S 0117 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
,CITY OF CUPERTINO BUILDING.-ELECTRICAL PHRMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT 1'1•DamwG-MECHANICAL
BUILDING PROJECf IDENTIFICATION;
BUILDING ADDRESS SANIT=API-LICAIION DATI3' g' (jr.� l f�:t �(.OWNP 'SNAME: li) PHONE COrn����NNIIIJ���fRACTORS�yyNNE' LIC NO:NI-tirk iiNICEER ARCIIITECF/ENGINF.I3R: LIC NO: pDl)R?S �rY �ry�/ �� ❑CONTACT PHONE VUILJ HUILDINGPERMIITINFO -
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
is
❑ ❑ ❑
LICFNSI DfONTRACTOR 51lICLARA Hi1N QTY I 't ELECTRIC PERMIT'1 ; hEE�
I Waren>nlEntmtl ,Ironed e �p rclpt 91 '.g t' JOB DESCRIPTION
�Z with Seausn]OIND ofD inflhc itu.' ass end Pn�fe ;C.l„and my fc .c RESIDENTIAL,
p0 /W J^1Y— �s PLRMIT ISSUANCE.
fall foneundensu' ❑51'DWL ❑KI'ICIII:N NF.X10UEh
�zw Lice rte Chis.. `— �� Licatr ^'��� of b APPLIANCES—RESIUF.NUAL ❑AODLITON ❑PLUMBING RE-PIPE
NQd Dole 5�'—IIr1 �TECTSContractor
ARCHITECTS DECi.ARAf10N ❑MUl:fl-UNIT ❑MODIFICATION p.pm PANELS MODIFICATION
Z O Z I undemand mY PWne,hull reamed.,public records
OZ—c - UI'I'O 200 AMPS
Licensed Pmfeseinnal 201-II0IIAMPS IMPROVEMIiNr GIDE OLINGPOOLS
..,41 OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODuLREPAIN ❑DIiM01.1'rION'
Hill Q I herehy u1Hrm the 1 am exempt from the Contremnr's License Law ha the
U full nb rev: I.(Sect 7031.5,[mimeand Profession,C We A y 1y r county SIGNS ELECT RICA],
❑lTl'HfiR
t ya wh h 9 putt or t I R p d omit ti Y'Imeerc c
pro
^,cps da t it e,alrequiresehapplicantf hp permit fl 'g J,wle nen $I`I'CIAI.CIHCl1 H'/MISC.
celCp 6f Thal henehcuwal pSe,liotnOnsef Divious none Cnmrsinss Lir Pref am Ch.pter9
pp (commencing suiteSeclian]II001 ofUivision 7Ol'the Business and Prmlca iCrxle)or 'FI?MP.MITER OR POLE INS'I'. COMMBLDGAI:
a y y
that he i..oaten therefrom and the basis far the ulleg d exemption.Any violation of ❑NEW RhDG/ADDITION ❑DI?MOLI'NON
YI^m
Section 7031.3 by any applicant for a permit subjects the applicant mu civil Penally of
POWER DEVICES ICI35 ❑TENANT ❑FOOD SBRVICI?
Zy nut more than Five hundred dollars(3500), _ IMPROVEMENT ,
SQ ❑ Las owner of the propert,or my employees with wages as their side cnmpencition. SWIMMINGPDOLELEMB[C
p will do the work,undtao simulate is not involved.tuff redlirwic(Sec.)1144,13mlre, ❑0'I'HER
Wa and Professions Code The Comtacmr's License Law Joax not apply m an Owner of oil'1['111S—S W I'PCi IES—FIX'I ORES
ec property who builds or improves thereon,and who Jces such work himself nr through
his own employees,provided but such impravcments are not intended or offered for NEW RESIDENTIAL ELECT R SQ FI',
sole.If,howim
evcF the building Or rrvvcllell is.sold within one yearom
fcmpinlon,the .Fr.1400R AREA SISQ.Pr.
