29933 _ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES=USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILULW)-ELECTRICAL PERMITNO.
BUILDING DIVISION , APPLICATION/PERNIITPLUMBING-MECIIANICAL 2 9 9 3 3
BUILDING PROJECT IDENTIFICATION
BU�NGAD jS: r2Os40 �� SANITARY NO. APPLICATION SUBMGL AL DATE
WSNAME: 1 , PHONE: CONTRACTOR'SN=f E: LIC NO:
C�Vw -4`INJLR G NIC CONTROL♦
RCHITECTENCINEFR: LIC NO: ADDRESS: ❑
CONTACT:- PHONE: BUILDING PERMIT INFO
1 ��� - . ❑ Coneulten[Fees Paid by Applicant(mita!) BLDG ELECT PLUMB MECH
.J ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE 1 hot affirm that 1 am Wenscdmillaer pmviamro of Chapter 9(amon"emg JOB DESCRIPTION
.0Z with Section
ce'7"oof Division 3ofthe Busimuad Posfewlem Coee.audmylic.is RESIDENTIAL
F�� in full forad effect. PERMIT ISSUANCE
QF VZ U License Clad Lie, ❑SiTi El KITCHEN REMODEL
V 6u Dam Cmtmuer APPLIANCIS-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
�' ARCHfTECI'S DECLARATION . ❑MULTI-UNIT• 11 STRUCTURAL
F 4 K l urtdcnond mY Phan.mull be uaeB Aare lecaJa� PANELS r y
Z O s- MODIFICATION
OZ-0 Oil TO NO AMP'
El INTERIOR ❑CHLSINEY REPAIR
j Licemul Plessimel ]01-IOIXIAMP IMPROVEMENT
< OWNER-BUILDER DECLARATION M
OVER I"APS El BATH REMODFUREPAIR DEMOLITION
C'�
6 I hereby affirm that 1 am e.aemp from the C,,care s's License law for the _
k306 U following mann.Section ion 7031.5.Busincv and Professions Code:An,city or county SIGNS HE PCIRICAL OTHER
YI t� which rearprome,a Permit to cononi at"impose,dcmolixh,on repair any atrucme,
prior to its iawen¢.vlsn quirestheWicvNfor.wch EHImit to rile a sigrx•J tor[coem SPECIAL CIRCUITIMISCwEP
.
6} slut he is lwenrnd pmlunl to the pmvisirms of the Contmnor's Ciccone law(Clopter9 '
hp0 (commew:ing wiN Senioo70101 of lTvinion3dtne Bunireu ad Pmfassim Cnde)u TEMP.METER OR POLE INS, COMMERCIAL:
a dw mpt he u exeIhemfmm ad the basis for the alEegd citiocion Any violation El NEW BLDG/ADDITION ❑DEMOLITION
Satim 70313 byany"icemf«a pemdt wbjecta Ne epplictimon.civil penalty of POWER DEVICES LLl�rn ❑TENANT ❑FOOD SERVICE
not 1,n shun rive hwvnd dollars y($5(X))m .
1- Q ❑LoBbe mrof Je poprny,«myemimewes with xo OTHER 11.1FNT
gu e<thnr sole cogenuim. SWIMMING I'MI.ELECI1tIC
11 do Rewade,ande The ontismt.LiecdmoEwdofou salespoly.711t-1,Bun,or 11 OTHER
ad Itofeuiom Code:The Cmvona'a L'ccnse law Jrca ra apply to w owner of OIfU.EI'S-SWITCHES-FIXTURES
hisco tY who builds po impovu 1 s,ho,end who don sah work himself or Oueugh ,11 A e�
Aix own empinym,pmvidd thvt...h impnrvemenu are no,immoJyd a,Bence for NEW RESIDENTIAL ELECT&
avle.If,bowevaiB h have
Ise eooimlrf pro,intiBar heiid norcymrof ,,owc im,0re -
SQ.FT.FLOORARFA� SrsQ,
prsa.f aR,L win love the harden of paving ihot he did not Wile or iinpruve for For. 'NAY
��
pose Msowne 'NA .199
❑ I,us, sof JIv Seac.7 y,am exclusively contracting with licensed on to
eomuuct Be,thpmjal(oa.7tHJ,Bueimv ad Rofeaims Code:)The Cmtron '.U. /a '
come Law Jori not apply m an owner ofpwcny who Amid.or imposes BxErst and QTY. PLUMBING PERMIT FEE
y�UrL
wlmemuncrs mrsohpmjens with aumuuml,)licenuri,onrmmthe Crmuacter'x - Urt1T7
L er.law. PERMIT ISSUANCE
❑ uderSy .B&PC orlhi rw
•fin �m Win ALTER-DRAIN&VENT-WATER THA) VALUATION
WORKER'S COMPENSATION DECLARATION I BACK FLOW PROTECT.DEVICE
I alEnn under penalty d'perjury me of tle following hclErvtiom.
