29005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERNSIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29005
BUILDING PROJECT IDENTIFICATION
BUILDINGADIIRESS: SANITARY NO. APPLICATION SUDMIITAL DAT '
OW E 'NN PHONE ON'IRA RS NAM LIC NO:
\ ti\ NIC CONTROL
ARCHITE.CANCINEII : LIC NO: ADDRESS:
CONTACT. PHONE, BUILDING PERMIT INFO
5 ❑ Cotuni Cant Fees Paid by Applicant(Initial) BIY¢�LDG ELECT PLUMB MECH
1:1 El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hceby amrre that l am Ilansed mala I orskion,of Ciba m,9 feantrcoeing JOB DESCRIPTION
�Qy Z with Secum7p10)of Divisicm J oftk Ba.htna attd Profmions Code,and myluno,is t
FOO In fall forte sal c0' PENMI'f I55UANC1i
QUV lice 're" ZA10^atC<C� SFl)WI. [I KITCHEN REMODEL
Z ty Dye Conga. APPLIANCES-RFSIDEI.TIAL ❑ADDITION ❑PLUMBING RE PIPE
p„dOy ARCHITECTS DECLARATION PANELS ❑MULTI-UNH' ❑mucTuRAL
Z OI uMcnrud my pi n"I ba usd n public toads . MODIFICATION
O z— UP TO 200 AMPS
Fyl-.O Lexnsd Prufnsiveul [I INTERIOR [I CHIMNEY REPAIR
201-1000 AMPS IMPROVEMENT
�Y f met I a exempt L anDECLARATION ❑BATH REMODEURFPAIR ❑DEsIOLFFON
Yi�d . I hereby itlimt thea I am exempt Team the Contractors Livens Law for the OVER II1fM1AMP5
3 a v folbwin,Tamm.(Sxtim 90]1.5.Buviteu end 14ofcxsims Code:Any city nr runty SIGNS ELECTRICAL ,OTHER
[-=O which"many•Penn,to construct,d.n,impose,denwlish,or repair any mucrvrt It Sy. rf\` 1 (]. K Q(S C
prior to in issuance,do,re,mrn the applicam for such pcom"n fie asigted stmement SPECIALCIRCUITMISC.
>• thea le in licensed pwwant to the ra,iocro.fuse Convacldel.icense law(Chepta 9 -_�"\oV
�O (nnrmenoin,ruim Smith 7001))ofaskion 3oDbc Heist.y !Pe,fitedere Ceds)a TEMP.METER OR POLE INST. COMMERCIAL,
a y o y 1M he Is eacmPt thertfmm vW De been.for the alleged cxcmpian.Any vinic tion of ❑NEW BLDG/ADDffION ❑DEMOLITION
�Rfl 4• Seeum703IS by any appliemlfia aPtra it%objects the applicant too civil pnuBy of POWER DEVICES
F, y
not ratthan five hudred dullars($9)(o. (]TENANT ❑FOODSERVICE
es
�6 (]I.eaaeerofthe lvopcny.mmy.ngRoy¢swish wegn a511eirwlecamfsnsi0im. SWIMMING FOOL ELECTRIC IMPROVEMENT
�O will do thewads,ted the sari isnot intmdd aoffesed far sale(Sec.7061,Basi. ❑OTHER
ad
arta Profn.iom Coda:The CnriVUTor'e license law dtea nut apply to an away of OUTLETS-SWITCHES-FIXTURES
d 3.. Por nY who balda or improve themor,and who don sten wort himtelf or through
his awn entploYetc,Prosids i thea ouchimpovcmamt.art not mteNN or affmad fur NEW RISIDEN71GAL FIECTR SQ FT.
sole
If.hotsxvee,the bondinga mr,sty.menti.sokwithin otrt year of<otttpinim.the SQ.FT.FLOOR AREA T/SQ.ET.
outer builder will here the humin of proving Nit he did no.build or improve fa Par-
pos of sale.).
1,a ulster a Rite Sr .7 Y,em caclasivcly eau sir g with Banc C na,n,mton m TOTAL:
nn.trun tM pnr}ar ISa.70M1,Buritesr yd Pndnslarta Cak:J'Ihc Cmvx�tor's V-
amel�wJocstntalglymannwnaofptryrnywtxrbuilJaorimpovcthaarn,and QTY, PLUMBING PERMIT FEE
whomnfa ouch pojvars with.mtwxta(e)IimuM prmeat to the Catatoh
Lions La,law.
