28458 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECRAMGL 28458_
BUILDING PROJECT IDENTIFICATION
BUJ14 *7I INO AUDRPSS: C S SANITARY NO. AYI'LICATION SUHMfITAL UAt '
!1 I '
VER'S NAME: PHONE: CONTRACTOR'S NAME IT N
r NIC cur Lg
ARCEFFECI INGINEER: LIC O FSS: ❑
CONTACT PHONE BUILDING PERMIT INFO
t ❑ Coruni tont Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ECP
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 see ny umtm my 1 am licensed viler pmd.ian or Cheater 9(commencing JOB DESCRIPTION
0.'Z with Session 700sl Divitian3ofthe Bu.inm"Prefauions Code.ad onylieeme is RESIDENTIAL'
in full foux and affect. PHRMIt'ISSUANCE
❑SFDWL C1 KITCHEN REMODEL
t a� D,de on�yw APPLIANCES-RMIDEMtAL ❑ADDITION ❑PLUMBING RE-PIPE
ZF�cei 3o in
Licensed Nofe.sioml ARCHITECTS DECLARATION PANELS ❑ CITI
MULTI-UNIT OSTRURAL
O
1 uMmtardl my plasudl W used m public records MODIFICATION
FN-W UPTDTCAMPS 0HWERIOR ❑CHIMNEY REPAIR
XII-1000AMPS IMPROVEMENT
OadI.assoup,RD',he CommenIONt's
OVER H=AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
1 hereby aDvm dart 1 L5 eaemp from the Commas Licrnx law for the
�(30.fV. fdlowing nuvn.(Smian]W15,Huntea.M Pml-aaiunw Gdc:Any villi.,county SIGNS ELECTRICAL ❑OTHER
1+10.0.0 yj which rryui,a a pumit so emani cher,impose,derediih.a mpa'u any strut -
g pilar m its iumnegvH,oatm then,licont for such permino file.signet swmtrcnt SPECIALCIRCURMISC.
ythis he u thenal puraamt m the pmriuona of the Cma.nors Liana Law,(CYupa9
00 (oummancng wllhSadim](10H ol'Divislun 3 ofhc Business soul Pmfeuiau Cuk)ar TEMP.METER OR POLE_HNST. COMMERCIAL
6 d K that he is eacrtgN dscrcfmm and the buffs for the elkgnl eaanpim,Any videtion of ❑NEW BLDO/ADDITION ❑DEMOLITION
ern Scctit 1131.5 by any eppiratml fora pundl wbjsu de applicwtwacivilpwlsy of POWER DEVICES
F„ mon fire broadest delars('$W OTENANT FOOD SERVICE
61 owarof he PaPcny.or my amplayeu withw."u wutheir wkcrvnpensadov. SWIMMING POOL ELECTRIC IMPROVEMENT
awiu ache work,ami the structure is int mrdd or Mraed for sila(Sat.]IN4,easiness ❑OTHER
W ad Pr,;Nj mmu Cada:The Cmaanue,License Law don oil apply to an owrct of OUTLETS-SWITCHES-Fl](TlIRFS
63 pmpeny w huilds o improve henean,ad who dues such wurk hiimclf or thmugh
his own enaliloym,povidd hat such impovesrcw an,ret intrndd a.Hard for NEW RESIDENTIAL ELECIR SQ FT.
We.IL however,me building or improvement in Told within one year ofmmpletion,the SQ.FP.FLOOR AREA wets FT.
owver-builder will Nave the Iwden of Posing met he did rot WIM or impose for parr.
pea or W e.].
I,as owner of he lantser,.n ta,lmivaly com.mli with canmn i- TOTAL:
anurvm the project(See 7044,Business mous Itrmfcxsioos Codc:)The Cwurus
tJ-
melaw does.applymars m.,mr of property who builds or innamvn there.,aro QTY. PLUMBING PERMIT FEE
who ennlmets for such prmjec a witha nmlerclols)licensed N.nuo the Cwarmor.
