S 2130 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY a� -
CITY OF CUPERTINO r BUILDING-ELECTRICAL - 11TESITNO. 2130 1 3f1
!J
BUILDING DIVISION APPLICATION/PERMIT v1.UMRING-MF'.eHANIOAI. /I J L
BUILDING PROJECT IDENTIFICATION-
OUILDINGADDRESS'. .SANITARY NO APPLICATION SUBMITTAL.DATE
03 7 IDA LN, OPEPM t,3 0
OWNR'S NAME: PHONH: C31'E11TIN11NAME: LIC NO:
,, N/C - CONTROL#
• 6RCHITENGINEER: - LIC NO', 14IRESS', -
�/ US �i 5S o tl S'ft. Z6 ❑ O 6
CONTACT.. PHONE, - '.BUILDIffIGPERMITINFO
,fI1Ur ,/1 f.•I�j'-LI I� C2! �I� C^�n� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEET
I°1 4 F-L 6 GF -TV o AR
LICENSED armar TCONTRACTORS DLCLARADON QTY ELECTRIC PERMIT' FEE .
I h by n m t I r c e p f chapter 9(comma a" -.. JOB DESCRIPTION
Woo with Section i nwm fDf ivem 3 of Bus d Professions Code,ard tay license,is Y� RESIDENTIAL
F In Cillo reead@fleet. _ _ 1'EltMll ISSUANCEJ
�UE" Ise ClnssA$ GR Lic.N 71 I ��S ❑SFDWI. [IKITCHEN REMODEL
y4U a /[o- l3 _'Q-9 Contract., L'1:. 12...'1 v2;f APPLIANCES-RESIDENTIAL WATICITION ❑PLUMBING RETIPIF
ARCHITECTS DECLARATIONF7 ❑MULTI-UNIT ❑STRUC'I URAL PANELS
ZOyZ Rlndclsoand my plans shill he scar os public records _ q MODIFICATION
p'y..q UP T02(IO AMPS Z 0 El INTERIOR F1 CHIMNEY REPAIR
fir. W Llcvnsed Prom ienal 201-1000AMPS IMPROVEMENT
16' t OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
(Wy 6 1 herehy vl7um obit I am exempt 6om tM1e ConOvenn's I:Inense Lnw for the OVER 1000AMPS ❑BATH REMODEUREPAM ❑DEMOLITION
iC 3 W F following reason.(Section 7031.5,13usiness and Professions Code,Any city or county SIGNS ELECTRICAL ❑OTIIER
y cel idrrequine,if permit m too suuet,alcor,improve,demolish,or repair any structure
F I'aOQ priprmils issuance,also requires theapplicant forsuch permiuo file asigned statement SPECIAL CIRCUEVAISC.
that hei,s licensed pursuant to the powaki n—fthe Connawods License Law(Chapmr9
(commcriat wiN Seefon 9001BmfDivision 3 of the Busineasand Part,..lov Code)nr TEMP.METER OR POLE INST. COMMERCIAL'
ti p,o a that he Is exempt therefrom and the basis for the alleged exemption.Any violation of EW BLDG/AUDITION ❑DEMOLITION
YXl LL• Sooner7111L5byare,,plienw fora perril-blcets the applicant mvcivil penalty of POW DEVICES
�y .NANT [:j FOOD SERVICE marc than five hundred Jul luta(8500).
F d Las ewsisk,the c,mm Imecdomfocd nrtheirsea mm wnsa6nn, SWIMMI POOL ELECTRIC 1 MENT
t] O ❑ proper y y cep Y 6 I
2W^eo will dothewons amde: he nce,Com iencsLicenslormf does
aplyin an Business �TIIER
fi13 and Professions CNE:The improve,
he tree land h do darn not apply m m through
OU'll, 'S- UCHES-FIXTURES- C properly whooy ie..or improver t suchn,and who dines such work ded er ifcod for -
,.I own employeese provided that pooh imat j,w I nls nm not iniended nt oiTeru)for NEW [S IAL E CTR FT.
,.If.Th howevwilhhave(hingur e harde 1pf,ruemieat he
thin on NOT
improve
fonut- SQ,FI'.MOORAREA $ISQ.PT.
neofbuilder will have the harden of proving that he did not build nr impmve fir par- �.. -
poseofsvleJ.
