S 2167F
a
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPRR'rINO BuHDIN'C.-ELECTRICAL PE lir No
IRJILDING DIVISION APPLIC TIONIPERMiT PION111 IS MECHANICAL 21 6 7
➢IDI.It4
LIC NO
❑ Consultant Fces Paid by Applicant (Initial)
LICENSED CONTRACTORS DECLARATION QTY.
❑ IY ZDl
I M1ctcby calm: dl:a I aI..'Iicculad under pnwisio I ilCha,aI 9 leo t ting
with Secliun90O)o1' viomr3ol Ilm Bout... and l'nd catli ,Cudc.andnav lice u it
� � -a full fixer untie e.
�UF LimaveC x kic.a ql It �
ydDoe Contractor OT�IPC
ARCIII I HUTl S DECLNtA'I'ION
w=mi NZ+ Iundcrnund:ny plum nholl he hied as public records
-❑
N F- W LicenudJ Pro&aionat
yt j OWNER -BUILDER DECLARATION
C
w< I hereby affirm that 1 v n cavacip, Runt The Commctot:c License Law far he
3 a Ffollowing reoI. (Section 7031.5. Buonee red Pr, l-onnx Code: Ana city of moony
y which mquinxa permit to construct. after, improve, demolish. or repair any structure
0< prior In its issuance, also requites the applicant for such Permian file a signed smmmant
that he is licensed pursuant o the provisions of the Carl mcmr's Liecnm Line (Chapter s
aQO (u:tmtanci ng with Sealum7010) of Di own 3oOhc Basinesx not Food aianxCo,la)m
y c C ono ha is cxc:hpl J:c:efnan ..,it Ibu b:uis for Ibc IJlegvvl cxatgnlan. Any viahtdan of
Section 9031.5 by any applicant For u pfrmit subjects the applicant to civil penalty of
not more than five hundred dollars (S5101-
FZQ ❑ Las owner of the promo or my employees with woga. as their vole compensation,
W will da Thew on,unJa, File ctum Lenolintended Law
do, apply
an ve
{all3 m amt arty who
m CN or improves
mp Cmwum2x land ve Luo dues n :rk b m a whereof
his o nY who Fuad. a ntpm that
t such
improvements upwho dansm n work deo or tar Ihnntgb
bin own employeese provided that such mensiw are not intended or offemJ lin
sale. If. withebuildingaren of proving
ishathwithinoneyearofmprove for the
ervhuilder will have the burden of pn:vmg Ibm be did not buil) or improve for Pao-
p are afx(o
[:] 1.owne Its wner of the Sec.7 y, on Business
Protracting Cod :) Bic Coal
construct owner
of and Professions Code:) Bic Commetor'v red
chow Lawdoesno apply to an ownerof proPeny who builds rs improves Contra and QTy
who contracts far such projects with u nmwmor(s) licensed puwmmf m the Camruemh
1]Ianocari, Law.
I unl escmpt unJe Sao. , If & P C f this Iruwn
Owner Dae
WOR KERS COMPENSATION DECLARATION
I hereby of tiro: under pcnnhy of pa, cry enc of Ibe fol low:ng it -clout
❑ I mocondwill ma:ntmnaCenificumuf Cmucnnu sof-inxury l'nr Wudcru Cn:npcn-
,.Ivan, ox provided far by Section 3700 of the Labor Code. In, the performance if The
k which this permit is Tassel.
.m)ace and will maintain Worker's Competnation Insurance as required by Section
flhe LaMar Cod, for the partnnuunce of life work for which l hi x permit is iuw¢d.
My Wn Coal c an lI-n.� - 'e carr ennui Policy nunEwr urs v",.4
My MyW(` s y { k t ps Policy Ns.:!g Yl Ip rI �a�_I^
CIiH'I II KATE OF; G%EM1IPf10N FROM WORK(:R�_� RS �_� �`
COMPENSATION INSURANCE
Thr, ore, aimed not IN nnnplmud irate permit is for cmc hundred dollem(SIIXO
or Ices.)
1 renifY (hal irate pcdommncc of the ward for which this Iwrmil ix issued. I shall
not employ any person in any manner so as to become subject n the WorkerContpen-
�Z nation Lawn of California, time
Z O Applicant
NOT ICE'10 APPLICANT. IC after making this Conificste of lxmapnon, ycu o nuld
Is, conte.abject,. The Worker's C(au,nsation provision. o1'the I.ubor Code, yon muni
forthwith comply with such provisions onhis pemtit nhall k deemed revoked.
a�
U z
CONSTRUCTION LENDING AGENCY
L7O I[(or.1alL That, Them it Ii so n(So,.3nlenJing agencyf rhe perptnuuncc of
Cts rim work Fa whiuM1 has IATmif is iswnl (Sm.3o9]. Co. CJ
Q U 1-malm's Name
}LunJur x/sdJmx
I" 1 certify that I have real this application and shim Nm the aMna information is
F4
h c Ica.(ugrccmcnn:ply with all mty:nnd apre—daliv- at and icy towsmluoa the p'l'y
U IZ aboveltget coned rolierd horny anition empre otwlive. nr rob city to ewer tgmth ma
abmc (wtlon re prolte ve for inspection
mnify an purep s.
lar
(sop agree ro rove, indemnify and keep hamdca the City f Cupertino against
incofiabilnsequence of life
exTisPe which may in any way accrue againslwiJ City
consequence a of Jae granting of this permit.