Ed will maintain a CenilieatenfCm.arnuo wlf-inwm for Worker,Limperit, DRAINS-FLOOR,RMF,AREA,COND.
aatim,as poviJN for by Section 3700 M the labor Codt for the perfumaae of Ibe STORIES TYPE CONSfRUCDON
work for which this perinh is iuucd. MATURES-PER FRAP
Ej I have Ertl will maiooin W,rkeYa CompenutWn Imurvrrce,are restored by Sarum
37W of the LaNr Ede,for tM Neomwacnr the work for which mi Permit is rutted. GAS-FA.SYSTEM-I INC i OUTLETS
OCC.GROUP AI'N
MY 3Varkenwrim a Compelewmacarne act carnad PMiry numha em:
C
Carrico Policy Na: GAS-EA.SYSTEALOVER J(FA)
CERTIFICATE OF HXOMPT ON MOM WORKERS'
COMPENSATION LNSUIGMsCE GRLASFIINDUSTRL WASTE INTERCEPTOR
(This sinn red nm he completd ifllc pmnit it forme hudred rh II—(S 1D3) BUILDING DIVISION FFFS
m less.)' at GREASE TRAP PLANCHECK PEE
I certify that in the p+fnnwnce.fine w...loowiM1ich Nislermitixissud.IJlell SEWER-SANITARY-STORM EA 3p Pf.
ru employ arry Ivxan in any maroon ser Error sections,wbj B w Be Workai Comlrcn- ENERGY FEE
Oz .shoo lawa,fcriliomih.lore WATER HEATER WNEM7ELECTR
Z 0 Applicant GRADING FEE
y' NOTICE In APPLICANT:If,afro making this Cmiricue of Exempim.You abmLi WATER SYSU:METREATING
a ; becarc subject to ins,Wooten;Cmrpenvumn pow,ims of Ilse Labor Cdc,you must SOILS FEE
0 foMwith comply with ouch povisiauor this ps,rmit atWl he dcvlN levokd. MATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ EL. PAID
I hereby afrinn that then is oc,tuvuctinn krding agrncY fou lire prROreanccnf Due Receipt#
{L O the wort,for which this Tes t is cooed Elia.300,Civ.C.)
O Uu Leos.'No. - TOTAL:
4] fendcns Adlres TOTAL_
t1 I ceulfy that I love read Nu applicatirm ed slam that Jc shove infvlrreliUrr is BUILDING FEE
rn correct.I agree hr comply with all city and coollyordinances aW ome laws mining to (7n'. MECHANICAL PERMIT FEE
U z building—,i-.adeby heramhorve re'rsiveofttc
hia atYmenrupon I, SEISMTCFEE
r alrrvcmcminrst Pool lir irupedion Purpres. - PERMIT ISSUANCE
(We)agree Io rave.idemnify ed keep bmndeu Inc City of Cupcnin .,alms ELECTRIC IEE
habilities,judgmend,ern and apemu which meym any way accrue.gains!said City ALTER OR ADD TO MECH. PLUMBING FEE
emseyuerce of Ile sterling of Sis pccr il.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINI AIR HANDLING UNIT(TO 10,(00 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,(W LTT1) CONSTRUCITONTAX
Simone,!AMbirstso Cminctor Date EXHAUSTHMD(W/DUCry HOUSING MRIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the aMlicamremoumdlildingrecupvm xtme orbadle hvmdw;mameal HEALING USE r(TO ixoau BTU)
m defind by the Cupcnirm Municipal Code,Chapter 9.11,ad the Health and Safely
CWc Section] 33](sl't IIFATWO UNIT(OVER I W,WO BN)
E3 Y. MINE,
viwri Ai'[ON FAN(SINGLE RESIDE PAID
Will Ile applicant or fmoc building occeproo tui rgaiplrcnt or levies which Date Receipt e
®emil broom].air eumamirund ax lefrtd by the Bey Atha Air Quality Marr nnst BOILER-COMP BHP OR IM.M BTU) -
Gotri"?
TOTAL:
❑Tea F1 No - _ BOILER-COMP(OVER 100,000 BTU)
AIRCONDITIONER '
1 have real the IurmJoua macnils rryuueocmr ulda Unifier 6.9.1 d the Cali- ISSUANCE
Antic Ilcmhh&Sufey Ga1C,Sanrni 25A15,255JJ od 25534.I urrlcremd Jvu if Jc NEW RESIDENTIAL MECH. SQ.FT.
building Jou Inn cvnrnJY Haut•ICltlnl,mu h is my respmeibilily Io ngifY tic occvpont ,
n(Nc rryuimnenta wnien muN ere met pia to iauuvee ars cenif we,rek'c,IParry.
Owrerw authorized agent Due TOTAL: ISSUEDBY:
OFFICE