlyof POWER DEVICES OTFl.'ANT asy if r.�F(IOD SERVICE.
y est more Nan live hundred dollar,(31100).
❑ 1.a.owraooflhe pryeny,or myemploym with wagesm hair sale compensation. SWIMMING POOL ELECTRIC' IMPROVEMENT
y Ildolhework.atdderrmcturtisiwlimendaimoRcrtdfaratleXce.' ,Business ❑OTHeOl.IJ�.r�V
413 m d Profession,Cde:The Contrsctur'a Liceme low doer nm airily to in owner of OUTLFTS-SWITCII ES-FlXTURIS 1 ��� •''`' �'�y�q�
IaoWrr who
hu;ld,air irafmi Thereon,W who des such work hi rrie f or Ihmug
oideal h Gil Y i w ...
his own eani Pe Und arch imFmvcrlenls are no intended air olfcrnl far NEW RESIDENTIAL ELECfR SQ FT.
sede.If,however,Be bothling or idifrovemenl ix.m10 within me year ofe mpletiun,dieSQ IT.Iq.WRI REAI UUU VSQ FT.
wrerta ilder will had m im
ve dm burden of rasing lhel he did tut Eailpose Pastor-
pose of.ownc - T Ill, 6iT`
L as owner of Ice Scc. ,am.'Jace and conmu0ng win:leaned antra ss'. to T
catemun Nc pojm(Ss.71144,Bu,imu and Hofes,ima Cade:)The Cmvrrtats V-
mlawdaa,nal apply omowrerof pmpenywN huiWs orinTovm thereon,and QTV PLUMBING PERMIT FEE
who contracts for such pmlma with a comrvtorts)lic sal pursuer,to the Conaxtds
fame law' PERMIT ISSUANCE
❑ Tom exceirt under Ser. ,H&P C for this mount
Ihm
If ALTER-DRAIN&VENT-WATERITA) VALUATION
� �-
WORKERS COMPENSATION DECLARMUON BACK FLOW PROTECT.DEVICE aas�
by uRrm uradcr pe'oa1tY of perjury o'x of Ile fdlow;,tg decbvxiam: .
�Qlhavc vd will mninuinaCmificem of Cmtscnnn self-instvc fm Wmkcf,Compero DRAINS-FLOOR,ROOF..AREA,GOND. STORIES TYPE CON.SIR UCION
aution,as provided for by Section 37W of the lobar Code,for the performance of be ,
work for which In.pe unit is i,ued. Fl%TURES-PER TRAP
D 1 base and will maintain Wol4dn Cmntsenuride Inwrari as retained by Section
37M of de lobar Code.forthe p:rfmnianc of the work fm which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Wanda Conacmuim lnwrmee rarrittiry'ImNer art: OCC GROUP APN
Canicr. Policy ulimy Na.:NCAS-EA.SYSTEMOVER 4(PAI
CERTIFICATE OF ID EMFIION FROM WORKERS' -
COMPENSATION INSURANCE GREASEIINDUSTRI,WASTE INTERCEPTOR BUILDING DIVISION FEES
1'llui rection need not he eosoplamd ifthe(aTnil is for one hundr]dollars(SIW) GREASE TRAP
mlas) PL.aNCHECK FEE
I,any Isar th Ile srrfmmv're of s t antic for which this the W.vsCo I Doll
Zat
mlcmPlny any Forum in any munncrmcc ur larumu subjet et lAm Wnrkcd Comi ,SEWER-SANITARY-STORM IiA.HIo ff.
Z aerimi Iowa.(California.Date 1 m ENERGY FEE
O AMUcanl WATER HEATER W/VFM/FIECIR GRADING FEE
y NOTICE TO APPLICANT If,door mulling Nia Ceniftcalc of E,o,ovion,you should WATER SYSTEM?REATING
I•" become wbjm to the Workd,Comscnwrim povi,;ms of the Iabta Code,you Ilan SOBS FEE
{�kl , fonhwin eamply withoucro
h pvisions or th;,penal shall he tkemai revolo,1 WATER SERVICE
Q � ,
7Z CONSTRUCIIONLPN'IIINGAGENCY NEW RESIDPNIIAL PLM). SQ,FT. PAID
L)0 Ihenehy alEnn Nol Ncne hnnmstnlnbm lending egrnry fnnhc Fcrfnmlunceof Dam ReceiFlx
O
F the work far which Bas permit is isW3W7
su (See. .Civ.C)
L) IstMed,Nurc TOTAL:
lender's Addre.0
F0. 1 ecrh y that I h oe'cad Nh ti'licatien and slue War Ne above holf.i n h BUILDING FEE
V) mom.l game to comply with ell city end coonty ordinance,and vara laws relating m QTY. MECHANICAL PERMIT FEE
L) Z buildingL stmctionwdk ioy asthnrioenep.ahilwe,of Nis city to court upon that SEISMIC FEE
` above-mrnliored l.ropertY fu imFceliw purycvu PERMRISSUANCE
(We)egret to oast indemnify anal kaer harmle.n IbC Cay of Cory--nimi ngaina ELECTRIC FEE
Ii,b;Iwea,iadgmrnrc stns gnd exren whim may in,ny war aerate ngaimt,nmchy
m amsequenee rf Ne arnMi^g of Thu pemdL ALTER OR ADD TO MECII' PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIM HANDLING UNIT(TO 10,M)CFM)SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER If."CFM) CONSTRUCTION TAX
Signature M APplicaunVCwVvtm Date EXHAUST HOOD(WMUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Ile epplicemor future building acurad,loeor handle hwardeuemercnnl HEATING UNI'I'OT)IW.M)BTU)
a deB'ed by use Cupenino Municipal Code.Chaps 9.12 and Be Ilcalth sod Safety
Coda Section 2553ZUU? HEATING UNIT(OVER I W JpO BTU)
❑Yes, . ❑No
VENTILATION PAN(SINGLE RFSID) PAID
WIl IM gppicunt or fvmre building.c.rmt use equirnt<m or Devices which Dam Rewipl R
emit hararrfou.air«mmmimnu as dcfrcd by the Bay Area Au Qdnity Mawgcmcnl BOILER-COMPQIPOR W,WOBTU)
DigriaT TOTA
Q Yes ❑Nn BOILER-COMP(OVER 10(),000 PTU)
I base real the hazaaAau materials nequiremenu uotler C-bapla 695 a Ile Ceh- AIR CONDITIONER
ISSUANCE DA
fnmia 11cilth&Safety Gslc Seedmu 35115.255]1 ural 255]4. ottrmanl tiw dNc NEW R[SIDF.YI'IAL MECII. SQ.FT.
btublagdne rat cmi base a Unearth that a is my responsibility to atify the«cvpw
oflfe negainanni whim mum be mel Friar to issuance ofa Cerific,le (lecvNncy.
(nwmmamlmnrN agml Date A . ISSUED BY:
OFFICE