24948 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO, 24948
APPLICATION/PERMIT PLUMBING-MECHANICAL
RUILUING DIVISION BUILDING PRO3E,Qf IDENTIFICATION
BUILDING ADDR�SS:7 //�J (//' SANITARY NO. APPIJGTION SUHMfITAL DATIi
Z/ (/ /•
Py
UNIT# LOT#
V,WiRS NAME PHONE NTRACfOR'S NAME UCaNO: NIC COMROI,#
�1RC11ffF.CTM"GINE LIC NO: ADDRESS: ❑
S Z
CON'fACf: PHONE
_ TY. ELECTRIC P.RMIT FEE
BUILDING PERMIT INFO
L Zl %.UM ELTI
�I� A�� �?� 'p/Z PFRMI'1'ISSUANCE
LICENSED CONTRACTOR'S DECI.,RAT10N APPLIANCES-R EFITAI. JOB DES IPItON
mwIMcby effirtn thatlam lian.te underprovininns ofChaptn Ylc«nmcrcirmg wilM1
w�00Saturn]0nefDiviaion3of the Nusille«old Pof¢ti«u C«1e,Wmy license sin PANELSEa /� �/� #
yw11-- u fix. Rm.
FZy Licmac Cl„"• Lic.X UPI02WA
,nQy Date Common!
,Z FONZ ARCHITECTS DECLARATION 201 I A PS Sp.F,f.FL AREA
Z0,— Iunacrslnnd my plan.dull4 used ea pumkra«dn. OVERT AMPS f/_JyV■r-_'/ ,I1y9. ��{1.
F c EcrnlcAL V
YocJ Limue Professional /
,eQ OWNER-BUILDERDECLARATION C LCIRCUIT
°.JOaFI thereby affirmffirm chatI wn Hemp frim ides Conuoctale Liceme Law for
the
y R.�O V' follmwing rtwn.(Secaim]0313.Btsdrla end Rafutima Coac:Any city«c P.MEP" LE INST.
which requires a permit ,,cdm4rcl aper,improve,d aulish.«repo],any,amour
pion to leaIssuance,also"aims ft.,lieum for such prmlt to file.m,W autemem WFRD
ty ooZZ_ O that M Is liccn.cl rmuanl to do provisions of Ce Canuactala Liceme Law(Clop«
1px, 9(cammencing with Sectidm]OUTI of TNviiltm Joflhe Buainw and ltnfwideu Code) $WIMMIN LEU'CIRIC VAI.GATION XI
W'-4tQ ear dor he it eaemptherefrom andbe Ineds far the alleged caemption.Any vu,au anof / ♦ Q ��
Section 70315 by any.ppperm],subjects the appliont co•civilpmalryuf OUDETS-S CHIS-EDCIURfs y{r'1V\
mise nxae idem.five humbedl"Harx113001 NEW RISIDLNIIAL ELICIT _SQ.FT.LlI,aeowmrntth Mp y.ormyemployemajO agwutkirwlernmpeme m, RIES TYPECONSTRUCTION
d3— will do the sours.and llcntrdurt EarminterabiuoHucd for all 7] .Businera
and FTofeuvons Cade:The Cammarlo/a Liaese I.w dorso.apply tot an owner of
pmpcny wlw bu ilJti«impovn Oacrto,end who d«a Hoch wvh himrcl f or IM1ruugh his
R U ITS
cmpbyen,lima ed ,rovehinrpwemrnmve one
iear of donoffemd(«sawn If. P
however,thebuildis,bur pf raving
shat within of ampldi feetheownn-
builder will have the burden of proving that be,did ma build«improve for purpate of
We).e.).
❑ I,mowrlerd'tic psWertY,areaeluaivelyamnrroningwithlicrnted antr.ctonto QTY. PLUMBING PERMITFEE E % Al
rooalmcl the poria](San 9044,Bnsirle,s and Pndami«le Code)She Commit
licmrse lewd«std epplym anowarofpoprnywho buiMa«intlewnlherml,add PERMIT ISSUANCE
whoantracm f«such popes wiNamntract«(s)license Pursuant to the C«mmnol. AL'IFR-DRAIN&VIN'(-WA'I1R(IA)
license Law. FEE SUMMARY
❑ I am exemp sea Sa. B&P C(m ides,man BACK]ROW PROTECT.DEVICE? ID
SANITARY Y N
t �:�;Owoe, Dale RECP,IPTX
"aS WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR ROOF,AREA.GOND.
