S 2012 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PIF19II'NO 2012
BUILDING DIVISION APPLICATIONIPRRMIT PLIIhIBIN0.M1fEC11ANICAI.
BUILDING I'RQIF:L"p IDRNI IFICA'I'ION V' .�
BUILDING ADUREP S SANITARY NO APPLICATION SUHMI'ITAL DATE
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T ARUU'RI LCUENGINEER I.IC NO Y AT )J El f/O ❑
l� oaaY•, IJ dil d Sn. 9_.5/2_ .
coNTACT PHONE. i r I . 'h BUILDINGPERIA[TiNFO
❑ Consultant Fees Paid by Applicant(Initial) BI 1
UG ELECT PLUMB/ MEC
❑
LICENSED CONTRACTOR'S DECLARATION
1 h,e I Q'ry ,, EI.ECTRIC PiRMIT
by.,Bng Ill,.,[an,hven,ed oodar p ul....rrh of Chapter a mnmmenelns I r FEIS Ir—C,
JOB DFSCRIPTION
MWZ wnh.Sv,l 700( ofU,vtano 3 ofthc Barnes,and l'rofe,aons Cwle,and mY hronsen f RF-SIDENTIAI:
F m lull farce and etfn ( PERMIT ISSUANCE { 'rQ
�UF Lmen L - LmN ❑SFDWL ❑KITCHEN REMODEL
6 U AI'PLIANCP_S-It13IDENTIAL ❑ADDITION ❑PLUMBING RE PIPIT
I-iZQL D. Cnmrvuu,r
AHCI{ITECI"S DI[CLARA IUN ❑MULTI-UNIT ❑STRUCTURAL
Z O,� It den,und my pinm,hall h usee a,puhhe re wlJ, / I'ANIHS MODIFICATION
OZ-n 1 UI'TU 21xIAM1t1'S ? 7 El INTERIOR [_1 CHIMNEY REPAIR
F.N.F7{.+.11 IJCen0.'d Profaannal 211-INNIAMPS IMPROVEMENT ESWIMMING POOLS
K C Q hereby aft Tito nWN au,le elmpt fnm,L he C n Irmur',License Lew tar the I OVER 1000 AMPS ❑RAI'II REMODI!IJRPPAIR ❑DENioLIT10N
X O a V follnxm6 remon.(Secret)70315.Buwms,and Prat ums Code Any city ur loamy SIGNS ELECT RICAI. ❑OTIIIiR y-x` ry '�
W 3 W whuh regmre,o permit to eonstiun,alter,rinplive,dermanh,or repair any amcture I J%Al K , Y 'aVAKA/dg6 C�`J
h= 'n... nwence,;d,a reynrren the a,kam foi-onin ennu e,LlcnslgncJ,lwemem SPECIAL CIRCLE'IYMISG
W` a•.. that he is licensed pursuant to me provision,of me Contractor,License Law(Chafnery
ak�QO (cominenclnswuh SCau,n]B0l)nl Drvmmll 3ofthe Bull bell IS UI c,,,nn,Code,or '1 EMI.N117 TER IIR POLE INST COMMERCIAli
Chill hew e,templ Ihcrefinm and the ha..for the alleged enemptmn Any,mla' o of Q NEW BLDG/AUDIT ION ❑[)FMCI-11 ION
W Sn,on 71131 5 by any appLcent fnr a penn,t wbJCan the nP'I,cnnl m n u„I paadty ul POWER DEVICES ❑TIiNANT ❑TOLD SE VTC17
not more than live hundred dollars($500)Z>• LMPHOVEh11iN 1'
ar+=Q ] Loshe worn(the pic,orr oemyemployted xvhered for sale 7044 Business SWIMMING POOL F:1,liCTHIC I-I
Co x,ll do he xrorA,and lhwtrumum is noumenAN nn,RereA for mlelSec](DJ,wonl,a O VOlill'.R
63ao and trolcaon,Codo,Th.C Enron,Larne Low Joe.not apply owner ml f1UT1,ETS-SWITCIIliS-IdXTl1RF.5
properly who hudd,or improve,thereon,and who due,ouch x.,k Iumvdf or Through
hl,uxn employee,,pm.dol thin,ulb,mprooloo-oa ere nal mtenJN ur JI'Lood for I NEW RESIDENTIAL ELECI'R SQ FT
sat a.D,hrwevetJIhouvddmgonmprncmen.that ,nnhm one yeernou,nooemm.the
SQ.PCIrCP AREA $ISQ.Ff
nor-hndwever,fire
hove the hwden of emeny that he dtd mile yd onmpnme Ito pure 1
pme mf,ah,I /I
a o OiA.'
1 I,a,owner of Ore'ro....D,en,...luvncly ameaamg wuh ueutr..tnn In
comes<t the prn)ect(Sec.7600,Busme,,and Pooke, us C1de)'The Contractor's I.,-
c clew dne,mn.rpply n,-owner A property who hard,nr rmpro,estherenn.and QTY PLUMBINGPF,RMIT FEE ��(y
x`hrcnmmrnl or,ucbp....bx,lhucnntraztnrb)hcemed pursuant no he Contractor', / Ijjj
Owner haw PLTIERi-DRAT ISSUANCE
❑Into cscrnuttdv,Sec .B Xr P C for this relnou f 'l/ qJ
2 ALTIiR-I]RAINffi VIiNq'-WA'I'IiR 113A1 / VALl1A1'ION
Owner Date
WORKER COM1II'I3NSA'I'ION DECLARATION BACK ROW I'RUTF:CI'DtiVlCli
t Iherehy affirm under pvnahy ml pcpuD mm of the follnxmg decla,ntiun.
