25660 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECIrWICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 5 6 6 0
BUILDING PROJECT'IDENTIFICATION
UILD�G(DDR�: UN1iT SANITARY NO. APPIACATION SUBMDTAL DATE
LOTH
I /1IIIRI�I
�{dCOA 'S N LIC NO: `
U.JT—W Ugm4U4
NIC COM'NOLN
RCHH71ECT/FNGINEER: LIC NO: ADDRESS
❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
PERMIT ISSUANCE / ❑ li4 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
mwz Ilrrchy off that l am licemcd udaprasvimuofCYupc9(cmmcocing with JOB DESCRIPTION
4100 Section 1000).(Divisim3 ofde Bwinas ab Prufesti«u Cad,and my license u in PANELS
ywfull force adeRem.
arnm
LIa--Z LiClue Lic.Y UP TO2W AMT'S Ir�J7Y�_7/'A-T
rxs a6 H
Data Cantrecta 201-1000 AMPS
F-y> ARCHITECTS DECLARATION SQ,FT.FLOOR AREA S/SQ.PT.
70rn— Iwdc«and mY plaru shell beuscdupublic rtconla. OVER l000AMP5
Fy(_41 SIGNS ELECTRICAL
a yKj Licrn 1 Rofessiaul
Kaa41U OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
x0' 1 hereby allirm iMm 1 stn excmM fmm the Cmtrvetar's Lkcnse Lew firOne fit
4134-rFn following reason.EkOion]OJI5,Business anal Professlom Code:Any cityacounty TEMP.METER OR POLE,INST.
which tequ'ue a permit to c,mv ,Win.Impove,dmnlith,an cl it aoyswctwe
prim to i4 isauwuz,also mryves tbeii'limnt for such pemdt to filcaugrd nntnrcnt POWER DEVICES
a0 that k is lice w pursuwno the provisions of the Cmtmcror'a License law(Chepta SWIMMING POOL ELECIItIC
66��' 9(commercing with Sectim]000)of Dividm JoftheBwinesx and Prvfwimu Cale) VALUATION
soh a Oat be u caemlx therefrom vol Oc basis fa the alkgcd cscmgim.Any violation of
$inion]031.5 by anyapplicant for a permit n.bjt.the cep Aicmitul civil pointy of OUTI_US-SWITCHES-FIXNRFS
n«more Own five hardier]dJlvn(SSWJ. NEW RESIDI3J'11AL ELECIR SQ.FT.
❑ I,wnwneroflheprapenY.«myemWoYm withwagnwthe'vsole RIES TYPE CONSTRUCTION
3� will do thew .ard the tRacNrt is trot inreMN martv i f«uk(Sac.7faM.Bootlev
sort Profevims Code:The Cartwnals Lit.law,l rot stiffly to an owner of
Poor y wlhohaiMs«impavrs Oorcon,and whndoeiiii work himself crOraugh his
son empbym,providcd that such impmvcmrnutirt ma iNeMcdaoRcrtd fmmlc.If. GROUP RIS.UNITS
bane r,the Wildingo-impwaantusold within acyw ofconrplaiomtkowm-
Wildmwill lave the budcn of lowing Nat he did trot build a improve f«purpose of
sole.).
❑ Luce o,,eh(See. ny.amexclusiv and Prnactingwlthal Th Concraats to (p'Y. PLUMBING PERMIT FEE OOD APN
Lnc t the project(Sec.71lowo Budof and Tsofr ild Coal vc Th 4 ,cels
whocorl2wdmnell rojc with
atfafpfnpary roto Wildor,oa va thmromard PERMIT ISSUANCE
who Lawr«.vuch prnjav with avantrenm(e)Iian iwtauenlmtheconusctNa
IJccx taw. ALTER-DRAIN h VENT-WATER(EA) FEE SUMMARY
❑ 1 am exmqu uMm Sec. ,B A P C for Nu reavon OUTS,IDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owam Date RECINP1'N
DRAINS-FLOOR ROOF.AREA.GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ eh'C df iohI ve or aecac ofc oUihoulf�imure,«•ob C.)tech EXTURFS PERIRA, RECY:IPfY
Wakai C«nprnmtim lruwvcc«acmificdmpythcrtof(Sx 380(1,Wb C.)which PARK FEE Y N
m oll etnpleec's under olds lis RECEIPI'N
Y Pe^" GAS-EA.SYSTEM-I INC.i OUTLETS
Pdky N BUILDING DIVISION EELS
COr"W"y GAS-EA.SYSTEM-OVER 4(EA) PLANCHFI FRC
❑ CcOifiedavpyiahembyfomlahed.