SCHOOLTAX Y
l❑'tlhnebyafinettthallhaveacenifteate Of«opy thermf(Sname,«Lan.)sect FlxILRrs A;R TRAP RECEIPfX
Wwterv'Compcnatian lruurane<mrnccnife copy thcrmf(Sa.3AW.lab C.)whicM1 ' �_ PARK FFJi Y N
N TcoOemall employa'a urdv this permit. GAS-EA.SYSTEM-I INC.4 OOHETS RECEIPTX
-Pr iry# BUILDINGI VISION IFPS
m1unY GAS-EA.SYSTEM-OVER 4(EA) PGNCHECK FEE
[red'”copy is httehY furishai.
❑ Cmife ct5ry is mea with the city imr(ccuan didsimn. GREASPJINDUSTRL WASTE IN'IERCEPIOR
ORADINC WE
CERTIFICATE OF IDTAUTION FROM WORKERS' GRGSETRAP SOILS FEE r
COMPENSATION INSURANCE
Mianectionree ll I be eranpvnl ifthe perrmit is for.huMrtJ aol]erz(1100) SEWER-SANTI'ARY STORM I'A.200Pf. ENERGY EEE
m 1.)
I anifythu in the,perf«mvee of the w.«,for which Nis permit Is imanti.l shell WATER HE)tTER W/VEN/ELECIR
nm mill,any paaun in any manner an as,In M1ecame aubja5 to the W«kec' PAID
Z Compcmwio Wwn of Cdifomiw Dao WATER SYSTE,VTRF.ATING Dare <ipt
Applicant 1
z NOTICE TO APPLICAM^.If,after making lhls Certificate of Esemplimm,ynu dtooW NEW RESIDENTIAL PIJOB. SQ.ET. T(JfAL:
b««ns subject to the Worker's C«mperuallo povlsi«u of the labor Code.you must
forthwith campy with such pmvisi«s«I his permit shell he dcerrcd revoke. BUILDING FEE
OW. (] CONSTRUCTION LENDING AGENCY SFJSMIC FEE
Z I hereby afllrm but Here is.c«nau:timn Enid,agemry f«the pecf«nlen<af
U Q the word,for which this pmmit is isnted(See 31097,Civ.C.) 1,: ELECTRIC 1' r
Leeds Name
LL U l<micla Aedreaa QTY. MECHANICAL PERMIT FEE PLUM e
1 certify that 1 have read thin applicmim and.,rate that Ibe ehm
uve infomlimt is
W conrcirs'e me lnromply withyatudy.rd conryidarivrcn maiyo,am rtlwingm PERMITISSUANCE MF NIC LFEE
hheme-meminn xtiirxm,i,d hereby euthoriu repvenwivn of lM1Hciy rot enter upon the
ahwc-mcntione n f nidm C NS UCIIONT %
L.) z popsy «Impe pugrow. ALTCR OR ADD TO MECII.
(Wed.grtc Muss,indemrdfy and kap twmins the City of Cuprtirw egeiw
Iubi0lier.Judgmenm.costa erdca sen which Huy in vry waY.cvoc.g.irt anid sty AIR FVWDLING UNIT(TO 10.000 CFM)
in con"umce heg tin mit.
AIR HANDLING UNIT(OVER 10.0)0 CEM)
"6^
Sigwu ,f AppicanuCcummnmc Dat EXHAUST HOOD(W/DUCI)
PAID
IUkTARDOUS MATF.RIISCLOSURE HEATING UNIT(TO 100.000 BTU) Da¢ Ramp#
W;Il the vpplicent«filum building rcca tetdaemhenalchvvd«aa materiel
ae dcri a by ms Cupenim MunicipW Cddc.Chapter 9.12,arm dlc Health ami Safcty HESTBJG UNII'(OVER 10 culfl BfU)
Code,Seen 0Y ❑No NT255J2(.)^
❑ VENTILATION FAN(SINGLE RESID)
Will IIY licant«futtrm bui,8 ma BOILER-COMPfJHP OR IW,000 BTU)
ISS NCE DATE
.pp rmg ulwttueayuiprrmt«derimwhichemit
conuameards u defined by the Bay Arta Air Quality Mmagemenl BOILER-COMP(OVF,R 100.000 BTU) � A,
touts air #'Y
009 ❑Ye 0N NEW RESIDENTIAL MITCH. SQ.FT. AUGI hove reW the lar moo es nwcrieH r,.bcdsaD under Chepw 6.95 of the ryry
Califon.Health A,Safety Code,Sections 25505,25333 and 25534. 1 unMv.d dw r
if the building dus not cvrmltly have a utum,that it is my otNtionsibility to notify the /k yv
Kcupml of ides rcyuvemcnu which must he mel pili m istunna of a Cerdfcate Of V�I I LJt-
Oauparrcy. � I�eu
aaaai
Ov sr or authorized Mem Doc ISSUED BY:
OFFICE