24860APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILI)ING-ELECTRICAL PIiRMrr"" f� 486 0
BUILDING DIVISION APPLICATION/PERMIT „�,,, orrr �Iu°"'opmlvmfeL'°nu,r"iC^I. rrrN en M,Yi4 G
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LICENSED CONTRACT'OR'S DECLARATION
I herebyaffmn tint l an licenadunderprovisensafClupm9(commeming with
Secure 70f)(1) of Division 3 ofthe Business and Professions Code, and my liceme is in
full trace ande ';
Littn'0 I41 NP
APPLIANCES - RESIDENTIAL
PANELS
p• ��
TO 200AMP5 G
JOB DESCRIPTION
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Dam GOmV q DECD
� ARCNffECTS DEC R
lundersund my Plans andlheused as Wb c
101- 1000 AMPS
SQ. FT. FLOOR AREA
OVER IOW AMPS
SIGNS ELECTRICAL
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'd - ,. , ._ OWNER -BUILDER DECLARATION
1 hereby affirm then 1 am esecep from he Conmeeola Li. Taw for he
following reasma (Bohan ]0313, Buainae coed Roteuions Code: AnY city a munry
which requires a pvmit u cmmwcl. Nmr. improve, demolish. o sepur any swttun
prime imissuu¢alwrequirnthe applicanlfmwch permittofileasigmd summent
s licensed ptmmnt N the pmvisiou of Ne Conuacmis tisane law (Chapter
thss he i._"
with S7)efDivisian 3aflhe Business cood ProctalmCode)
9(commencing aum0W
rather he is exempt thvefmmaM the basis for she alleged exemption. Aayviolulmmf
Section ?031-5 by any applicator for a permiraubjecm the applicant N a civil pemlry of
nm mute thin five huMrtd dollen 15300). ,. �
❑^I.mowneroftheproperty,mmYesnPlayaswithwegesutheirwlecompen anion.
on Code: The Convwmla Lew don not apply w w owner of
end do Nework Cde,. The rnueisnmimm�dedmoffemifmnle(plyW an cancer of
and
SPECIAL CIRCUITMISC.
TEMP. METIER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
.,
POUTLETS - SWITCHES.FIXTURES 6 .�
NEW RESIDENTIAL ELECRI _SQ. FT.
STORIES
TYPECi
eny wh who
pre mplohobuildsraimptova Nermrs.vmmmmmtihwohhimalffmro e.hf,
conemployee;pt titinsuchintiswlmrnuarenothoardedopl cm,i sale. If,
OCC. GROUP
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•roTAI:
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bowirvaill haved'mgmGnp fpcovitithathothinoncyw or improcdagtMownv-
Sm
builds will hove rls bmdco of proving dunhedid not bMldmimpove fm psvpoee of
.•
❑o-acwnitoa
remexclusiv uu4ng wiCtholdiae)m
FLOOD ZONE
tiAV.L14 eGaiY �CamK ev. C
cmutran, she project (Sex, 70 Bunioand Perofeaua ThMewCn
Lerawm.gglymwoao(proprtwhobdmmmaa,kad
PERMIT ISSUANCE
whocontracts svchprojecte withawnuacmr(s) licensed punuwtwthe Comromen.DRAW&VENT-WATER
l:
(EA)PBB,S
MARY�;,
, �.._.......1%fl.4l
-
[3, 1 am acmp rads Sm. , B @ P C fm Nis recon
-
BACK FLOW PROTECT. DEVICE
SANITARY Y N_
Owner Due
WORKMAN COMPENSATION DECLARATION
DRAWS- FLOOR, ROOF, AREA. COND.
RECEIPL'N
SCHOOL TAX Y N _
_
❑ I hincty affirm the l have amdfiate ofmroern Waif -inure. or. aatiGcamm(
v ified copy thenf(S.. 3800, last C.) which
Workers'Compenum Bnurm.or. eenrc
moven ell employssuvde this pemdt. -
Policy M
a
-PER TRAPRECEIPT
PARKFRE Y N_
RECEIPfa
GAS - FA. SYSTEM -1 INC. NOUTI.ETS
BUILDING DIVISION FEE
Company
❑ CEAlfied copy i leenbY fumielud.