APPLICANT UNDI!RS'IANUS AND WILL COMPLY WTI If AL1. NON -POINT
SOJ,INCE kEGULA'1'IONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicnm or future building occapar:t aamor hundlu huruNnm luuleriul
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Hcalth and Safety
Code. Section 25532(x)'.
Yce
WIII he appfieam ar future hulking u cupam use equtpnwnl ar devices which
mit hamrdnus air contaminants as defined by the Ifuy Area Air Quality Management
Dinlricl?
C3 Yr'
I lave read the h:rurdeuu..... nd, re,nin,amundaCltnpmrti95ol'IheC:Ji-
fnmia Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that a the
building does not currently have a mnanL That it is my responsibility ut notify Ne tccupant
fmni�hich mus, he mepoor,. kvmnccaf a Ceniie eaf Occupancy,
(�a"N�Owmrmnmhnncia, 1Dn
ELECTRIC PERMIT I F13E
PERMIT ISSUANCE
APPLIANCES - RESIDP.N'I'[Al.
PANELS
UP"To201AMPS
201-100AMPS
SIGNS FILE CI'RIC\L
SPECIAL.CIRCUITIMISC.
'TEMP. M17I]!R OR POIA: (NRI'.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLI71S - SWI fCHIiS - FIXTURES
S -/v- ?`
CONI ROI. #
7E
BUILDING PERMIT' INIY1
BLIK LEC I' TIM
M 1
❑ INA[��I
JOB DESCRIPTION
RESIDENTIAL
❑ Shut
❑ KITCHEN REMOUEL
❑ADIIII ION
El PLUMBING RE -PIPIT
❑MULTI -UNIT
❑STRUCTURAL.
N.TER - DRAIN & VENT- WATER (EA)
MODIFICATION
❑INTERIOR
El CHIMNEY REPAIR
IMPROVE.\fENT
(3SW'INVOING POOLS
C1 BAT] MriL,S�'ODEIIREPAIR
Cl DEMOLITION
❑(TTI 11:R'�1�1Q
-
t-1� •Q -.fol GPS
L
�l QIC—
GAS -EA. SYSTEM OVER 4 (EA)
COMMERCIAI,
C1 NEW BLDG/ADDITION
[I DEMOLITION
❑TF.NAM1-1'
❑FOOD SIiRVICIi
IMPROVEMENT
SEWER - SANITARY - STORM EA. 201 [IT
❑ OTHER
ENERGY PER
NEW RESIDENT 'IAL ELFC.r R SV FT.
SQTop FLOOR AREA
VSQ. E -U
'IU'IAI,
PLUMBING PERMIT FEE
PERMIT ISSUANCE
N.TER - DRAIN & VENT- WATER (EA)
VALUATION
r-
BACK ROW PROTECT. DEVICE
DkAINS-ILOOR, ROOF,AR ,CONI:
STORIES
'I'YPI3 CONS'1'kUC'I'ION'
FIXTURES- PER TRAP
GAS - EA. SYS TI'M-1 INC.4 OUT 1.17
OCC. GROUP
APN
GAS -EA. SYSTEM OVER 4 (EA)
GREASEANIIUSTRL WAS r. INTERCEPR R
BUILDING DIVISION FEES
GIt E:ASIE'I RAI'
I'LANCIIIiCK II31?
SEWER - SANITARY - STORM EA. 201 [IT
ENERGY PER
WATER BEATER W/VENTIELEM
GRADING FlA!
WATER SYS 1'IIMoTREAIINC.
SOILS IEIi
WATER SERVICE
PND
NEW RF_SIDIENTIAL PLMB. SQ, FT
Dom Receipt
TOTAL:
TO AL,:
BUILDING IIiE
MECHANICAL PERMIT
FEE
SEISMIC FEE
PIiRMII' ISSUANCE
IiLECTHIC FIA:
AFTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT (1010d100 CFM)
MECHANICAL IEE
AIR HANDLING UNIT(OVER 10.010CFM)
CONSTRUC IONTAX
If XHAUST'HOOD (W/ISUCq "
I IOUSI.NG MEI GATION ITE
HEATING UNI '1'('I'0101.(M1 BTG
HEATING UNIT (OVER 80.00 BTU)
PATI
-'
VENTILATION FAN [SINGLE RESID)
BOILER - COMP (3HP OR 00.000 B'TO)
-
TOTAL:
BOILER-COMP(OVER 100,010BTU)
AIR CONUI'IIONER1-t1K III
Q
ISSUANCE DATE
S / �^ �a /y r -f
ISSUE[) BY: 7 � y
NEW RESIDENTIAL NIF.CFL SQ. FT
10 AI
OFFICE