❑I,os mwneror the pmpenr,am sines and Profession,wah licensed pontradmra,- PAh
nmhadlhoes;notapplyo(anownerof property
whProfession,buids oD)The Comrocmr, nal - I /' C)
reLow does not apply,ani.merof property whesed..otimpto Ili Contra.
or, QTY. . ILLf W r IT FEE (y �y
whomnfevclsf,such pmjenswith ncomm�emr(s)licensed pursmmmlhe Cnntmgor's
l.icrarse Law PERNIfISSUANCE ( O
El I am vxwnpt ander Sec.' ,B&P C for this rennin -
Owner Date .ACHER-DRAIN&VENT-WATER(FLA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROINC'f.DEVICE /�
I hereby done undo,peunlly of perjury(me of the following decleutimne: p . '4:0
❑ it and cert mainmfna Certificate of Consent to,elf-insure for Workeds Compem DRAINS-FLOOR,ROOF,AREA,GOND. STORIE. TYPE CONSTRUCTION
seism,as provided for by Section 3900 of the Luber Code,for performance of Ili
work for which this permit is issued. T FIXMIRIS-
C1 I have and will maintain Workers Comlwnsalimn Insurance,as required by Section 1�
3900 orthe Labor Cede,for the performance of the work for which this permit is issued. S
-EA.SY Cpl NC.40I' LH'ISMy UCC. W APE
/ Grncrrker�Py W;tRmylts rrLhrnld PoNn/nun, A.SYSTEM-OVER 4A)
CERRTTIIF11ICAAATTE OF EXEMFFvFTON FROM RCEk (H
COMPENSATION INSURANCEr-F/1 TRL&A. F. P ,. p ,
(Ibis section need not he conrplemdiflhe permit in forme,forme,hundrW dollars(5I(IO) ey A y a l(ILQINO DIV191
arks'.) 0�J('HESS{ # ` .b " y
( ASETRAP PLAN I:' FEE
Loy any Driven
int he anymarterofts I workme subject
Worker,'
Cilshall S> tR-SANITARY-STORM P.A.200 FE
Indent L employ any parson m any manner ss nr le become suhjeet to the Workers'Compw. [S EE
N Applicant
Lnt of California,Use . ...
sal
Ppiiram - 4G
pI NOTICE TO APPLICANT.If,after making this Cedimeatc of Excerption,you should WATER SYSTEM/1'BEATING
F become subject to the Worker Cnmpmrsalion Powisu e,of the LeborCede,you must 5011 FEE
W > forthwith comply with such pmvisint orchis permit shut hedeemed IevekN. WATER SERVICE -
�O CONSTRUCTION].ENDING AGENCY NEW RESIDENTIAL PUSH. SQ.HE PA
I hereby after that there is a construction lending agency foo the performance of Dale kereipt# iI
L>w Fthe vital,for which this permit is mired(Sce.3099,Civ.C.)
Lenders Name qpT�
Lender's Address -
t~ a 1 certify We 1 have rend this application and:f that the h information Is - s BUILDING F's r U!
VI corral lagree m simply with II ly Indcounty I' ecsu d.to law,rclofngw QTY. 'MECHANICAL PERMIT FEE- p
VZ bufldin,,miarawfnu.melherehymuImnieremcsenmtivesofthis city memeroponthe / gE1S 'If 7V
abave•mennoned property for inspection purposes. -
(We)ugrce m xuve,indemnify and keep harmless the City of Cupertino againdl PERMIT ISSUANCE ELEC 1 E
Iiabl11 dcy,judgnrems,rosls and expenses which may in any way arm,against said City matinA L FEIROR ADD TO MUCH. PL1 FFP D
mrtscyuen¢nr the, &of Ibis permit ��I®f
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.00Hr CPM) MEC NICALFEE
SOURCE P,GULA NS. '
AIR HANDLING UNIT(OVER 10,01%1 CFM.) as CONST ICTIONTAX
.I,nm of ApphemWConlmcre, Drop EXHAUST HOOD(WMUCT) HOUSING MITIGATION THE
I IALARDOUS MATERIALS DISCLOSURE
Will the applicant or future building wcupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) q ,
as deliuel by the Cr ire Municipal Code,Chvprer,9.12,and the Hmlth an
Scott d Safety �(,
Code.Sec25512(r)1HEATING UNIT(OVER 100,660 H'I'U)
❑Yes , ❑No VENTILATION FAN(SINGLE RESID) PAIDa -
- Dam Rmmid#
cell ohs ar coma infuts a building y the B use ea Air u of Manna which BOILER-COMP(3HPOR 100,000 BTU)
Dish huutNoua air contaminants as defined by the Buy Area Air Quality Management TOTAL:
DisviwR
' ❑Yes ❑Ne BOILER-COMP(OVHR 106.000 RTU)
1 have rend fire humNeus materials requirements underChu ter 6.95 of the CaH- AIR CONDITIONER
25P ISSUANCE.DATE
fomiagwesnot fret CNOSectena 25505,25533 ad wponsi34,1 Ingodydlhatifthe NEW RESIDEN'HALMECII. SQ.FT
of,hemgdoes lrwemwhichmoally st be fact morme,nr (if a�ihiftytonoarympoiary. t /�-- Z-3.—.Q
or cop regrdrooronla which most be n,et pdormiraaance eraeemfnste eroecapamcy.
Owner or authorized agent Date OTJIT ISSUED BY,
OFFICE