29146 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY T
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /1/1
BUILDING DIVISIO PPI,1 ION/P IL171T PLUMBING-M' ANIGI. ; L `4J YV�
eUIIDISG PROJECT IDENTIFICATION
BUILDING ADDRESSSANITARY NO. APPLICATION SUBMITTAL DAn
OWNER'S NAME; PHONE - CONTRACTORS NAME: NO:
N/C CONTROL#
„•ARCHITLCr/F14GINEER: LIC NO: ADDRESS: - ^�Of i
CONTACT. PHONE - BUILDING PERMIT INFO
❑ Consultant Fars Paid by Applicant(Initial) u>G PLUMB MECH
Ii1ECT
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE x— A
Z
1 hereby affirm Than N
1 em hce.,al ucr povkionsof Chapter 9(comrrcmeing JOB DESCRIPTION
WOwmSectiml]000)M'Divisivn5ofthc Busier,.and Rofcaaiom Cdc,ad myliccwelt NT
1-WO fou Portad
Peace eRst. PERMIT ISSUANCE RFS:IDIA]
�. �F =
�F.LZ>5 u..a. _ . Lic,# OSFDWL O KIT CHEN REMODEL'
NQ2 Date Contnctm APPLIANCES-RFSIUENITAL OADDrHON ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANIJS
IPI-DNR. ❑STRUCTURAL
Z0oal -
1 urhalad my plans shsl he urN as W blit mtdv
MODIFICATION '
C)r/�sE•, - rt UP TO 20)AMPS
Ltmlad Profm®
lel ❑IN7-ERIOR� ❑CHIMNEY REPAIR'
pQ� OWNER-BUILDER DECLARATION 201-I(100AMPS IMPROVEMENT'y 6 1 hereby affirm than 1 am exempt(taro the Contractor':License Law for the OVER IOWAMPS 0 BATH RENODEI/REPAIR 0 DEMOLITION
3 a U rdlnwiny rwsan.l5atim 7031.5,Buuness red Pmremions Cade:Any city or ewnty SIGNS EL0
ECTRICAL 0"; _
F O Pry which requite,a permit to cmmruct,alter,improve,dclrolodt,(r epir any 4Nclure �V l ^
m� priortoiu iauuec.also requites the applicant for such permino flea sigrcdsutementSPECIAL CIRCUITMISC..
��. than he i,limoved Pntuam to On,pmritian M Oe Cmuictors Liamn Lae.(Clover 9
�ap0 (a+nmertcing with Secacn]000)ofl),islm 3ofthe Buri.,and Proftudeav Codc)a COMM TRMP METER OR POLE INST. �Al-
li q o q hat he iv exemq Ihcrtfmsn ed 0w basis for cite alkged exemption.Any violation of ❑NEW BLD(JADD C ON If#10' DEMOLff10N
iLLfl LL• Sceuen]O313 by my applicant for.pe.it,.bj.dr apylram ma civil Penalty of 'POWER DEVICES 0El NEW BL El
LIT[ONSERVICE
Z} tla orae than fire hands!dallan(3500). IMPROVEMENT
O ❑I,a,owtterof the pmyuny.ur myemployer with wags va theirsolcailnpenwtitxt, SWIMMING POOLELLCT'R1C
will do the wok,ed the strvcnuc i�ms Intealcd m oRered f«sale(se,.]6w.Bu i. 0 OTHER
td Prothron s Code:Tte Conaxtert Liana Low drct.apply to no owner of OUTLETS-SWRCHES=FlX'RIRES
6';-' property who trout or imprvrw Berton,and wM dace wah work himalf or through
• his own employ.,quoin that ouch impmve,cata ire on,intended or MTemd for NEW RESIDENTIAL I:IECTR SQ FT.
tale If.huwe,er,do,building or imptovemcnt is mM within one Y..f completion.the ^ SQ,ITT FLUOR AREA V.W.FT
owra builder will hove tk burden of toning That he did rot build!or i.,.,e fa poo
Pow o[.ulc). �� (�'� l
- Lnowns dde pec.70 oroexclusively caltractitrg wd.)Thn Crnntrmat to IL L (,//tom{{ a.
rnnswct the pojca Sec.]044,Bluirea.ad Podtsiaty Code)The Comrvemre Li-
."in U.dot rot apply to an cvrcr or ro,rty'wT,out*e er itnp,va thrnvn.nro QTY. PLUMBING PERMIT FEE
wbo,aero..for such ptujeca withacoonctw(,)Emoted Puc u to the Confactda
Lecme Iatw. PERMIT ISSUANCE
Om l aeocrttpt under Sec. .B&P C fordo,tevkm
ALTER-DRAIN&VENT-WA - VALUATION
Dm
• under
trOM PPNSATION DLCLARNION' BACK FLOW PROTECT.DEVICE I I I �?w
hereby EonnunGa Certificate
of e perjury ore,of the fdWwng Workertium. b �.{!
