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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL P r ITNO
BUILDING DIVISION APPLICATION/PERNIIT PLUMPING-MECHANIC,IL O J 1 L
BUILDING PROJECT IIIEMPIEICATION
PHONE
LIC NO.
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONUAC-fun's ULUI ARAulln
I hcreby .Tian Ihm I am Iwansed uralcf rovisimu of Chapter 9lcommcreing
wilh ,,ion 7(Mp) of Lb,ion3 of the Bminc.a and Iwfou.ians Coil , reed my filen, is
QTY
❑ KITCHEN REMODF.I.
In full face and effeel.
❑ PLUMBING RE,PIPI?
Lilco.¢ Cluu Lich
para Common,
ARCHITECTS DECLARATION
IF
1 uMcnurd my Man. ^ball hn used! u Public ream,
❑INTERIOR
LICen4d Pmfusinml
IMPROVEMENT
OWNER -BUILDER DECLARATION
❑ BATH RIiMODELINEPAIR
1 hereby ufbml Ibar 1 em e,empt from be Commcmte Lueme Lew for the
❑GIBER
follmving rasa,. (Salinn 7031.5. Had. art Plofcedrns CNB: Any ea, or county
which rqullcs a Permit to nmstruct, alter, impow, demnfish, or rcPair tiny struetim
Prim m in do., alw Twine the appfieart f« such Pelmil to File It signed sudamen'
the, he d liccnma Puri ... I to Ina prtrvisinm of Ile Cwlmmde haeme Uw (Clwpmr 9
Iwmrleleing with Seclinn 7007) of Diviainn 34the Bushels aN Itufasioa. Codd or
Jut be is ucmpt d,o fom Bret Inc hui. for the alleged uem,tirn. Any vior ion of
Salinn 70313 by any aPPlimnt for a permit subjects the alfieta l to a civil Penally M
ret moa Iden Five hurtled "lad ($5(I0).
I, u swner of the lanlK^Y 'c mY empinym with xagu a their Iola c W' Hioilion.
will do Newak. arde: nructuaismtimke. sol dueeo ouk(Sec.to an,u nerof
cal Pmfesoms iW m. Tho o, ,, 's Lrd.,o de dlss nm apply himself lf rMrcr of
li Town wWWits mimprove Nsuch endwWdoe wenwortcoloa Nmugh
his own emPlny� .Ire ,deJ that such n imPnI, sc,ld y' tirt m. ire �Ildul �v 1inifW rhe
stc. Ir, noxer un rmplmel rs wild n oM icer of ion. the
de
vin at b rri,uw
mrWilder wiu Iww me W Nen of coving that W aid not build or iinPmw gr Pnr-
will the h
Pcaeofsalt.).
1, a urn of the Pnryeny, ren eaelu,vcIY corer aadng with licensed! conlrattors to
consnucl the Project (Sec. 71Na. Pusims. and Peofto,whe Crede.) The Cnnawnnh Li-
<ed4 Uw dine, not apply loan owher of peperty wle Wilds a impmws Wcicon.and
QTY.
,,bo ,om.., for such projects with a cuht.torrI) Iiccn4d .of to tM Cur mcbMs
Liadse law.
I am eecmp under See. . B R P C for Ihis rcuwm
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RE IEDENTIAL
PANELS
UP TO 21X1 AMPS
SIGNS ELECTRICAL
SPECALCIRCUITAIISC.
TEMP, METER OR POI.E INST.
12WER DEVICES
SWIMMING %)OI. ELECTRIC
LITS - SW'ITCllli$ - FIXTURES
NEW RESIDENTIAL ELECIR SQ PT
I}wncl Dao
WORKER 'Snalty of ,aryorATION DECLARATION
1henby Nrm older penaltyof.fc. saeof theinorm, for Ikd:uminu:
3,4
I have and will maintain•Cion 37teof the Labor
self-Infosfm we"err eoPer-
f(be
wino, a povtW fnr by Scclion 1]00 of Nc UFr CWc, for ILC prfwmnce of the
wvxk fnr whicM1 thio pCrrnil is i..w.
❑ I lure and will mainwin WAcls Compcllwinn I.e. u Icqu'ucd by Section
371MI of lie. Uhnr Code. for Ne pefhrrome, of I W work for which this prnnil is is,ed.
My walkers Cmt,amuninn in.. carrier and %diry numbs are:
Carrier. Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fm'u rection mil m be wmpk¢d if IIIcpYrrlil is faorc hmdmi Aal Wr(SI W)
es.)
1cv tiny ren in Ihn PMmrther Mllc worck e,whjchNispmnitsu
isised.-shed-
nd cmPlny any Iervm in any manna so u In bomc wM1Jtta In ILC Wmkei ComPcn-
z satirm laws of C.M...Date
Z AA.