❑ Ccr rlf cwyuflNwi$r ccityinspcctimdivixim, GREASIWNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF FXFJdPUON FROM WORKERS' GRP.ASF.TRAP SOBS FFA?
COMPENSATION INSURANCE
(TJusxectionne not WcemplchJ ifihe permit is formehwdred dollars(gl W7 SERVER-SANITARY-STORM EA.2(303F1'. ENERGY FEE
a leu)
I cmifythat N the pvfattwceoftle work fawhich this p n is lvued,la hall WATER HEATER W/VEN`GVLCIR
not ..ploy tiny Paaon in any ow as to Wcette subject to the Womkm' PAID
z CanpcmNinn Wws of Cilifomia. Date so WAWA SYSTEM)TRE.ATING Date Ra ,a#
Applicun
00 NOTICE TO APPLICANT:If.Nm resting 0.Cmificate aEaemptim.ym should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL'
I-- y became subject to the WorkersConn,nrtim pruviaims oft he labor Code,yes nowt
C4
> fonbwith comply with such pr.Ga.o-thu permit shill he ii revekcd. BUILDING FEE
G (] CONSTRUCTION LENDING AGENCY SIISMIC FEE
UI trebyaffirm that Ilwse i,et ot,iruction leading agency f«the fs fomuNc of O the work(ar which this pnmit is issual(Sa.9091,Civ,C.) TOTAL: ELECTRIC FEE
O 5 Tndefs N. PLUMBING FEE
le"dcls Address QTY. MECHANICAL PER MIT FEE
I certify that 1 have rod this applicalim and some Them Oc above informatim is
mrecu I MECHANICAL FEE
agramwmply with all city and caunry ordiramv and some laws relating to PERMIT ISSUANCE,
f— C/� Wilding conwaction.md hncby audwriae teprvrnotiva of Otis city tomta upon the
U Z above arndoonal prymty fo-iorl,elianpor,oal ALTER OR ADD TO MECI I. CONSTRUCTION TAX
(We)agne to rave,indemnify aral keep haorO,as the City of Cupenim against
liOiIOa,jtalyrcms.cw aspcmu which fay many way eaw ageiw said City AIR HANDLING UNIT(TO 1),000 CPM)
N (Toemeoft eNingofthiapmnit.
6 � 12— 1 AIR HANDLING UNIT(OVER 10.000 CFM)
cof A'Ii Coon. Dare EXHAUST HOOD(W/DUCD PAID
HA9ARDOUS MATERIALS DISCLOSURE
HEAnNGUNIT(TOIKt WBTU) Dere Rccei,#
Will Oe r the suntor MuWdolingoccupantninear handlehamN«umatrnd
r 1 the -
u Jefby Cuni
perto Ftuticipal Cade,Clupmcr 9.12,aril rhe Ilcdth and Safety HEATING UNIT(OVER IW,000 BTU) TOTAL:
Cak,Sema"25532(a)]
E)Yea No
VENTI ATION FAN(SINGLE RESID)
❑
W01 Oreappticant or furore Wildineocctµrw toecgwpmmt«dcvimwhichmtit BOILER-COMP DHP OR IW,OW BTU) ISSUANCE DATE
haaardora ah cmtandwnu as defined by Oe Bay Area Air Quality Maruge t
DisOict'l BOILER-COMP(OVERIW,OW BTU) PAID
GA '
❑Yes ❑No NEW RESIDENTIAL MECIL SQ,PT.
1 have rad the Incfelt'Coos rwmerlrs 505.25ena rt 25 C. 1 ur 6.95 M Ore OCT 2
Glif have
eonac&Safely C«k.Sections 25505.2 533 sod 23534. I Chapter
6.95 ul Nat
if Oe W i",dues ml c.orly have a taunt,that if ;my retponaOility to notify the
occu(mN Of the rtyUITIC114 which nom be met Polo-b iuuanee of a Certifies¢of n, , 1 NU
Occop .
Owrcrm auNodacJ agent Date TOTAL ISSUED BY:
OFFICE