S1060 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY�F CUPERTINO BUILDIN(:-ELECTRICAL PFg`f.11T N0
BUILDING DIVISION APPLICATION/PERMIT PLUM ROJECTFIDENTICnI. AP 1 0 6 O
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
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NO
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O 1,! AM(JL^"4N4 D7.rlE v 77� f) CTUR/q'SN MF p Y70i COIjTROL#
• pRC111T.CT/ENGINEER: LIC NQDDRESS'. -ff'" � ,rvN2r• Y^•(/"
� / L1CONTpLT. PHONE'. Jz BUILDING PERMIT INFO
El Consultant Fees Paid by Applifant(Initial) BLIND ELECT PLUMB MECH
/
/[l _8n ❑ ��" ❑
LICENSE NTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
. I hhy aRt»t to hall am Rccn.ed def fm..lm..or f Cnatn 9¢ommcmcing _ 306 ESCRIPTION
�
C%ZO wim Sedan 700(ord D. -'m 3oftW Bu ndY resopr CMc and my lire na is RNID NTIA +
PERMIT ISSUANCE
UU in full force and effem ❑SFDWh [I KITCHEN REMODEL
pa.Za LIcame Clcs Comment_ APPLIANCES-RESIDENI'IAT, El ADDITION El PLUMBING REPIPE
rVns ARCHR ❑
ECPS DECLARATION PANELS MULTI-UNIT E:1 STRUCTURAL
dn CZ-
Imale'and myplans Tell Be used a. hit,arords MODIFICATION
OP TO 200 AMPS 71 INTERIOR [I CHIMNEY REPAIR
�,y„1"'� LicemW Pmfcsional 201-TBW AMPS IMPROVEMENT E]SWIMMING POOLS
Z OWNER-BUILDER DECLARATION
C I(XX)AMPS
O ❑PATH REMOIJI?IJREPA�DEMOLIITON
yy W Q 1 hereby dlirm that 1 rept f the C ten 1' Lew fm the C1OTHER �� 1
x1U following purser.(Sec's 70113 Rusim,o m d PmfapsimsCdr Any City OrCounty SIGNS ELECTRICAL
a 3 LL
which op premit it)ocromet,elleT,im"ve,dennelism or repairy svunure
F.�.0 Marto ts jamaher,epw rNmmsthe rMlmantfresum Monit to fk a Togrard mtcent SPECIAL CIRCUII'IMISC.
6�
hat he liccrs Portland a the M i' n filic Controctor,License La (Chunar9
00 (c°mm.nc ng wilhSect on7fMNq of D'v's mn3n[lh.Business and Profaomis Code)or TEMP.METER OR 'INST. COMMERCIAL'
that he ie ucmp beafrm and the nape for Bw alleged]rsprmnioh.Any vmlarion of NEW BLOGIADDITION El DEMOLITION
�ne Seemin 7011.5 by any ii,licatn for arymmitohEa,the applicant to a civil family of POWER DEVI - Ll TENANT ❑FOOD SERVICE
g, not more,then Evc hundred Jdlum(SSW). IMPROVEMENT
� G ❑ 1,-,,.r of the property,or my cmploycee will,wages-,hair axe compemmion, SWIMMING FOO
y will do the wh.vM the dremrein nN imm�Jwl er nlTeml!role(Sec ❑OTHER
70T1,13minesz
W-' and profee.imc Code:The Cmtact«k License Law does not apply m an nwmer of OUTLETS. -SWITCHES-FI% IS I
imperty who build,ar'm,ore,theorem and who des inch wM hlm.wlf or through NEW RISIDEM1 DAL ELECTR SQ IT
hie own em ,ple,ea provided Net.weh on,wemro
enis are t inictdW«offered for SQ.FT FLOOR AREA 5/SQ.Up
sale.If,how—,the building or impmvemcm is cold with'm nxx:y ser of rompl,num,the
crhuikier will have The W edea of pprvin6 mvT M1c did rex W i1J«impmre(«
',ca
r-
paw of vele.). TOTAL:
Ej L as mvrcr of the pmpe.,,ans exelacivdy loo meting with liareed emuueturs m -
n.Wrt Tire project(Sate.](Pied,Bueinev.end Prof sion,Ind';the Grommet«'a h
ranee lnwdms not apply m on uwhe,of poypery who huild or improve mnatm.atd QTY. - PLUMBING PERMIT EEE
whoemtraete foreach pro}cswoh.amtmet«(e)Immsed Punsueh In the Conlrminrs
La.I,- PERMIT ISSUANCE
❑ I ren camp me,Scr. .H&PC for Thi. —,n -
ALTER-DRAIN&VENT-WATER(EA) r �IV1d�1 ION
Onomp Doc N
WORKER'S COMPENSATION DECLARAI ION BACK FLOW PROJECT.DEVICE. (e.\
I hereby vRrrh realm'malty of perjury ore of the following declamli«s. Vl
L]I Domand will maintain aCcoificvtcof Conwnttuxl(-incur,fnr Worker'.Coma- DRAINS-FLOOR.ROOF,ARBA,COND. STORIES TYPE CONSTRUCT ION
.,tion,a provided f«by Section 3700 of me Unfair Conic,for the Mfomtvec of the
work fm which W o pa mil iz]esu d. FIXTURES-PER TRAP
��Wvc toed will moment Woders Compereminn Inwmna,as oppimm1 by Section
37W ofihc labof Cork.F,de, ttwnnI ren work fm tos'uc
whirl,this Te n is ied. GAS-EA.SYSTEM-I INC.d OUTLETS OEC,CROUP APN
My Wprkt j�`117N�W^1 rand Policy numbcrme:
Cersen rJJ //// ePolicy No.: GAS-EA.SYSTEM-0.VER 4 UA)
CERTIFICATE OF EXEMPTION FROM WORKERSGREASFONDUSTRLWASI£INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION MBS
IThie section need not ermnpldcd free lemir is Rxmc hundred dollars(31IXry GREASETRAP
or ItPIANCHECK MY
-
I certify matin the pMoomenecoftl,e work fnr which thispennit is i,swd.I droll SEWER-SANITARY-STORM EA.20 FT.