GAS -EI SYSTEM -OVER(
'�
C
�isnified copyisfded with the airy impeeuon division.
GRFASEPiDUS WASTE eRC R
DW
CERTR7CATE OF EXEMPTION FROM WORKERS'
GREASETRAP
1 P!'E
_
COMPENSATION WSURANCE "
SEWER -SANITARY -STORM EA. FT
(TMs cation neednot be completed ifthe permit is for one hundred dollars(5100)
ra IcaJ
thuinthe namf far whiche iubject to the
��"`
WATER HEATER W/VEN Nes.cCflt
mploy inWoalu0
person N my mouser w ss m become subject m the Wmkcri
nm employ my r sm m
PAID
,Z
s
nuy
Compemetion lawmf Califomie. Due
Applicant
WATER SYSIEM/TRFATING
Uam RmcipsM
NOTICE TO APPLICANT. If, oftertrWcing this Cerufiam of Exemption, you should
NEW RESIDENTIAL PLMB. SQ. PT.
TOTAL:
G In
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become subject w dw Waite. Compenmtia surecdmmofthe labor Cok.you must
forthwith comply whit such provisions or this permit atoll be deemed revolud
BUILDING FEE
SEISMICFEE
LQ
CONSTRUCTION LENDING AGENCY
DZIhereby
O
F.
❑ C.)
" W
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y
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aft thin there is e commotion lending agency fm the performance of
he worth fm which this permit is issued (Ser. 309], Civ. C.)
Landale Name
Londe!. Address
TOTAL:
ELECTRIC FEE
M#{ V ^}q,Ywuem4.AH%y b*v!@91n14tiY.' J: 'IjW:drS+i i1'
QTY. • 4°.MECHAM(AL PERMIT i=..� FEB
1e' 1._. - 11
PLUMBING FEE
1 artih Nat 1 Tuve tad Nia appliation area Lute that the above infomution is
correct. l agree to comply with dl city and county ordinances and sum laws mining to
i
buildng concoction. and herby suthoria expreamuivesof Nis city memeupon the
above-mentioned p ave.ifmimpeetion pupohar
(We) agree ss ave, indemnify and kap the City of Cupeniao against
•• ,e.::a :r>-nauw•.'� .s
PERMITISSUANCE
ALTER OR ADD TO MECH.
MECHANICAL FEE
CONSTRUCf1ON TAX
cosuand ex pain which may in any weyacrneageinstuid City
may id
AIR HANDLING UNIT (TO IO,Of10 CFM)
incrommiluudgmrnn.
in consequence of the granting of this permit.
AIR HANDLING UNIT (OVER IO.IgO CFM)
Signatureof ApplianUCo rrecmr Date
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Date Raeipt0
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Will the eppliart or future building acupum came, or handle h timmus material
se defined by the Cupenino Municipal Cod, Chapter 9.12. and the Health and Safay
VENTILATION FAN (SINGLE RESID)
Cod, Section x)?
Yes,
❑ Yes, L9h
Will i1m.,diommrfumm buildingmcuparomic tipmcmmd,Ams whichernit BOILER- COMP(3HP OR 1000,000 BTU)
harardous air conumiments m defined by the Be, Arae Air Quality Management BOILER - COMP (OVER Hill BTU) F A i D
District? ��
❑ Yes EPN. NEW RESIDENTIAL MECH. SQ. FT.
1 have read the harmdous maedis rquirmemn under Chapter 6.95 of the - MAR 15 1993
Culifom a Health L Safety Code. Sections 25505.25533 and 25530. 1 understand that
ifthe building does not cursntiy love a moms thin it is on, rc,omibility m mrify the C i) Ur vu rrn IvU
ecu which must be met prior to issuance of a Cenificate of
Oce - y. 3-6--93
Owittn such air , Date TOTAL: ISSUED BY: ✓
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