Lka.Law' PERMIT ISSUANCE
I.meacmpwdn See. ,B&PCfm t]bs n
Owmmn Dox ALTER-DRAIN&VENT-WATER HDO VALUATION
WORKER'S COMPFNSATION DECLARATION BACK FLOW PRO=..DEVICE
I thereby elfrm under'rida,of perjury arc of the following dee Wmiom:
Fl I haveamlwill maimaine Ccnificne ofCmant roWf-in.wx for Worker's CumIsere- DRAINS-FLOOR,ROOK ABPA.COND. STORIES TYPE?CONSTRUCTION
sodas,u Pmvidd for Nw
Y Sim Thenbar 3707 of ICade for de Pa .aha
work for which this permit is issued. FIXTURES-PER TRAP
0 1 nava ad will nWtatin Wakm.Compnuvuon luura .at aquird by Section
37W.fthe labor Cale,for the pa rho rimice of the work for which mi.permit is i.saJ. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wohers Compemalion Imormice carrier ad Pdicy number are:
Cam¢ Policy Na: GAS-EA.SYSTEM-0VER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
(Thunniim Teti nothecuryiktd fibenernul is forneelmadr ehillsn($100) BUILDING DIVISION HIS
err less.) GREASEtRAI'
p1.ANCHECK FEE
Toy my marisinn penfmrmer orde wort for whim thio pcsnilinirs Co I.near
not employ any Rnas in an mhcome wbjalw doe Workers _ SF.WBR-SANITARY-S'IDRM EA.21)0 FT.
Z swim law of California.DateucKrmu mtpco ENERGY HE
z WATER HIATFR W/VENT/ELECfR
Z 0 GRADING PEP.
h NOTICE
CEE b*l I.the,
Wort is idler Cromastronng sCmifaa of FLabor ,on,ymdNuld WgTE1f SYSTEMTtCATING
f' bnvne ucomp r the Worh fro Canpmaiis eraNdou M dle lei Calc.Ym m,,.t SOUS FED
fmhwim comply with such pmvisionsty thio permit.M1all the d¢med ravokcd. WATER SERVICE
aQ
Z hantheCONSTRUCTION LENDING AGENCY NEW RESIUEYI'IAL PIMB. SQ.Ff. PAID
L) I For
mudmene issued(construction0 Cing agency for time perfrmuni¢of Dex RccciPY
� � ma work far which this permit is issued(Sec.309],Civ.C.)
O 1<oder.Name TOTAL:
,Leder.Addovs TOTAL
6. I anify mot I have read his application intestine mat the above infonaamnD,meq - -- HUILDING FEE Q
V1 correct.l agree to comply with u l city andcmum�yy..mdimnun ad sale b i rtluun�in QTY. MECHANICAL PERMIT FEE
V Z building cotwnsamlon,and M1emby author.rc es nwives of miu city to anter upon rhe '1 SEISMI FEE
above-ircwimd Pupeny for impntion Pup- 'PE MIT IS9UA 'CE
(We)agra w urc,m,R mdfY and kI ph°°''���eu yy fCupenifih aBeinu ' , EJ-ECl
Ii.bBidea,jWgmenu,award eapcnxa wldeM1 mnyiow drrveripinsiLtaid City ALTER OR ADDTO lol t
meomma.I.mcearmegrendngarlmiperrmii.. 'aa^ '�----�� PLli�igrycFEe S'
APPLICANT UNDERSTANDS AND WILL CI P YXIT ALL NON-POINT `- AIR HANDLINQLN CFM) 1 C, -
S 'CERF.GULATONS. h�' ` a u k MECHANICAL TEL E�ifAt�. a
' 1 RlI O.IXp CT+M) CONSTRUCTION TAX
re 0fpplic.nVC a H, STHOOD UCU I` HOUSING MITIGATION FEE
H, RDOUS MA LSD CLOSURE
hcappliunsafmurebuildin pants sue w heMk harurelaus material .-
HEATING UNR_,MI MOM BTU)
u defined by the Culacroo Monicilxl Code.Chang 9.I2-and he HealthHealthanal Safety,
Code,Section 25532(a)R -r`+��^'—""�- HEATING UNIT(OVER I W."BTU)
cjYe[ 7N VENTILATION PAN(SINGLE RFSID) PAID
Date RetaiPN
Will time air c rine im fuwx Wilding by the B ata ra Air u a dMana which BOILER-COMP(3HP OR 101ND BTU)
emit hemmdous air rnnuminants u end by the Ary Area An Duality Management
TOTAL
Diudn'l 0yes ED No BOILER-COMP(OVER IIp,g10 BTU)
1 have reed The luvenoo,milmalsa under Chrperb.95uflhcCut-
AIR CONDITIONER ISSUANC T
reyuirenxm
funu Halm&Safesy Code.Section 255(13,25533 and 255M.1 udaamud hu if the NEW RESIDENTIAL MECH. SQ.f ..
building Gest nom curreandy have.xnunt,That it it my aspmsi olhy to notify de macular
of he m[amea mans wiueh mm he mar Prior to isuwce of a Canifcex ufocrupaney.
Owe a eodmoriaJ agent Date ISSUED BY:
OFFICE