NOTICE, TO APPLICANT: IL after making this Cefibcaa M E empties, you should
ice+
[-� bcmne wbjecr to the Wmko's Cnmpemelim povuiau of ac UWr Crrk, yes muu
� � fathwilM1 comPl> wilM1 such P^�vi.siims nr IM1i. Pcrmil .shall he accord mrArd. 2
c.
CONSre iI. RUCTION LENDING AGENCY
UO 1heatschihi llKAcle iso d(See iw IClalidgagmreY for the prrfmlmrcc of
the wxk fnr whkh this peons is isved (Sec. 115], Co,. G)
QIendcee Nacre
U
Hd terdcr's AhEes
6. I c,my then I bri mad Ihiasppliealion and nam Nnl the above infonwtion is
N edxrccl.l aglcc to comply with ell cilY and cnunry rmlimleca arW sue few. slating to QTY
L) huiming cwelmctbn, and Wreby oulhamc repte. nmtive of -hie city R, omen upon lW
about-nentinncd Propeny fa iforaffion pmpo*es.
(Wt.) egme lo eve, indemnity and kreP lannfe. the City of Cuprninu ngnina
IiaMblies.luagmentscons and caRn4s which may In any way xewe uIt ansa Cily
in ema,,,ree 4 the granting of Ihia permit,
APPLICl UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
_. _
IIA%ARIUUS MATERIALS DISCLOSURE
Will IM1C aPC.Penl a furor" I'adi ng rrmpnl sum a huddle Health
and Safer l
dcbnN by Nc Culeniw Municipal Cmdc, CTynu 9.12 and the Heellh and Safety
CMe, Ssetlm 25592OC
❑Yes FI N.,
Will Jt..,,beam m future holding occulsant ore equipment a dcsicu which
"mil hvadaus our ennu orrom. a. defined by the Bey An. Air Quality Manage.'
Disuict7
p Yea No
I lure read, Be haaa jolpt marmot. Iequiameah, under ChWter 6.95 ot Ile Calf
Tania Health & Safety Codes Scrion, 25505, 25539 and 255.4. 1 un k oom that if Ill
Witting Joe, ru cwcmly love a amnt. Nm i1 is my leptr"abodry to nodfy the tic vlmlt
of the 11,ioo ems wh'elr muu W n, nIr m ix,arcc nfti clnifrm"nf (kcurtme,
PERMIT
PERMIT ISSUANCE
ALTER - DRAIN k Vi! TF; EA)
BACKFl.OW' %ifITELT. IIEVIC:
DRAINS - Fl.Of]R, ROOF, AREA, COED.
FlXTJRIS-PERTRAP
GAS - IA. SYSTEM -I INC. 4 OUTLETS
GAS -IA. SYSI3EM4)VER3(HiO
GRHASIMSTU.SIRI, WAST? INTERCEPTOR
GRIASETRAP
SEWER - SANITARY -STORM I1 2(M) ITP.
WARER UEAfER WNIEM'iELFCM
WATER SYSITM/TRIATING
WAITS SERVICE
NEW RESIDEMIN, I'LMIL SQ. 19'.
MECHANICAL PERMIT
PF,RMIT ISSUANCE
,.SER OR ADD TO MECII.
SIR HANDL]NO UNIT(TO IB(MIO CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EX HAUS' I IOOD(WIDUC I
IIIATING UNIT (TO IW.(MX) BTU)
HEVDNG UNIT (OVER 1(X)J") PTU)
VIEM'ILATION FAN (SINGI.ERESID)
BOILER - COMP OHP OR I (MtiO0 BTU)
MOILER-COMP(OVER lyf0G)BTU)
AIR CONDITIONER
NIEW RESIDIN]'IAL MECII, SQ. FU
FEE
FEE
1_761
NIC CON] 'ROU X
ID so3'7�
BUILDING PERMIT INFO
11ELECT%"I.U�MB A7
11
JOB DESCRIPTION
RESIDENTIAL
❑ SPDwL
❑ KITCHEN REMODF.I.
❑ADDITION
❑ PLUMBING RE,PIPI?
❑MULTI -UNIT
❑SIRULTURAL
IF
MODIFICATION
❑INTERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
SWIMMING POOS
❑ BATH RIiMODELINEPAIR
❑ DEMOLITION
❑GIBER
COMMERCIAL:
❑NEW BLDUADD%'ION El DEMOLITION
&NAM' o A j 6FOOD SERVICH
IMPROVEMENT M
❑ OITIER -
vr11.FZD()RAREA ESQ. IT
vP1' Vi VVYL- Iv
'7jo � l'SO � ►�
$,S3�I , 6o2110'
BUILDING DIVISION ITIS
%ANCHECK ITE
ENERGY FEE 5 ��
GRADING FEE
SOILS FlEE .,
PAID
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fi ATWU •
IF