24900 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILD N -ELECTRICAL PERMII'NO,
24900 p
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 2 4 9 0 0
BUILDING PRUJECT IDENTIFICATION
BUILDING ADDRESS: L SANITARY NO. A 111 nIX SUBMTT'ALDAIR
DO F E be • UNRN LOT#
O S NA Er''� PFIONE: CO CfOR'S NAME LIC NO:
#�/ N/C O OL M
s ARUIfI£Cf/EIiGINIFR: LIC NO: ADDRESS: ❑
"CONTACT: PDONF Qom, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT P.UMB MECH
•' pz. PERMIT ISSUANCE EJ IK El El
LICENSED CUNTRACTOR'SDECIARATION APPLIANCES-RFSIDLNIIAL IOtlD S Pit{ '" ✓i'
G L'Z Iheeeby aff Inst taco CONTi,mat A(7TOR DE CIIARD,Ta9(emurlencinB with
4300 Section7WO)of Diviaitm 3oflbc Bminea,and Profeuian,Cutle,aM my licence is in PANELS
full fmmondcffim.
FF¢Zu1 Licrnc Clue Lic.Y UPTOMUAMPS
yQy Date Conmctm 201-IOW AMPS
ZOv"i� ARCIITII:CI'S UIiCLARATION OVER Mal AMPS I AREAE S/SQ.IT.
OZ—❑ IunJcnlend mY plans shell be u,ainpublic necmd,. ., '
Fw I=mo SIGNS R Fi2TtICAL
hq E� Licenaal PMminmal
S �U OWNER-BUILDER DECLARA'f10N SPECIAL CIRCUIT/MISC.
N c,.F 1 hnelty M.that I am exempt from Etconlrnne Csclar's LicLaw for the
ulLLy following reason.(Seeion 7031 J,Business std Pmfdions Cock:Any city or county TEMP.METER OR POLE INST.
�LLO� which requiem a permit to mnwucl,allm,improve.demolisli.or rep,ir arty smrclum DAT
T2 prior toiu lhcapplicamforsuch Permilm ilcasilined.vtehement POWER DEVICES _
yWj__ p Ihul he is licroscd pursues to Ne povisi«u of Cte Conv.clor's liuxue Imes(Chapter
e �2 9(c#omancrng with S¢tisin 7")of Division 3 of the Bu,ir=u artl Pofrivwu Coder) SWIMMING POOL ELECTRIC VALUATION
y�'_4t' nrJw he is exempt therefrom and the hasi,rnr the illegeJ exemptim,Any violation of
1_.Z� Section 70313 by any Wlivent for a pemtilsubjau the applicant to a civil poetry d' OVIlEI'S-SWITCHES-FlX'IV RES
O t snore than five htmdrtd do1Hn(SSW).
I,uawnero(Bcprnpa,y,mmYmWloYmwith,vagnnlhelrwlecomlcmadm, NEW RFSIDEL ELECIR _SQ.FT. STORIES TYPF,CONSIIt N
of mim,,Coll:The Conarav minimical«Law
i1J s,no,apply
to an Boaitt a
prod ofrvla, Cak:The Cnmmu<Inr's Licene Lew Joel mol apptY lf rt owner a(
propcny wha boJd,aimpovnthcre«r,endwhodm such work hitmclfathmughhf.
uwnemr.the ,ildingir milro cM1 siolme inhiiina imetdMmorfaei furulelL OCC.GROUP NIS.UNITS
hailti ,the building or impmvenaml ia.weJ within me yew ofmm�pkum,Ocowncr- T
Mulder will hnrc the bwJcn of pmvioe Iha he did rot build a improve her purpm,of
ink)
❑ mQTYPLUMBING PERMIT FEE FLOOD PARI: APN
comtrvcl the prujen(Sec.0614.Bu,inn,wd Porea.iau Cmc:)the Cmnmctar's
License,low Jon mr apply to on wMbuild,orimpovn tltcrwn.asd PERMITISSUANCE
Lict.Ltoi.r«Lech faojetts wiN accmtranm(,)licrnsed posusnt ro Jc convrtar',
hkcvc uw. AhTFR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 wn exempt under Sec. ,B k P C for thin reason BACK FLOW PROTECT.DEVICE SANITARY Y N
\ Ou"na Date
RECEIPT#
WORKMAN COMFMllSATION DECIARATIDN
DRAINS-FLOOR,ROOF,AREA,COND. SOIOOLTAX Y N
❑ Ihnehy olf tFa,lheveattnifiutc ofca,xntmself-inwrt.«a nrtifwwe of FlXTIIRES-PFR TRAP RECEIPT'#
Worken'Cmnperostian lmunarcc«amtired mNlhvwf(Ss JEW,Lab C)which PARK FEE YN
,rn W emPloycx,under obi,Permit- GAS-EA.SYSTEM-1 INC.4 OUTLETS RECF,IM N
Policy# BUILDING DIVISION FEES
Company GAS-EA SYSIFM-0VFR 4(PA7 PLANCHECK ME
❑ Catifid copy is hneby fwJ,lnal.
