S 2782AP4l1CANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONfl-ERMIT DING PROJECBING - TIDENTIFIC
H1111.1IING PROJECT '
PERMI Y NII.
C� 2782 0 2
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BUILDING Ord"..SS,
SANITARY NO.
APPLICATION SUBMI I I'AI. UNIT
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ARCHITECT'/I?NGINpER: .IC NO
fIDDRESS'.
COyTym PHO�i:`'I
BUILDING PERMIT' INFO
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❑ Consultant Fees Paid by Applicant (lniltal)
BLDG ELECT ELE IT PLUU-MB MICA
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LICENSED CO 'RA :S DECLARATION
nanny affrm mm I :m, ueen.ae tomer provisions nI Claprtr 9 (a,Imnendng
whh Secti 700fini'Divitinn none Rosiness lm, I'ro ssi .Gude, undmylieeaeeis
A
full tome and ullde,. U
License Lic.N
Da¢ Comrades
Q'pV. FI,F TRICK MIT FEE
.FOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑ KIT'CHEN REMODEL
❑ADDITION QPLUMBING RE-PIPIT
ODLTI-UNI' ❑STRUCTURAL
MODIFICATION
DINTFRIOR ❑CHIMNEY REPAIR
0SWIMMING POOLS
ATH RP,MODIiIJRHPAIR C1 DEMOLITION
❑OTHER �J
!J/4%/ 1 %2ct
PERMIT ISSUANCE
AYPLIANCI!S—RESIDF.NTIAI.
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Alt'111'IECFS DEC.ARAON
I unJeremnd my Plan. ,hull rte used as puM1lie recorzi
PANELS
Oil TO 200ANIIIS
(3 W
cowe m z Q
V
3 O vF
04n
Licensed Professional
QWNI?R-BUH.DER DECLARATION
1 hereby aRnm Ina, I am exempt from Ne Commeror's Licen¢ Low for the
fidlerein.....om(S,atm.703I.S. Busincssand Profs,ionc Code: Any city m county
which requires a permit ,o construct, Ate, improve. demolish, or repair arty .torture
pn: I I :: ,aLtenpinstheppl ' ,r M1I ), 11 '6 I:rmmem
?01-I000AMPSEMHNT
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUI I/MISC.
.
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L IlatG
xIw
hZ}
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{y.0
nalCm
1hath I Iponlu J p lam. fll ( Ir , L (Ch,pmr9
(co h ',h Sen 9(100) fllve :,File Buires and ],fast U,c Cock),,,
chat be Lv exempt therefrom end the hasis fonhe alleged exemPhon, Any vinla,i.n of
Section 70.11.5 by any applicant for a permit subjects the applicant,, a civil Penally of
ore than five hundred dollars (5500).
.11, me
1. as fthe property, Y employees with wagesa their I com,persation,
will ,h k Ilhe.l r ,' acadici or (chnnalf le (Sea 90M4 Has sa
.,ad Prote,i ... t, Cc.c I ha C oure,tor, License I ply of
IhMR MEf1.R OR POLE I N S'IL
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TI?NAN'I' ❑FOOD $HRYIGii
IMPROVEMENT
❑OTHER
POWER DEVICIS
SWIMMING POOL ELECT RIC
OUTLI'I'S _SWI 'I'CUES -171X'I'LIBIES /
/
L 6
property wit, hold, or in prnvs,hcreon, and who d,ws...It work hire,melf r Ihr ugh
Itis own employees, provided IImt such improvements ore nm intended or a fecd for
sale. If, however, the building to improvement is sold within one yearof completion, the
NEW RESIDENTIAL ELECT R SQ IT.
SQ. P.. FLOOR AREA
5/SQ. PT.
ovrra-buildcr will have the burden of proving that he did not build or improve for puf-
po a of role.).
❑ Lac towner of the properly.,m, exclusively umnaotiag with licensed mantmmmr, m
TOTAL: 26 1 60
••r
Insmmt Ila pnl,l,c, (see. 91114, uasma,, and cil'l ..lout CH,:) Lot Cn i,acor'.v hi-
-
acute, Luwdnewo, .,I, .,at owner nf,upany who builds or improves ,hereon, and
UPY. PLUMBING PERMIT FEE
who contracts fnrsuch pmjecl, with a commetor(a) licensed pursuant o the Contractor's
Licence law.
I am exempt under Sec. ,B& 1' C forthis reason
PERMIT ISSUANCE 3ss�
ALTER - BRAIN & VENT - WALL '17R LEA)
Owner Date
VALUATION
5-Lz5,0 �-
WORKER'S COMPENSA'GON IdECLARATION
HACK FLOW PROTECT. DEVICE
I hmbyuffinm under penalty ofPer,myoneof the following Jeclamdnns:
18
❑ I bmennd will mmeoun sCeniOcmcof Ccamem moelf-moor, for N'nrkrT',Co.,d-
satinn, a, provided for by Section JTBII of the Last, Cale, for Ibe performance of the
kfmr which this Permit is issued
will immuce, as ll'IrcJ by Section
DRAINS- FLOOR, ROOP,ARHA, CONE).