❑l am eaempt unkr Sec. ,B d P C fm Nie reason PERMIT ISSUANCE
Owner DataALTER-DRAIN&VENT-WATER LEA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE q�
• Ihereby eftimt tater petwlty ofperjury me of the foltoxm,d Iaraooa: w�)
❑have and sill maintain aCmif.of Cnn.ennosl!-insure for Woha.Cumpcn- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION
syiao,an ptirsided for by Sc nim 3700 of the labor Code,f«the penfmvna tof the
k for which thio permit is issue, FIXTURES-PER TRAP
tr/y�1 have rank will maintain Worlv'.Comp.Inmm ..tegiind by Section
.(]fall ofthe laMf CMc,far tlr perftmwce urthe wart fa uldeh thi.permit it uslN. GAS-EA.SYSTEM-I INCE OCC GROUP AYN
My Warn �otppntmsyw-NuurArrcx come,Poli policy numhcr are:
Cyder, J n CATS OF
PION No.: OAS-EA.SYSTEM-0V I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COAIPENSATIONINSURANCE GREASNINDUSTRL WAST _ R
(Thu scetion vl at be compind if Ne permit Or for One,hundred dollar(hand) BUILDING DIVISION FEES
GRIr.ASETRAP� �� -
PIANCHECK FEE
Loy mytheam in anv m atteso a,to
to thepermit( e,%'Cmpem- SEWER- 'ANITAR ORM EA.2W FT.
era employ any perann in any manrcr w e er Msatte subject w the Wtxkrn'Comprn- ENERGY FEE
OZ fa tion Lassa a California.Ila. WATLRH W %ELECiTt
z O Applicant GRADINGFEB '
h NOTICE TO APPLICANT:If,after making this Certificate of Eacmpion,you should WATER SY.'TEWt pATING
ban subject no the Wohc/s Compntution positims of the labor Code,you mus SOILS FEE
WfiMwith comply with such to,kions or this Fe mit had he deamd resakd. WATER SERVICE
z CONSTRUCIIONLENDINGAGENCY NEW RESIDPNDAL PLATO, SQ,1.. PAID
U O Iheehy affirmthea there is a crosmnim lending ugam,y for be proorn.a ( Due RacsipY
D. F r e w
thort for whdh This permit is ]09
issued(Sec. 7,G,C.)
C) Leal/e Nene TOTAL:
w Landde Addrt.s TOTAL'
0. 1 eartify than I lave reel thio y,4icvion and stye that de,above information I. BUILDING FEE
to mmct.I agree 0o comply wl0h all city ind counD mdiwnces ate sate law.ayin,m QTY. MECHANICAL PERMIT FEE
Uz buidingrntyrvetinn.aed hereby outharimrepreanDtivn of this city treater uponihe SL'ISMICFT'E a C
abavcmcnumd propcny for inspctiw prnpsma, PERMIT ISSUANCE
. IWe)agree to Talc,indemnify and keep hennle.cr tic City of Cupeninu vgein.t ELECTRIC FEE
Iiuhifimae Jaipraents,mets ud eapcmn whirJi may in a nyunye¢rveegm,diaid City ALTERORADDTOMECH.
of the grvnun,of chi.pmtic PLUMBING FEE
APPLICANTU RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIRIIANDLINGUNIT(TO IO,(MCFM)
SOURCE REGULAT S. MECHANICAL FEE
T� sA;a EXHAUAIR ST
NOGG VIDUCIIT(OVER 10.000 CFM) CONSTRUCLGONTAX
Srgnumrc
HAZARDOUS
`Uye�l EXHAUST HOOD(W/DULT) HOUSINGMRIGATION FEE
HAn orf. USMATERIALS DISCLOSURE
Willy epp.,nior fmartb,ICoe.CTs 9,12,hatdk hartidiaa rWcrial HEATING UNIT OO 100,0000TU)
e def nd by the Cupcninn Municip.l Code.Clupa Y.12,ltd tie HCWOt end Safety
Cade,Saban 233320p9 HEATING UNIT(OVER I01.(000 BTU)
[3 Yen No
VIiNI'IIATION PAN(NINGLP.R151D) PAID
Win the a"Ai.or future Daikin,oeeopanm uvc'uripnent or hvkvs which Det. Raeip N
emit hawdarn ear amamirants an dcfnad by the Bay A.Air Quality Mamgcnrcnt BOILER-COMP(3HP OR 100,000 BTU)
Di.trinT TOTAL: G
❑Yn - No BOILER-COMP(OVER 1001000 BTU)
AIR CONDITIONER
1 have and Oc heeadoua tttaaials O5,M533 an pec Clapn 195 tee Edi ISSUANCE DATE 0
Rindal deen& earn Cale.team,,IM,
2553].425SJ6.1 urdenwdthe(if the NEW RFSIDENTIAI.MECH. SQ,FT
building din trot is sho y have a.tunt,th.0 itis my renlxusi andf m ttntify the acsvpent
atle rtquirttrcnn which tawhnn peiermi.ruerce as Cmif me a0aopatey
Owrsr or unhon d.gent Date TOTAL: ISSUED BY:
OFFICE