S 1226 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY04'CUPERTINO BUILDING-ELECTRICAL rEliymrl'NO, 1226
Ituu,nIN6 DIVISION APPLICATION/PERMIT rLunlHmr..mF:cunnlcnL �`,J
•,'B(IILUIN(:P12O.IRC'f SDICNT'IFICATION/ U.""
*UILDINC�I�R ,•i•�� SANITARY NO. AI'PLICAI'ION OSIJHMII"IAL DAPI!
PI I!: ICIORSNAMELIC NO: , � I #N/C CONTROL#Lso
PHONE: VY` 'Vt"BUILDINGPERMITINFO� � ❑ Consultant Fees Paid by Applicant(Initial) R )G ?C" t MEI.ICFNSPDCONTRACTORSDECf ARATIf)N t r, - - --r ,
QLY ', I.LECTRIC PERh11'1',., ' 'MI Ea:.`
l nerebr arrmre 11d d p ,. : lcbamer9 canon A , r . - -,. JOB DESC RIPTION
.,It Seat o i➢Jill)of Divi;,r 3 of the Fits and Professions Cale and my licenses RESIDENTIAL'
m OO PERMIT ISSUANCE
I�W F in full force and effect. ❑SFUWL ❑KI,CIIEN RFMODEI,
QUU License Class Lia. APPLIANCES-RESIUEN'UAL ❑ADDITION ❑PLUMBING RIS PIPE
NGL Dale Contractor
Dm ARCIIITELTS UECLARA'IION 1'ANIi15 ❑MUI:I'I-IJNIT ❑STRUCTURAI.
ZONZ [understand my Pias.hall bauscdasponlicen,ard. ^ ClJIMNMODIFICATION
O Z�J� Dp T02W AMPS �/ INTERIOR ❑CIIIMNEV REPAIR
F.,4an I'.....II GeeroW Prom,,miralTION 301-1000AMPS IMPROVEMENT El SWIMMING POOLS
CCC 6 I thereby affirm mer IOWNam yxtranLEmn the Contractor's[teeme Law for the OVER 1000 AMPS ❑HATH REMODEIJRI:PAIR ❑DEMOLITION
3 a F following reason (Section 91131.5,Rosiness and Professions Cale:Any cal y or county SIGNS LLEC'I WCAL ❑OTHER
F O Q which maim ns a permn ,,construct,altar,n,inrava nein„lisn.nr renair any orest c
J
lition, .. al reunite,the applicantf hpe—it fl y datmemem SPECIAL C[RCU IT/MISC.
' } dhath I �dpom I h p 'tan fIM1 C tar I' I (Charer9
�QpO (ca g thS«n 9(10(0 fll'vivi 3 Ill 11 as dl f.:' nsCrde)of ILMI'METER OR POLE INST. 8 �:
thA he is excerpt(therefrom and the halts for the Argot!uien Iumn.Any violemn of r RLDGIADOITION ❑DI!MOLFI'ION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally 0t POWER DEVICES TENANT ❑FOODSERVICE
nod more Iran Eve hundred demos($500).
FZY ".,a OVEld
C 6 ❑ Lee owner of the pmpeny,of my empiny.vs wish wages anheir sole amrpummun, SWIMMING POOL ELECTRIC
2�0 will do the work,and the duration,is tar Intended motored rordale(See 9044,Husinasa 11 OTHER
F
Lam
mWro Colt: oLicense Lawdoes not Imowner
( FIXTURES
pmpernywhb idor improves thereon, J M1 d .such work hi lfof throughgh F
his r
own caliployers,provided[list h improvements d. rc nor miciated at nfl'a,cd or NEW R0.51DEN'I'IAI.RLI!CTR SQ Ifl'.
sde It the building or an1 'ea can,,,old ninut lar,auirf completion,the S(fj7ACj)ggU!A $ISQ.IT
-builder will have the burden of,wria,than he did int build or Inrpmve for par-pave
ar- M.