., cr-hudder will have the holden Of proving that he did not huild or Improve far aur-
you of.-sake), I _
TOFAL:
1 f theproperty,am exclusivelycontracting with licensed contractors to 11
ter t tib d 1 't fS ]1144 B .' c:'a JP ('” .Code)'Ih C m mrsL -Av
can eLuw dax not_apnly man owner dpmfeny wbnnuad. rinpro e:Ihcr nn and QTY.4 ' ''I"PLUMBINOPERMIT' �' FEE '
who contracts for such pmjectx with a comractorls)IicenxW tiumuan tar the psmncmr's
Llccase Ww. PERMIT ISSUANCE -
❑ I am exenrrt under Scc. .B%P C for this reason 3
AUTER—GRAIN Rr VENT—WATER(HA) VALIJA'I'ION
Owner DIO
WORKER'S COMPENSATION
reuaO,on DECLARATION BACK FLOW i'kOTIiCr.DEVICE
I hereby aftlrm under Penalty of perjury one of the following declarations:
'Q l have and will nmintaina Cenifcateof Consent tosell'-insure for Worker's Cnmren- DRAINS-IT.i)OR,ROOF,AREA,CONDSTORIES '1'YPECONSI'RUC'HON
sation,as provided for by Section 37M of the Labor Code,for the perform:mcc of the
work for which dr,permit is issued. FiXTU HES—PERT RAP
I have and will maintain Workcr'a Comfwnsalim Insurance,as required by Section
3700of the[..hill Cssde,fort.performance of the work for which this Nauru is issqued GAS—IiA.SYSTIdd-I INC.4 OUT OCC.GROUT" APN
My War e1 jmnsntir Insur cc
farrier and Policy n pI�tee:llta�g1/
Cartier. 11/ Policy Nn: I GAS—IIA.SVSTIIMGVI3RJ(IiAI
CERTIFICATE OF F.%EMPr10N FROM WORKERS'
COMPRNSAr1ON INSURANCE. GREASEINDUS"1'RL WASTE INUERCEPI'Ok -
BUILDING DIVISION FEES
ITiilx section need not be completed iOhe rental is for one hundred Jnllury IS I W I
nr less.) GREASIi TRAP I'LANCIfBCK PER
_
I reairy that in the rerformanee oOhe work for whlchon,permit kis.nd.I.ahall SEWER—SANITARY—S'rOHM FA.21X1 FE
nor employ any person in any manners as to become subject to the Workers'Counted- ITNIiRGY LEE
z n';vmr Lmv,of Cmimmfu Dav WATER HEATER W/VENT/ELECTR
Z Q Artificial ' GRADING LEE to
NOTICE TO APPLICAN'.If,after making this Campeau,of Em
eeption.you so, WAFER SYSTEM REATINO
f" ,I become subject to the Worker's Compensaion pmvisi ms of the Labor Code,you must SOILS LEE
o--t
forthwith comply with such provisions or this permit shallbedecneJ resided. WATER SERVICE
a �
CONST'RUCION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Ff PAID
`7 z I hereby affirm that them is u conswetion lending agency for the performanceof Due ,7,,,e
IL.O Ire work for which this'permit is issued(Sec.3097,Civ.C.)
t—' Lender'.,Name RIVAL:
O L) Leaders Address TOTAL:
>a0. certify - _ _ _ BUILDING FEE
1 Ih t 1 have with
Thisty a f d.rot that enc above ,Finan t r
Q V) nnreec l g ! ply hereby[city and county N stud slam[awe reit g to 'UTy„• 'MECHANICAL PERMIT s FEE"
U $ hu led ngunswu on and hereby authorize presentative of this sty to ental urns the 1n ' � -' SIiISM F�D
.. above-mentioned property for inspection purposes. PERMIT ISSUANCE,
(We)agree us save,indemnify and keep front...the City of Coadien against ELECTRIC PEEielvrov
liabilities.judgments,costs and expenses which may in any way accme ardell said City ALTER ORADD TO MSCI I.
in asequence of the imilingoflbis Permit.' P INI�. g
APPLICANTUNDIiRSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(To lyoo)CFM) IIANICALFEI;,s spJ
SOURCE REGUTATIONS.
AIR HANDLING UNIT(OVER 10.000 CpMJ CO S"HIUCYION TAX
Signature of Applicam/Contracter Free EXHAUST HOOD IWDUCI') HOUSING MI'F1GA'fI0N FF.F.
E IA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building overlent store or handle hazardous material E ENFING UNIT(11)1110,000 BTU)
as defined by the Cupenino Municipal Calc,Chapter 9.12,and the Health and Safety
Glue,Section 25532m)P HEATING UNIT(OVER 100.0110 BTU)
E3Yes Na❑ - PAID
VI!M'ILATION PAN(SINGLP,RESIDE pate ItmciPtk
ms
Will the opplieam or fmure building overrun!use equipment or devices which
emit hldnus air contaminants as defined by the Bay Area Air Quality Management BOILER—COME'IMP OR loo,"BTU) TOTAL:
Llwl
BOILER—COMP(OVER Istood BTU)
El No
ad the Msardnusmaterielsrequirement-under Coupe,6.95 of,hc Cali- AIR CONDI"I'IONER ISSUANCE DATE
Safety Code,Sections 25505,25573 and 25534.1 umlcrsertd that if the NEW RF.91pIiNTIA1.MECH.I. SQ.FP ///���
buildingrncum Oy veulenanLthatieismyresPonsibllhymnmifytheoxcupanl �/ O 4i
me'w ' tMmu prior In iseu:ma oft Cam matt(kcupnney. 1�omc eb Da TOFA L: ISSUED NY ''
OFFICE