S 0052 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[B.Uli,DING
TY OF CUPERTINO BUILDING-ELECTRICAL PERMIT
BUILDING DIVISION APPLICATIONIPERMIT PING PRNG cTii, riFIC �,vw sT
BUILDING PROJECT IUFNTIFICATIUN ��7�J`..' •L
AIIDRGSS: SANITARY NO. APPLICATION SUBMITTAL DATE
O 5 %;1AAj
' \ML PHONE: CO ACTORS N _ LIC NO:
WW
NIC CONfRO1,N
ARCHITECIYEaGINFER: LIC NO: DDDR ❑
I Q-lt5Co13. L SS )S\moi
CONTACT: PHONE: BUILDING PERh11T INFO
❑ consultant Fore Paid by Applicant(Initial) BLDG ELFCIPLUMB MHCH
❑ ❑ ❑
LICENSED CON'BEAM OR'S DECLARATION QTy ELECTRIC PERMIT 1 FEE
I beRhy afhrn wr I am Iieenaed under pnavatens of ayvef 9(edmtmer�ing JOB DESCRIPTION
DMZ with Section 70000fDim,idm3nfThe Burinuaed l'mfesakma Gds,andmyfieenae is RESIDENTIAL:
` ulOp s�� PURMII'ISSUANCE
in full fusee std eflc 47��� ❑SfTJWL O KITCHEN REMODEL
uss.Clue — Lica APPLIANCES-RESIDITTIAI. ❑ADDITION ❑PLUMBING RH-PIPE
j FZia) Ila¢ Cnnntr l Qe T..
t Fly ARCUFfECTS DECIARATION �
PANELS MODIFICATION OSfRUCfURAI.
Z O Z 1 Inxlersurd my piatn shell he used u public remrda MODIFICATION
❑
OZ�O ' UPT02N)AMPS INTERIOR 0CHIh1NEY REPAIR
I-NE-W ueei Pmfasidmul 201-1000AMPS IMPROVEMENT SWIMMING POOLS
F OWNER-BUILDER DECLARATION OVER 11XXJAMIK - 0 HATH REMODEIIRFPAIR CDEMOLITION
6 i be¢hy a0irm that I and Hemp Imm die Cohnaeon'e Lia®e Law for the
O a V following demo.Cistraom 70315,Bashi ande Phnssinm Code:Any dry a cdrmry SIGNS ELE47FEUCAL �(TfHfJt
yl3"1%%- which mgab,;a Pennon to con Wel,otter.imprnve,demtlish,ar repair any awawn:
F�05 prior In its lswuree.Wm requires the uWhicanr for such p horitto rile a tignod statement SPECIAL CIRCUITIMISC.
mar he is liccovd 1.m the pmvisiona of We cenuctor's Lessee Law(Claylcr9
(.hhhencingwilh Ss,rbn 7000 of Division 3 oflM1cPwinnsanit Profitaiama Codd or (IMC METER OR POLE INSI'. COMMERCIAL:
C.a a dear be is eo n o therefrom aW the hoses for dbe alleged exemption.Any violation of - 0 NEW BLDG/ADDITION 0 DEMOLITION
�H Seetion 10315 by any apPlicad fuapthroat rubjMr the applicant to a civil penally of POWER DEVICE'S OTI-NANT FWD SERVICE
nut nnme thou five hundr cl doll�Wqp.
N Z Y IMPROVEMENT
fit: ❑ La�he wol,.ttcp,,snuear mYertinteryas orNwale fo tale(See 0a4,Btariov, SWIMMING POOL ELL'CIRIC
WL. willddnft.i.Co the LnKlxreuMnlnreme. offered,nora(Sac.1(W,own,ra
6 3$ and 14ufecsiams('rvL::Th Cnnttix'Inr's I.icctue Law doe.rot apply to an mutter of OUTLETS-SWI'(CHES-FlKfURES
prepeety wM builds ce improve,the em,and wM does rush xv himself or through
his own cmplcyca,provided Ther xuch improvc oshis are no,mtmded or oRacd for
NEW RISIDFXIIAL 1'AJiCfR SQ PC
ads lf.hmwever,tM building arimprovetrenr k.wW within otic Yrm of completion.Tim SQ,IIT,FLOOR AREA vSQ.FE
builder rill lave the harden of proving door h<di an Wild or iodprox:for Put,
D
I ❑ I,as owner of the Enefeny,am esclasivcly rnnlraclinc�re
e with li d cmtmcars to
construct the,project(.Sec.W,D,Busio s and Nnfe km Cade:)Tlr Ccblwbrs U
j diene law 1,cs mm.prly ,,w owner of prulcny wN,hWlri,nr iho,oes t hemm.and QTY. PLUMBING PERMIT FEE ,n�as� 2� mml
I{ whncor..fM,Rsh Projectawtlh..uacton')licensed fwhou bObecen.hes WAY
focenne Law. PERMIT ISSUANCE
O lam cacmplutde Sec. .B A P C for Ois ream,
ALTER-GRAIN AVENT-WATER(EA) \ p
Dntc
WORKER'S COMPENSATION Df at fallhwing BACK FLOW PROTECT.DEVICE
I hemby eR amen Penalty of per3uty anis of the fadMwing dslvuimu:
0Ihaveami wielfor by nnCcni37M of cbe 1,Ibdne,le.awGr WlnkchCe4th- DRAINS-FLWN.R(%)(,ARBA,COND. STORIES 'fYPIi CONS'I'RUCIION
widen,u pndvided for by Section 3100 of de Labor Cade.for We perfamatta d the
wrr1 f<rwhich thispcmdtis orker' FlJCNRES-PIiR TRAP
❑ have and will muinwin Wotkch Canlrnwinn hLsurvrm,as tuyuird by Solation
J1gl of dac labor Cddc.fm tM1c perfomarce of We wort for xtich this pcnnk is iasled
GAS-EA.SYSflhf-I INC.a OUTLETS JCC.GROUP
A o4es Cvn'tnatior lmunance cerin and Policy tomM1cr oro:
artier, Policy No.: GAS-PA.SYSITM-OVER d Odd)
_ C'ERTIRCATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTAL W'ASTF,IN'IERCL'YTOk
COMPENSATION INSURANCEHUILDINO IIIV ISION IBIS
Thissx,ncor ne inon beebropletcl if Ne pemur is fox ae hutdnd dnllua(Slfp) GREASETRAP
or Inc) PIANCHECK FEE
Loy any Nat in inpurfnmtmaco as wort,fm subj Nispermit isixsucd.IXlwll STORM EA.2()()FE V SEWER-SANITARY-
mt employ any prrum in any marver a as ro b t to Compmr ENERGY FEE:
— ^ WATER HEATER wrvPxrrEl.rclx
O A,,hea con ��IR
GRADING EI?E
tO NOTICE TO APPUCAN7R If,efts making Thu Cmifb oe of E.acnnptierh You sbwW WATER SYSTEM/TREATING
1--' Fuvme s.bjeel to the Worte,CnmpemaTnm pmvisims M the Ishdr Cde,yaa—0 SOII S FEE
I fonbwilh comply witM1 such pmvisiun.of Chir prnnit shall he dismal rcvokN. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL VIAB. SQ.FE PAID
Y
z Uum keeeiglM1ntbere irecmrs+auctrdm ktding agency fm The r
pehrr .f
UO I hereby affirm on,work for which this permit is kwiedl(See 3041.Cil C.)
Lanier"Nane TOTAL:
>- Cel I-smlera Address TOTAL. BUILDING ETF.
1 ccnlfy that I have reed this application and nate that the above imfirmation is
F- rail correct.I agree m comr4y w O nn ei(Y and county dmliwc and vwtc laws mw ing m QTY. MECHANICAL PERMIT FEE
UZ Ivildinycvnatasnien.atd berebyiorrrw ix repraetguivaofdr,city Internet upon the SEISMIC FEE
above-rrcntiorW(foo ny hr inspersion purlmrn. PERMIT ISSUANCE
(We)agree,m.,m,aintemmfv vol keep haankas the Co,of Collection aghirat ELECTRIC 1713Eagre
Iitarbinin,judgroseom cosh and eapema which rtay a any way..frdmt said CnY ALTER OR ADD TD MECH.
in nnsequenee of the granting of lhl.permit. PLUMBING FEE
APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT
AIR HANDIJNG UNIT((010.1100 CFhH
MECHANICAL FIE
SO ,k1iGULATiONS. r C
J�_p AIR HANIILINGUND(OVEk 1LUX)C17M) CONSTRUCTION TAX
Hamm olAppheanuCox
ntrtor Date EXHAUST HOOD(WNUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Mlllbe applicant or furore building occupant stmt or handle haaudous marcriat HEATING UNIT(TO 101i BTU)
as definW by the Copenimo Municilul Cods,CwDi+9.12,and TM Ilcahh sol Safety
Cade,Seclion 3512(x)° HEATING UNIT(OVER 100.01X)BTU)
Ies ❑Nn I YVENTILATION PAN(SINGE RF_SIDI PAID Dare keceiDM
Will the apPicum or future building ceeb,,at use egoipmen ce v,a which
chni henndous air ummminanu u defined!by the Bay Ara Air Quality Ma s,ershcnt BOILER-COMP IJHP OR 100.1100 BTU) TOTAL.
Di.u'rT? HOLIER-COME(OVER 1000MHTU)
Oyes ON.
I haven ,Ib,hanod mucrwls tcquire..utukT ClaPa'rfi 95of the Cid, AIR CONDITIONER ISSUANCE DAT'
faroia Hnith A Safety Cade.Sections 25503,M533 and 25531.I unbvud then if Ne NLN!RESIDENT AL MECH. SQ.17,
huilding tikes nm cornntly have s Teran4(hal i(L,my rarymriMliry to ratify The.,,ant
4 doe nyuiremenu which ttruR be ni pried in r.of e Cerdf we a Oavparcy.
Owter ar euTMriaN ddgcm bore TOTAL: ISSUED BY:
OFFICE