qar,erof )
[]I f the proper, I : lycontracting 'th licensed I tors In - - ']DIAL: yy �r
JrD
construct s ct thproject is ]BbtB I Pnf:.' n.Code)Iec d dors[. )• re r -r - . r AKAR 8
nsc Law does nodapply t an ownu afp gany xho n
bolds ripr beo
ns . , 1 QTY ' PLUMBING PERMIT � FEE'
xboconnucts Ovsuchprojecmwidhacumtructor(s)Iiccnsc.Iprmuatalolhe Contractors r',
License low. PERMIT ISSUANCE GIIY ' (°
C]I urn exempt under Sec. H A,PC fonhi,rni,mn
Owner ])ate AL'1'f:R-DHNN&VEMf-N'ATI:R(I-AI VALUATION
WORKERS COMPFNSAI'ION DECLARATION RACK PLOW PROI1:CI'.DEVICE
I hereby affmn unser malty of parlary one of the following Jeclamtiom:
❑I base and will maintain a Cenifca,of Comentto selpasure for Worker's Cotnpen- DRAINS-FLOOR.ROOF.AREA,COND. S'IURILS 'I'YPI!CONS'I'RUCTION
.taboo,as provided on by Sectio 3700 of the Labor Coda It,,the perinnnunc.of the -
w rk ls iwhieefm
hlhis Pa is i—ed, - 19K1'URiis-FEE TRAP
I have and will maintain Wndsf,Comprmodhml Insurance,as remain J by Sectio
J ofdhe"bar Cole,for the perform:mec attire work for vshal"hi,permit is l"ual. GAS-FA.SYSTEMI INC.4O(1T[.IdrS OCC GROUP APN
My Walk c' encafnn Insuronw aur cr and Policy num e s
m
Canters o � Policy Nn.: CAS-1!A.SYS'{LM.GY1!RJ(EA)
1/dtnC T}FUC']E OP i%li ItI'[ON FROM WDRKERS'
^^✓� C/COMPIiNSATIONINSURANC�. GREASPJINDUSTRI-WAS 11;IN'I ERCEPfOR
Bl L 'Ci >IVISION FEET;
(Thi,section need nal be completed ifthe pec,it is Ionone hundred dollars IS IW) GREASETRAP
orlesaJ - PLANCHECKF
Loy tiny Eatontwoon in ptriaanturner
nnrofthe wmk Rn which this IscrLire Wkurv'Com,sall SEWER-SANITANY-S'[ONM CA.301114.
not employ any person in any mnnerw osmbmome subject to WnrAcri:Cnmlwn- ENERGY FEE
Z saline Lawsol'Culifnan.Data
C) C) Applicmn WA UIR HI!ATFIt WIVI!Nr1EI.ECUR GRADIN 'Eli
rr NOTICE TD APPLICANC
[f,after ranking this Certificate of Exemption,you shoulJ WATER SYS'1'1!MJI'REAI1N
' G SOILS
a > become .bar,, it,Worker',Caopen......n Prnvixiniw oI rte Lubar G..to.yon nnist
7.
fmlhwith cuacdy with suetplowmaroor this permit rhall be deonnd revocad WA'fERSERVICE
CONS're isC'r runc!NDINGAGENCY NEW RISIUF.NPIAI.PIM 13 SQ,FT. PAI])
z the NeceiplN
L)0. I flat xx :dF nn that Dere is (ea.30 lending a&ency for aha perfomranm of
the work Inr which this pcnnid is issued(Sec.30YJ,Civ.C)
'� E"o IsnJer's Nanta TOTAL:
V Lento's Addrexx IGTAL
Bl11LDIN FEIi
I certify that I h aJ this applicationd state that Ih M (0ntwfon s r f _
� h conal lagmetocoapfy win,.11 cily 1 Iy v' I:rI l . mmHg to QTY MECHANICAL PERMIT I ';FEES'
U ,Z thuildng cmivlmLion and thereby audhrve representatives offiffis city inciter uponane Lr SEISMICTE
alnrve-mmnioned pmpeny for i r,pectinn Imrinawc PHRMII'ISSUANCE
(We)agree w Save,indeniiiify and keep Imnalcss the CII,of Cupertino 1,ono k7julELECT IC FEE
liandities,judgmenda.ca...bull expenses whVhuay in any way accfue li'mula mid Cidy A 'I ER OR ADD IO MSCI I. �� PLUM[ NO FEE
in All
ounce oft tingof thi s Pem,it.
All LICAN'I OF F: ANDS ANI)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO 10,IXXI CFNE
SO IRCF.REGO ,T �S. MECIIAN FEL!
n�Iry.IyQ AiR II ANGLING UNIl'(OVER 10,000 CFM) CONS'I'RUCTIGN ' X
Sip re of can✓.ni actor Data
p%HAUS'I HOOD I WIDUC'I) HOUSING h11'fIGA'll PY.E
ALA JS MAIP.11 DISCLOSURE
Nk
WdIIhcuppimr nr linurohuildingoecupnis, ruof handle nazatdme mmcrial HEATING UNIT T0100,0X011'fU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the healon and Safely
Code.Section 25532(0)^ HEA'I'INC,UNI'r(OVER 100.00 BTU)
Cl Yes ❑No
VEN'I'I_AT ION NANISINGLE RES IIII PAI]) Uwe R,,X#
Will are applicant or future building aucupant Ine equipalnnl an Aeviaes which
rt Mla.Nom air untarninanl,as defnal by Inc Roy Area Air Quality Management BOILER-COMP(31,111 OR 100,000 BI U)
DoOT L:
arca”
Yes No
BOILER-COME(OVER 110,100 BTU)
❑ ❑
- [have rcaA the hamnhws maicnalsmyuimnemi umlcr Chapter 6.95 of the Cali AIRCONDI"1'I9NFR ISSUANCE DATE
(rota llexlth k Safety Code,Sections 25505,25533 and 25534.1 undo land dhllf the NEW RESIDENTIAL MPCH. SQ.IT
hotting Docs nn d c ua my hivc:Icnnin,[hut iI ie my rcalwnsinilidy to notify the oceuptim
of the requirements which must the met priorm issuance of a Cenificme i f Occuµlncy. Ic `
11 MAY
Owner or authorized agent Data v� TOTAL: ISSUED BY:
OFFICE