S 0959 (2) • " APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO BUILDING.ELECTRICAL _ PERMITNO.
HUILDING DIVISION' APPLICATIONIPERMIT - vl.umnwc, MEcxpNlcnl, �^ 0959 9 _9
+�. EUHAANG PROJECT IDSNTINICATION lJ N
BUILDING All) ES, I - SANITARY NO. APPLICAT11ON SU9MITTAL DAIL
OWNE ('fT/C/// n. LIC
O O T AC ' AM - LI N6. ��rr1r
$V� NIC CONI ROI,
-3y
ARC] I'F,Cf/ENGINEGR: NO AD NEP$,./
}1, BUILDING PERMIT�INFO _
CONTACT: PHONE r
r
- ,. r❑ Consultant Fees Paid by Applicant(Initial) RLDC, HLP.CT PLUMBI MECu
❑ ❑ D
'1 11DFN$LD CONTRACTORS DECLARATION QTY. `/t•ELECTRIC PERMIT - FEE " -
1 hereby'« (]let I ank licensed arrater provisions of CI Pt 3(c JOB DESCRIPTION _
AaZ wall S ti 9W0)nfD 3 till R 1Ir tie C Imylle se -- RESIDENTIAL, -
P�2 fall PERMIT ISSUANCE -
�� m 3. Q ❑SFDWI. ❑KITCIIENRIiMODCI.-
�V$VLe Ives Lop APPLI ANCLS RESIDENTIAL El ADDITION ❑PLUMBING RHPIPF
F C IY Date r t �Cnmmmnr
m IY - ❑MULTI-UNIT ❑STRUCTURAL.
F=0 ARCHITECT'SDGp.ARATION PANELS -
Z p y I understand my plain shall be asst ns Public retards - MODIFICATION
OZ-,A -. - UPT0200AMPS, El INTERIOR ❑CHIMNEY REPAIR
i E"a Licons«;„ncby,titin,OWNER-RI III, xclmplEfRDECL DECLARATION
P01-THIO AMPS IMPROVEMENT SWIMMING POOLS
0.y ❑
J �� _ OVER IHNIAMPS - - ❑BATH RFjD -CLITION
I en. L for the, \/1
S GU foil 'ng (Section 9031.5 6n,i c l Priales,done;Ckadei A y c ty c unty t SIGNS ELECTRICAL ❑OfI IP.R
-r�OyF wM1 h 4 ' al n i tt II p - -1 IIM1 p Y.Iructure
6 prior In it,alminers,all. 1aii,cl'he tillearmaf rich permit file a laimed:I t r SPECIAL CIRCUITN .
that he licensedmomere todaTum,alialsot m Cnabomme,L (Chapter 9' - _ -
00 (w tagwih5 t IDW) till nT !II B dP I .: 'C 1)ar TEMP.METER POLEINST. COMMERCIAL
L m a that hes exempr1herof nal the buss rx Ihv alleged exempt u.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^rn
Section 7031.5byanyvpplicnnl for dpeamilsubjects the upplicot In ucivil penally-of POWER IIIc ,HS ❑TENANT ❑FOOD SERVICE
not more than Ove hundred dollars($50(ry.
E] 1 VEMeNT'..
$$SY
d 1,m,nwnG of thepay, yet Ply th g d I pen I SWIMMI POOL ELP,CTRIC '
m k titt he tut I mendedaltered s t (S .'loan HCR
;and
anJ P f C e 'Ih C t m License L 1 :n Iplyt evere,or OFILETS SWITCHES I'IX I'URCS '
_
property who Imildsor improves memos,kind h d . : h k hinkskiffahm...ad
his own employees.provided that such improvencous am not intended tf mA for NEW RESIDENTIAL ELECT R SQ F.
sale,If,hwcvertire madding orimpmvmmnts.[it kthiore yorofconfiliation,the - - SQ'Pr.A0JR UHA $/SQ.Ff.
owner-builder will have the burden,[prirvimg that he diit not build or improve for Par-
rose f ).