❑Ihvve ad dllmoiby S, T ona 3 roofCanmtu to Cove.foeoCOT M'orkcrn Comprn- DRAINS-FLUOR,ROOP,AREA,CO STORIES TYPE CONSTRUCTION
,tion,v pmvidhi for by S,'tion 3]00 of da I:aMr Cdc,for the pcAuntwrcc of the
wuhfur which IbisTintonis orlote FIXTURES-PER TRAP
37 IlyreeL will ode.(r Wmkch Canpemee, Aforwhi h tcgwtdki Section
My Worker
Labor Code.for Ne Pvrce carver
arver T thework fnrwhichthispa11uia ueJ. GAS-FA.SYSTEM-1 INCA OVfLCIS OCC,GROUP AIN
My Wahcr'rC,mpenvtim lnmwtce carriaed PeNiry number are: "
Cankr. FWicY No.: GAS-FA.SYS7E1, 0VER4(G)
CERTIFlCATC OF EXEMPTION FROM WORKERS' GR WASTE COMPENSATION INSURANCE BUILDING DIVISION FEES
OLi,section tminot MComp)eted SUN Pend ufineve hurdscddallass(S I00)
or las.) GREASETRAP PLANCHECK FEE
Icn,to,Tat in the pM1rGtmmoce ekhewnrk furwhieh thinpermitki.uuNJ uwll a '
SEWER-SANITARY-STORM EA. FT
ern employ arvm pcin aLo mvuer w as to her". abject to the Waketx'conal ENERGY FEE
C) mumtiofw of GlifanieLoon
e
7�O Applicant - WATER HEATER WNENT/EL[CIR GRADING Fl:I; "
�? tA NOTICE TO APPLICANT:If.after making this Cer ifi,eon of Eacmpion,you sManW WATER SYSTIUUTREITING
became abjen to The WeAcrt Cvntpcnaetiw Ioovuinnr of the Isba Code.you mu,t SOILS FEE
fordwilh canply with such povisxm or du%permit hal he dccntd mvokd. - WATER SERVICE _
7 Z) i
5, CONSTRUCfIONLENDINGAGENCI' NEW RFSIUIllI'IAL PLMB. SQ.FT PAID
I, 0 Thereby vRnn Out these isacanwtnuvon leading vgenry for the perfanwanf Dote Racipx
{L 'de wok fa which thio permitui.csud(Sa.Ip)],Ci¢C.1
O v Lecky"Name TOTAL
W IAndert Ahbcss _
1 certify Wet I M1ure mad Thin aPplketiun ud swtc that IMC Bova inlnmtaim in 1WIf BUILDING FILE
h cacao legrte to comply with all city and aumy ad'uwet artd stare lnwtaWivgo QTY_ MECHANICAL PERMIT FEE
V ,Z building caaoccTion,xd hereby audurc �
ien rtvtroetive,ofthis city tocnter upon 0te SEISMIC FEE L
" abuvementiured jmlpcny for napecrim pu,aa,t
(We)agree to.wre,inricertify and kap harrelea,the City of Cutnairo against PERMIT LSSUANCE ELECTRIC FEE
Iitdoli t,judgtrctun,emu attd expenses which may in any way same natinu said City
in cora qucrce of the granting M this fcmiit. ALTER OR ADD TO MECH. PLUMBING PER
APPLICANT UNDERSTANDS AND WILL COMPLY WRHALL NON-POEM'
SOURCE REGULATIONS. AIR HANDLING UNIT(70 10.000)CFM) MECHANICAL FEE 2
AIR HANDLING UNIT(OVER IIIA GPM) CONSTRUCTION TAX
Sig"•"m of AppliosuContrecter Date EXHAUST DOOG(WMUCT) HOUSING MITIGATION FEE
HATARDOUS MATERIALS DISCLOSURE
WE the appllcunt aTorun,Trudding oc,a,m,oreor trundle day .,mancrlW HEATING ON IT TO IIp,gp BTU)
u deftreal by the Copatiw Manicipi Code.Chapin 9.12,ad The Hea1W ad Safety
Code.Salim 25532(01 HEATING UNIT(OVER HIOJg BTU)
❑Yt- ❑No
VENTILATION PAN(SINGLE RESID) PAID
Date R.ipt#
Will o,applicant of future building by the Bt use ea Air Q t m devices which
mit hvswau air mnnivnts a def ted by the Pay Area Air Qwlity Mvnagemem BOILER-COMP tJHP OR 100.(#p B'N) ^ ...a
'OTA V /
Uwtct2 I C]Y. -I No BOILER-COMP(OVER ift"BTU)
I have trod 0d leaurMm ttntenaln teyuirtmenta oda Chanter 6,95 ofthe Cali- AIR CONDITIONER - ISSUANCE DATE v
fawn Ha1th&Safety Code,Sabers 25305,25533 road!25534.1 uttdvsard then d the
building dna currently Invert I..that it in my rnibiwy to notify theoccupwt NEW RESIDENTIAL MECII. SQ.FT.
oI liver Tir,tvnL,which mn,t he net Prior tooi.eora Certifier,of Oceupancy.
Owner or rtmbarixd.gat net, URI ISSUED BY:
OFFICE