clot employ any person in any nen er m us to heconoc subject To the Wod er.'Comfen- ENERGY FEE
union laws of Caldomie.Dare WATER HEATER WNENVELECTR GRADING FEE
0 0 Applicant h
NOTICE TO APPLICANT:If,after making thio CenifTcum of P nn,mo,you should WATER SYSTEM/ EMING
aF-i become,ombject to The Wodfr'a Compenwtion provitions of the I<Wr Code,rm imT - SOILS FHP.
W forthwith comply wim ouch pmmsmons or this pmnir shall W JanN revoked WATER SERVICE
JO CONmucrIONLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.14. PAID Date Rrec,A4
'x 1berch,uUmn manhcrc ie u amamclim lcedingagency for the,Perfmmnec of
4. the wo L for which thio pcmoit i,.iexunl(Sac_3097,Co.C.)
0 ULamee Name
W 1<Mnr's Addmez TOTAL:
I certify that 1 have mad this application and slate the,the alnve ofonramon iz B
UILDING
Tai3 r«rect.I mgrs m ommmly wim all shy and Treaty ordiwera and state wwS relating m QTY. MECHANICAL PERMIT FEE
U hdldingco-or ion.and hereby autMmdm repezcnlmivu ofthiNchym cnteruon The
aWve-mentiorW property for im tcOiml PUHnrcxe. PERMIT ISSUANCE
(Wa)agree to use,indemnify and keep hnmlcaz the City of Cupertino agaimm
Iiabilitiu,juJgm.ntx.rnmaminparwc whichnmy in any wry rccmc agahLa mid City ALTER OR ADI)TO MGCIL
'num yuenic of me granting of miN permit.
APPLICANT ' ERSTANDS AND WILL COM LTH L NON-POINT AIR HANDLING UNIT(TO I0,000 MIKE MECHANIC
SOURCE TEA ATIQNS.
AIR HANDLING UNIT(OVER 10,0110 CEM) CONSTRUCIONrAX
Sigrulemof AUlian✓Ce d« Do, EXI IAUST GOOD(1111) DOUSING MITIGATION PEE
HA' DOUS MATERIALS DISC SURE
W1111W applleor or fame Wonimg mau,ern a""hmordo-nne'er.l H13AT'I NO ON IT(11)100,000 BTU)
a.defml by the Cupen no Municipal Code,Chapter 9.12,and tW Hamm and Safety
Cede.Seemed 25532(a)R HEATING UNIT(OVER 100,000 BTU)
Ej Ycs ❑No VENTILATION PAN ISI NGLE RFS IDI MY
Will TW applicum or future Wilding occupant use equipment or deviate which BOILER-COMP OR 100.000BTU)
mit hesardeus air cmtamhwns to deGrcd by The Bay Arca Air Quality Management
oDinnel^. BOILER-COME 1001X10 BTUI❑Yes ❑No
I basin tend the havalloux nwtenWz reyuirrm:nu'under Cnaper 6.95 M me Cnf AIRCONDITIONERforma Ilcdm&Sofcxy C de,Satliom 25AH,25533 and 25534.1 dock rand lndl if the NEW RESIDENTIAL MECH. SQ FTbuilding dud.cmramly Wvu a lmrool,mut it LN my rup^usihiliTy m oolfy de cwaPentof the is sirememl which round.W mel pn«m iuuence M a CertiraTm ofOecupney(Tuner or mthonuaf agent Dere TOTAL:
OFFICE