E]I f the P pt ry exclusively couloacting licensed
J contractors In
#, t TOT
AL:
construct theprotect(s 9044n d P r cm1 )m e t cl L I 10 RECT
I `
cers,Law chs,not applyt owner rproperty ahe takilib,or'Oproves thereon,Find QTY `PLUM BINQ°PERMIT , I- law PEEL r�„, '
whoInnards f such i I.wlnaaeer G rc. license ap tnin meC one
'LITS( (k)I t,UrCH'IW
License Law PIRMI r ISSUANCE -
❑ I am exempt under Sea ,B�&P C for this mason
ALTER-DRAIN&VIiNT-WATER(EA) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affima under penalty of perjury ane of the following declaration
•❑,l have and wi 11 maintain a Certs tienroaf Comnno.cclf-Insure for Worker',CoaTI DRAINS-FLOOR,RODE,AREA, r
intima,vs piovided far by Seerion P00 of the hnhnr Codc,fna0ao perfo.munre of the COND. PS TYPE CONS
iv kl'nrwhichmi.v Permilieisucd. FIXTURES-PER TRAP
❑ I have and will maintain Workers Conapentation Insurance, on dbys tion -
3700 flie L,b Coe f h pcf Ill work bar 1 0th.p nu is ,: ed, - GAS PA SYS]EM I INC.a OUTLETS OCC.GROUP APN ”
MyW k t aper'i 1 . a c.t d Pa I'cYq����6t p� - -
Ce 4 6 Policy Nnd ��� 'OAS LA SYS 1'EM OVP.R a(EA)
'RTII ICATF OF EXEMPTION FROM WORKERS -
COMPENSATION INSURANCE GREASEJINIIDS'I'kI.WASTF.INTERCCPI'OR
_ BUILDING-DIVISION PCLS
('thin section need not beoompleaed
it lhopern!it is fimarchamdmddnilres($IW) GREASE TRAP'
of
It,,.). PLANCHECK PEE
I certify that in the performance ofthe wink for which this permit is i slued,l shall SEWER-SANITARY-STORM EA.200 FF.
no,employ any person in any metric,so as In become suhjecno the WorkersCompels- ENERGY THE
Z sk iota Law,of Cnlifomiu.Date WATER HEATER W/Vf�T/HLP.CTI2
Op ApPlicmn \ GRADING PEE
NCH]CH TO APPLICAN'E If,after making Thi,Cmifi,rwe cf 5xemplinn,you should WATER SYSTEM?REAPING SOILS FEF,
- H become subject In the Workees Compcn,etion pmvi,len,of the Labor Cok c,youw
tat `
Rmhwhh comply with such pmvaims or this Pmol,hall be deemed revoked.• WATER SERVICE
U z union
CONSTRUCTION[.ENDING AGENCY NEW RESIIIEN'1'IAL PLMR. SQ.F"I'. PAID Date
ccs IN -
VQ k for
rwhich this
rh emit i is..ed(Seconstriction 97.Cilending agency for the performanwof P
�' the work for which this pemnh is issued(Sea JOY],C1a.C.) -
I1.+.0Leaders Name TOTAL
O V IAnd AW ks - - FOIAL:
Eralet, } BUILDINGF.
� � 1 reetocfify m hall : pal t ordinances
cesan Iw r I, .( Iy. l+,
y7 cermet lug ecmcon ply with all city d Lyda d.t t hrelatingl ,QTy' , N({;CHANICAL PERMIT, 'I PFF it
V r7. building eon,wet on and hereby umhonze representatives ❑Ii,e'ry to enter upon the a+ r' �� � SEISMIC
have armed mal property for mpectlonpnrposes. PERMIT ISSUANCE - ,
(We)as,.to snick indemnify and keep Inflates,the City of Cupertino against ELECTRIC PEE
linbilities;judgmems,rests road expenses whadnmy Lanny wayaoeme ugainst,aid City' pI.THR OR ADD TO MECII. -
consequence of the graining of ibis permit. PIAMRING PF.E
U ry „
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON:POINT AIR HANDLING UIM I'(TO I0,010 CPM) MECHANICA FEE
SOURCE REGULATIONS. .
AIR HANDLINGUNI'I'(OVER 10 CPM) CONSTRO ON TAX -
Signator,of Applicnm/Cuntmctnr - Date" EXHAUST HOOD(W/DUC HOUSING MITIGATI PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the epplicamor franc bailelmg necupmnstnre or handle haznamnanterial HEATING UNIT(TD I 00I - -
a,defined by the CapGlino mmeripv ode,Chapter 9:12,and aha 1lrollh anti Svfefy .-
Code,Section 25532(0)! _. - I IEAHNG UNIT( FR 100,0010131 U)
El Yes PAID ..
- VENTILATIO FAN(SINGLP.RESID) Dam Rciplp
WTlthenpp,ramcorms. rf more building the
uAeaAiI t Jv1ec, hick BOILER- O MPQIiPOR100,000RTU) •
cash h d s corms n'wm.a. do ad by rh Bay A A Q I ty Munngo t .'i CTAT
Dimuncal .. BOILER.-COMP(OVER 100,000 RTU)
[-]Yc, ILK
AIRCONDHIONER ,
IJ rend diel Nus nater al q 'n.murt.undo Ch em 695 el lh Cali- ISSUANCE DATE
fatal,Hea1r&Safe COM,Secllon,25505,25533 and 255341 anda,nfnd rel if Thu NEW RESIDHN'I'I Al,MECH. SQ.FT, -
baildingdo len Gat isleaam,that itis my responsibility In anm'Y the occupant - -
oft re I c -st e it IleTim keo[nCenif I�e of Orenpan�
ze1. .
Owne ndngent - Date TOTAL: ISSUED BY:
OFFICE . .