B 0301F
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.DING- ELECTRICAL PERNITT NOS 301
CITY
DIVISION APPLICATION/PERMIT o PLUMB NG-NlKcxnrvrcAh,lr,N - SOOOI 1179[
(rr-F-i,Nw(oJb c.4 --
CONTACT. PHONE
g3 F- 3g,y-s-/.?3
I Ia eby Ohne that I tint I'Immnd under provisinu t Cmpter 9 (mmmcuing
1°y,�0 with Smion 71001n1lyivisim3oflM Businco and Pmfexvrn. Codedntylieen.wi.s
in full fore and effect.
<Uu Lmcw Gw ut.x
Der T`SDEa_
ARCIITfECTS DECLARA O
ZyZIuNrntad my plans.slall be used a+lanik rttvnd:
F- W Licrn+N Pref—iorW
yd ,E OWNER BUILDER DECLARATION
of I hereby alum Net 1 am eaemry from as, Cmaactor's Lkcese Law fa the
° G U following ,sewn. (Soon.. 7031-1, Busins� arld Pmfeainm Cufu Any city or county
3 LL which rtGuiR] a pcmdl to n nearro 1, altar, irrFrervc, dcmtish, M refer, any ramcmrt
° Prior to as mumae, dearequins, ar npdicent fiar such pmnit m fik a tinted atalGrtam
tom he is licensed puonanun td pnrvraions ofthe Coban --s License Lose Ulb"e'ri
y.GC)
° m�rnrc(cming withSecdon700o)uflTvision 3 ofax, Business ad Prnfwions Codc)w
a o that Is, is cscmpt rberermm and the hasia Im the, .paged stenyaim. Any viontion of
Seetitn 7031.5 by any applicant for a pcnon-Ina," d e appliemn to a civil p:nalty of
mx ave than five hunbed Jullan (SSWL
o❑ I.ssowner nidi larMany, or nlr emdnrea. w;m wa�ea �. mcb ante eranr:a.
will do the work, sod me be, Corers ort rmcMd m oFerd nM.vlc(Ss. to an Busman
a 3
and Pn y .1so b Coda: Tlx Conaasenrs land l law doe. rat apply m ll Warr t
his osa wbo lands or imgrl e,tdr tMrton, r s win nts ... h work hinlxlf ofcterl for his own employees, Pxovidcd that ouch imptmeolds etc on imcmksl nr Namme, fol
-r If,hoover, doe
o,a lo,lgor,rif ros,n is sold withinerryear M'rno,vV lion, the
rwnenbtildm will have the hmden of Pxsrving Ifat la did nnI huilJ or imPmw lin pur-
prsc t mk.),
❑ 1, is owner of the, PnRcnY, ur exclusively eon casting with Iicea.N aoa a on to
e.. Poor,, (Sec. 7(H4, B- and Prol Osla:) Th: CM hill -s Li -
series, law docs and apply to an nater of property asho Ivilds or irrrl roves thamn, and
w ho c areacrs for ,ch projat, with a conIaXtM L) Itecnscd sentient n tM Connector
I-eense law.
❑ IunexempuederSs. ,B&PCformiareawn
s/2014q
.DDH S' -
❑
❑ Consultant Fccs Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT
❑ ❑
PLUMB MECO
❑ ❑
)TY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KIT'CHEN RENIODEI.
C1 ADDITION ❑ PLUMBING RH-PIPH
STRUCTURA
MODIFICATION ❑ L.
MODIFICATION
❑INTERIOR ❑ CHIMNEY REPAIR
IMPROVE1sIEN 0SWIMMING FOOLS
❑ BATH REMODE-REPAIR ❑MWOLITION
❑ OTHER
PERMITISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO200AMPS
201-10100AMPS
OVER 1100AMN
SIGNS ELECTRICAL
SPECIAL CIRCUITIMISC.
TEMP MFR OR POLE INST
COMMERCIAL:
❑ NEWT RLDT(ADDRION
[ITENAN'
IMPROVIiNfENT
❑ o rHF.R
❑ DEMOLITION
❑ FOOD SERVICE
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLEI'.S - S W ITCHES - IBXT V RFS
NEW RESIDENTIAL EIACIR SQ FT
SQ. IT. FLOOR AREA
_ Sm. IT
I 0 PLUMBING PERMIT I FEE I
IO mr Date
e WORKER'S COMPENSATION DECLARATION
I hereby affirm tartar Peralty of erjury ora of IM folLwmg dealamtnns
Ihavc and wi0 mainlnin aCmif le of Conncnuosclf-insumfmWMdKmrprn-
nal-. as pmvidcl fa by Section 3700 of me L oNar Cade, rM the perfmnlmac t as,
•�wkch this perma is caad.