❑ Cerdfiell copy is ftlN with ilc city inspection divlema GREASEANDUSTRLWASTEINERCEP1'OR
GRADING FEE
CERTIFICATEOFEXEMPTON FROM WORKERS' GREASE TRAP SOILS FTE
COMPIl!$ATION INSURANCE
(Thio section reeJ not becompined if Oclertnit inf«ane humlreddolim,(SIM) SEWER-SANITARY-STORM HA.IWFT. ENERGY I'll
or Inv)
I omifylhat in the famm mai oflhe work for which the permit uiasueL l,ndi WATER HEATER w/VCNT/FLECTR
nal employ any pc^,m in any manner m n to beconone,wbjttr to the Workai PAID
Z Compevad-Lawsof Celif«nia hate WATFRSYS'ILMTREATING Date ftcccipY
Apple l
C 0 NOTICE TO APPLICANT:If.after making thin Cntificac of Paempian.you should NEW RESIDENTIAL PIAIB. SQ.FT, TOTAL
I--' In becr+ne mbFelto the Well Compemaum Provision,of Pe tabor Cade,you mu.
fimhwith comply will,smh ptoviaion,or thin p.il anal)be dcemN revokm. BUIIDWG EIY
y CONSTRUCTION LENDING AGENCY SEISMICFER
I hereby RIF—temk
there in•cmwntmien Ming sgemcy f«the perre
fonno,of
U O the work for which lei,pcnm l i,named($Ce.3119 t,Cim C.) I OTAL: ELECTRIC EEG In ,
LI. F 1<Mer,Name
C) (� Lerwit Address QTY. MECHANICAL PERMIT FEE PLUMBING EFF,
I emify that 1 have read this application and state mat the zmvvx informatim in
t a enneet. Iatme to coni with all city aNon
ecty ordirunm,art]Mae law,relating to PERMIT ISSUANCE
MECHANICAL FEE
F"' Cn buildingcmunction,zenHantby auth xire egvvmtatirn oflhis city brnurepon the CONSTRUCTION TAX
U abovn mrthonedn parn,f«inspection pwryvea. ALITR OR ADD TO MEIDH.
(We) Srox,to,even indemnity and keep harm the Cityof Copenin,aslwi,,
liuhilitigjudgmenu,mumdnprnnwhich mayu any wayacrnuegu'muaid Clly AIR HANDING UNIT CFO ILBM CFh1)
in c eco gran tingaflhuperoll. Y
_ a AIR ITANOLING UNIT(OVER 10.000 Cf+M)
93
S'kshed-Apfificanwohnican, rxq Dow
D EXHAUST HOOD(WMUC
PAID
HAZARDOUS MATERIALS ISM.OSURE HEATING UNIT TO I W,OM HTC) Dale Rccclry#
Will(lie applicant a future bondingoccurrent store or hardier harandow material HEATING UNIT OVER M."BTU) TOTAL
u let by Its, nma CupeMunicital Cade.Chapin 9.12,and the health anal Safety
Code Sectio 2612(a)3
❑Ye ❑No VENTILATION FAN(SINGLE RFSID)
�,ay�•
.?E.'"f_�,^`� Willihcepplicent«!wort Wildinyo¢ulwuuscequipneotadcricnwhichmtit BOILER-COMP(3HPORIOLMOBTU) ISSUANCE DATE
G_ l hvArdwn air cmuminenu as defined by the Bay Arta An Quality Mmayrnrnt /n
Dhirio? BOILER-COMP(OVLR IW,IXIOBTU) A I D
I,� ❑Ye, ❑No NEW RESIDENTIAL MECfl. SQ.PT.
MAR 25
1 have read the hvaAw,materials mquiremrnu mode M. I un ero of the 1993
Califumil,ingdM1 n al cam CNc.Section ah.I"5.21533 mrd 25534. 1 urdmtaN Oat
ifthebuof bdna nm cvrnm which
a Merle,l,Natiter my rt,pauiof. tonotifyNe
oecoIem of the n9oUc^e«+which muM be act prier to tetra a of a Cenif to of (ul I I v-
Qcupaetey. V Uf Gl r l I's
Owrcroroudtoritan]agent Dam TOTAL ISSUED BY: �
OFFICE