/, ,❑ I halo and 1111 Tnrnt.un n CcridlK,1ent(:omenl m,ell-,nwrcfnr WnrAch Cnmpen- DRAINS-FLOOR,HOOF,AREA,CONE) S'IORIIiS TYI'li CONSTRUCTION
,mien,a,p.oided for by Section 3]101 of the Lahr Conn,tar the perinnnancc of the
/,k lur which lM1„Pennon„wed IIXTIJRES-PGR TRAP
1�1 I have and will mammm Worker',Compc,n,lop Inwreynycbc�,a,rcyuveJ by See Er -
My erlt�un Cnde.h(t retard
�k }r r�ewe�9,°ueJ GAS-EA.SYSTEM-]INC J CATTLE?S i i OCC GROUP APN
My W. mpcn In nil I'nLCy n
OAS-EA SYSTEM OVER J(EA)
Car CIiRTIFICA'IM OF EXEMP DONE FROM WORRIES'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING U VISION 113E.S
IThommmn raccoon becompletedit the pemut i,formrehundred dallar,($lan) I GREASE,RAI' !�
ur le„1 PLANCHECK Plili
I cenify Nat in Ne porfnnnana ofthc work lnrxhlchth,permitl,isucJ.l shall I SEWER-SANI'TANI'-S'IUkM I3A ?I1d 1'I'
ism employ any p<`nnn m any manner w,a,n,hcome wbleu m the Woden.'Cnmpen- ENERGY Id3E
O 'n h Law,nl Call nrnm Um^ WAIIiR MEATIER W/VEN'I'/ELECTR GRADING FEE
Z rrNi NO110E'TO APPLICANT"It.alter making this Cemlicateof Eacntplinn,you should Wr111iR SYSILAVI It13A1'INO
a > become ab ref m the Worker',Compen,,t Pnrvrann,of the Labor Code,yon must SOILS FEE ` )l
forthwith comply with such prnvuran,or lhl,PCrnm,hell hJeemed m,aked WAI 17R SERVICE e—Y
Q
UO CONS I RUC'I ION LENDING AGENCY NEW RESIDENT[A],1'LN111 SQ.FI' PAID
thereby e(firm that w a construction lending agency fnr the performanceno )al Receipts
i-I die x.,k for which do,permitw,,wed I Sea.30117,Co.C91 /'/
Lender,Nam^ ll 'I pTnh
L) LenJer,AJd.... r..�OTAI
I BUILDING ' H
I cerity that I have real this application and ante that the ebu,e mlonnation w r
correct Iagree tovomplywithan city andcounty mdmamc,end,Bne law,«(sing n' QTY. MECHANICAI;PI7RMIT FEE
U buildrngemnamnum,and hereby anlhonee representative,of his city to enter upon the 'EX'ICTEIi
nhove.ntemmneJ property IoI Inµrechon Purpose,
1 Wet agree m,arc.urdvut and keep hannlu„the City of Cupertino agamal
PERMIT ISSUANCE Ii1,EC"I'RIC ITl
in coisequenceofth,cmnsg capis surnuch,ney m.up'wisp mcrnc ag;nnsl n,ud C,ry' ACI ER OR A A I I O hI HC Ii l
omequenceo(lhea't, nd r,ttnpemnt PLBhIBING PEE
APPLICANT UNDERSTANDS AND WILI.COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(110 IQINp A SOURCF.R UL� [ rNN.MANIC I IONT� � AIIt IIANULING I1NIf IOVER IJ` CONS`D1�11}(:PION TAX
Slgnal„re nl APPlr MCu urnemr , (/ Date a LXIIAIISf H(JOD IWIDUCT) v ^ r IIOUSIiVyn` 1(I ATION FIiIi
H i.')OUS MA]ERIAI.S DISCLOSURE V/ s
•
Will the e'ph,enl nr Comic hn,le„tg mcnpanruerc or hanJlehwuNnn„mnnrel HEAUNGUNITGOIo0,Ixq B'I'U)
u
as des wed by the Copemnu Afumarp.rl GNe.Chapter Y I2,and the Health and Sen•D
CnJc,Snun 255321.Oa HEATING UNIT OOVER IIXI,INNI BTUI
Ole, ON. VENTILAT 100 PAN(SINGLE BESIDE \ /t pale RerelptN
091 the applicant or Iumrc building occupant use equipment or device,which VENTIR-CON EAST(SIN LE BE]B'i'UI '•r`
r -{nu heewd.,u,arr eonto orn 1,a,defincrl by the Bay Arc.Au Quality Management ,TUT•,•/• _
Dnolct” BOILER IUVER 100,10X1 RTUI / / 1J' I 1' 1
❑1'c, 0 N / I V
AIR CONDI I'IONEk
I Health reed be h ode.Se mnto 255 5,25533 an u2553 Chapter bra of the Call- ISSUANCE DA'fE/I
5,mra Health n,Solely CI,JC,Smrnn,255(15,'3573 and=553J 1 unJcnemd(halt the NEW RfSIDIeNT1A1,MLCH SQ 1'f. ,~[ .- I (U7F/•
IF of the redm,not which have aten.o,pthatn,smy rca of hJnyu,nuofythnccupam YW/
I of the nyuircmenn which stmt h met prior m I„uance of a Ccnllicale of On,qumy I I
Owner or nalhort agent Date 'TOTAL. ISSUED If I' L)°J(_jp'k
0FFACE 1=