STORIES
TYPE CONSTRIIQ'ION
�r�' J
^�-
FIXTURES -PER TRAP j
. ormatain pkclurnmmnthewation
- of the Lah,a Codd rk lot witch it stm.1.
�}} ]]
My ir, 'LL IS
CrHo
tTGOPIi%E
GAS-EA. SYSTEM- I INC. 40U'IT.I'RS
OCG (ilt011l'
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APN
3BgU���
GAS -EI. SYS '1VM-OVHR4(EA)
ETIFlI AVI'IOnI Ob1WOR10.
AA COMPENSATION INSURANCE.
GREASWINDISN111, WASTE INI'ERCF.PTOR
BUILDING DIVISION FEES
(Thisoc,linnneetl not be completed ifthe permit is forma, modruWnllms(S IND
or less)
GREASE IRAI'
YLANCHF.CK PCE
Icertify chat In Ne prfnrm,umoofche work cur which lhixpemlil lsitwul, Ishall
no, employ any parson in any boomer sons In h,nmm suhjua m,ha W aoc,' Cmmpen.
SEWER -SANI'fAItY-S'T'ORM PA. 200FT.
HNI?ItOY FHB:
WATER HEATER WNENT/HLEC'I R
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sation Lows of California. Date
Applicant
Fli
GRADING
NOTICE *11)APPLICANT If. after making this Certificate of Exemption, you should
become athj,o to,he Worker', CourKmation p,oviior, of Ne Labor Calc, you most
forthwith comply with such provision. or this pontic shall be deemed revoked.
CONS I is a trONLENDINGAGBNCY
I herehyal<thu Naulerc isacn ((ammo ]coding agency tonne lmrfnrmance of
,M1e work for which ,his permit i. issued ISec. 109]. Civ. CJ
Lender's Nwtic
WATER SYST'EMf1 BEATING
$DB.S PDI?
WATER SERVICE
PAID
ate Receipt If
NEW RI?SIOIiN'1'IN,PhMH. SQ. F'I'.
TOTAL:
Lender's AJArest
TOTA 1.: 6g,,
IUILDIN(1 THE
cenily o comply 1 nave read ll city anealim and boa chat the u al, l w—lauton is
all city and comfy onlin sand oily to eider
c Ieux f:Igrea,fr,ad de,
building a,n.tmedno, and hereby authorise repra,entmlvos o[Nis city munmr upon the
Q'fY. MI?CfIANICAI. PL'I2MIT PEE
SEISMIC PER
PERMII'ISSl1ANCE
ELECTRIC PER 6. 6
above-memion,J property for inspection pur amu.
(We)agrcc to save, indemnify and keep harmless the City of Cuprioo against
liabilities,judgmants. cost uad.,t rocs whichmay in any Way accmcti,mmisaid City
to ran xquence afthegmaur,ofthi, permit.
ALTER ORADD TO MECH.
PLUMBING TTI? 6-ar„ 70
AIR HANDLING 11N1'I'CfO IOJNxICFM)
MECHANICAL PI?li
APPLICANT REGULATIONS. AND WILL COMPLY WITH A1.1. NON-POINT
SOURCE RI%,111.ATIONS.
AIR HANDLING UNIT (OVER 10.01NI CPM)
CONSTRUCTION TAX
Signature of Applicam/Contmnor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST 11001) OVIDUCT)
E
,MATING UNIT (TO I00,000 ll' 1' U)
Will the applicant or from: building occupant store ter handle haralloos material
as defined by the Cupertino Municipal COL, Chaplet 9.12, and the I Judd and Sntmy
Code, Se,cion 25532(x)1
No
❑Yesn�f1
Will the applicant or future building mcmpnl use equipment or devices which
emit haeardou, air contaminants us defined by the Hay Area Air Quality Management
Y Y 6
DinricB
❑Y,By
HEATING UNIT I (OVER 100, N)II It'IU)
VENTILATION N(SINGLE RIiSIU)
M MA.1,
pp ,
LAID
L1 J_lle J
cipR
BOILER- COMP THE OR 100,0HI H'I'U)
TOTAL: '
BOILER- COMP(OVER 100.00HIITU)
AIR CONDITIONER
\
I have rcuJ the haraNnus n,a,crialslequiren,cat order Chapin mf the Cal-
fomiu llexlth&Safety CWe, Seniums 25505,''5] nd 25534.1u u. JWm if Ne
-din ms nm currcn0y havcatenan6 Nat- ty resrym.ihiliry a yNe cecupa
ISSUANCE, DAI'N�
NEW RfSIDEWHALMECH. SQ. FI'.
oft mon which robe he ran Tocola Ce'man focalne
ISSUED BY: T�L ��%J tiL.CCC•
TOI'AI.:
water, .nnher,dagent U e
OFFICE