Uj l he's, t dd win meinuin workcra CmlyrnLwtion Ircum , - sW inW thy. e Tian
3701 o�ffda lahrz CCcr r.Lky, sf�oge,Wrye perfom wand oll rpxurgwyhcic�h dpda lnx�ml�it is ipcw�ed�
CIaWA ]T.U1r (TY EVIL/ YoIwY NoI f716 Z(W
CERnnCATIE OF EXEMPII(lN FROM WrlRK1iR5'
COMPENSATION INSURANCE
coriasection recd ort IcrnrnwlcRd iflhe 'mal "f«me naalmf fallrm(sl W)
or Eco.)
1 ¢ntify that in Inc larfrcmuae of me went for whim this pent is issued, l shall
nal employ any perum in any manlier ur u to become ohjcct to the Workeni Corall
Z saiun laws of Citlifnmia. Dare
ApM.t
NOTICE TD APPLICANT If, tinr nwking this Certificate of Exemption, you should
a ; become sun) v to the Workers Cnmpewnm Pmwision. or the Isnor Codeyear moa
fmthwim eamdy with such provisions a this pent shell be lkemd rvNd.
Q
Chea rat RUCTION 1-ENOING AGENCY
UO Iherery fior,0R mot sari isned!(Sa3007nding a.) nor the peRmnanc,t
he work fm whkh his permit is inapt [Sec. 31197. Civ. C.)
0 F -r eader's Name
[01.1 L<dn'r AJrtrtes
04 I eenify that 1 nave rend mix epplieatim ad arum mal me anuve mforoatim in
N rnnrst l egrte m rnmply W m ell airy ad cumty mdimnwxa ad slate lax, rtblin8 ra QTY,
U Z nti Win6 cnnawclitn. anrt hertnr aalMxi[e rtlMr<nl0livt,mlhiacitr memCr Upon lh`
adrac-mc iacd pryrnfon inspcc,im purpos
st
(Wands. O sera m sear, iMlemnify W keep heIbc city of Cupcninn against
Iianihlisw'.iadgrn:m.. a,an and e.rvnvc, wnien near m am Cayasdn.a sad airy
to rnnsse uercc of the psi of oris µ,mit.
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RBGULAUONS.
I IA]ARDOUS MATERIALS DISCLOSURE
Willtheopphamnrfroom buildingrmetpunt store on herdlu na,e ,el radeisl
ss defirsed by Inc Cuperaw Monicipal Coag, Chapter 9.12, and the Halm and Safely
CWc. Section 25532(a)'f
I]Yes
Will IM ryrylia. or futon bund., oestew, use cgripme. or levies which
nidi hvnrdas air ermwmirranra rest dist l by for, Bay Anes Air Quallly ManaSemcnt
Dimja'!
Yes
I have lad 0r hanaAoaa TCW intestinal
d
oer Llbt,s fi 95 of Ill Csli-
fomia I"Ith & S�dmy �C1r��/fL`. $sio 25115. I'll, ad 25534. 1 tdersmnd diad dC
buidlne dos nM Yw"1YV "iH1: a tv it is my, rtsprtxihililY In nrgi[y Ik ncupanl
PERMIT ISSUANCE
ACI ER - DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT DEVICE
DRAINS - FLOOR. ROOF, AREA. COND.
FIX'IURIS - PER TRAP
GAS -EA.SYSTEM-1 NC- 4OUHJDS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASIYINDUSTRL WASTE INTERCEPTOR
GRFASETRAP
SEWI7R-SANITARY-STORM LTA. 20117L
WATER HEATER WNENDELECfR
WATER SY91 EMC REAHNG
WATER SERVICE
NEW RESIDENTIAL PLMH. SQ. IT.
MF.CBANICACPERMTT
PIFMIT ISSUANCE
ALTER OR ADD TO MUCH.
AIR HANDLING UNIT CUT IQ000 CFM)
APR HANDLING UNIT (OVER 10.010 CFM)
IJO FAUST HOOD (WIDUC )
I IPAfINC, UNIT (TO 1011.000 II'I V)
I IEAi'ING UNIT (OVER 100.000 BTU)
VEND V310N FAN (SINGLE, RESID)
BOILER - COMP (3HP OR 100.(00 BTU)
BOILER-COMP(OVER 100.001IRD
AIR CONDITIONER
NEW RESIDENEAL MECH. SQ. FT.
m rvlh«ird al'rnl TOTAL
:
OFFICE
vALUV ;6 ON
BUILDING DIVISION FEES
PLANCHOCK FEE
ENERGY ITE
GRADING FEE
SUITS FEF.
PAID
Doc Rscipt M
BUILDING IEP
EEE SHISMICFEE
ELECTRIC FEE
PLUMBING FEF.
MECHANICAL IEE
CONSIRUCHON TAX
HOUSING MITIGATION FEE
TOTAL: