24910 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL �I 91O
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI TALDATE
UNIT N LOT N
OW AME: PI{ONE: CO DR'S NA LIC NO:
A077— 4? - aw-r- E Sa7/e Nrc CONIROLN
ARCI{ITI!CDINGWt LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ULIXT ELECT` PLUMB MECII
PERMIT ISSUANCE r1�
LDCINSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDP L L7 POB DESCRIPTION
Ihurby.ffrm thin l von liccnxd under pmvisioruo(CTapter9(commencing with
�Q00 Salion7M)).f Uviaion 3 ufthe Hu,inn and Pmfessiorn Calc,and my llwnsc is in PANELS
y�j�{ya�L full face anJ elle /'fit—
FGW Liven lic.N fOJ..aO ,/�� UP TO 2(MI AMPS /ena.L o /•C'I
yQy 0.the.�"-' COovanu N� MI-IOW Ah1P5
hy7 ARCH CT'S DECLARATION SQ.FT.FLOOR AREA SrQ.FT.
ZOy— I understand my plana shell be pearl an public rtcuds. OVER I0p0 AMPS D I
P_�1+1 SIGNS ELECTRICAL
N26y wsa.,'pj Lianad l`mfesieW 1
OWNER-BUILDER DECLARATION SPECIAL.CIRNIT/MISC.
XOwUF. 1 thereby N bad I un eaemq firers de Calo-acmci,lirenee law for the
VJ3°-+n followin,al .(Section]031.5,BusineseaMProfueiou Code:Anycityacounry TEMP.METER OR POLE INST. 1�
g°g which re,t6m,a .it to eominc.Cher.Intprme.dettmr>h.or redir any a otwhe DATE
;jNs prior e,its iesoanes,dlea m mt the a,uItcanl toreueb Pemtil m me eagnWumnam POWER DEVICES
a a that he ie hcemN prearami to the*ovi umn,of the Coml i Lirrnx Law(Ctepter
dX cmmrtwreu SWIMMING POOL ELECTRIC
y
( gwith Stttim]000)of DivieWnlaf the Busireu ad Professivna Code) VALUATION
ty_,, ethW he ucxemq therefrom ad the Nsie fa the allegd eacaWtion.Any violation of OUTLETS- FIXTURES
t.Z¢ S ion703i.5by enyawlicantforepmnitsubjttt,theeppli lwacivilpcnaltyof SWRCHFS- / �•��
x�$ are moon In.Fac handed!Mi.tf5(10).
CS ❑ I,esownmoft property,urmyclnpluycdwit %UcxextheirwleemmWnwi . NEWRMII)FMHALELI;CfR _SQ.FT. STORIES IYPECONSTRU-IT N
2 will dOthework,aMe:'ph, tweia,to iI Licerde Law d ri�nt ly to
owner
erd Pm%Wu Code:TM Cmtractor'e licen,e law doe rat apply if downer is
propcny who W Jd+or improvethermnaM wlwdvevrchwork himalfa through his
employ¢,,ptoviJcdthuslehimpvvrnumuart ruimcrdnlorolcrcA forsele
If. OCC GROUP RFS.UNITS
however,the Wilding or impmrvement is cold wilbin one Year of carnpletion,the owner- TOTAL
Wilder will have the belch of Waving thu he did not build or impove for purpose of
fie')' QTY. PLUMBING PERMIT FEE FLITOD] NE APN
❑ I.0 owrreraf thepmpcny,uncaclpurcly mmnacting Mthliccwlmnvaclaato
cortafuct the ,ojcvt(Sec.]Olid.Bud.aM Profaviou Chile)The Contractor's
I,icrn+e WwJOamtapplymwowTerofpmpenywMbuildaorimpmve lherem.and PERMIT ISSUANCE
who,ntmme For smh pmjecle with ncoul rre-i)liceneul purxuant to be Cour mdMs
Llcrnx Line, ALTER-DRAIN&VFM-WATER(EA) FEE SUMMARY
❑ I em exvrrpt u..a..Sec. ,B&P C fu thio re voo.
BACK FLOW PROTECT.DEVICE UTSIDSANITARY T N
O n,, Date DRAINS-FlOOR,ROOFAREA.COND. RECELPD'Y
WORKMAN ,
EN
COMPENSATION DECLARATION SCIIOOLTAX YN
Cl I terthy affirmlMll have a certificate ofrouse nus elf-inse,or aanificate of - RECF.IPTY
IIXTURIS-PER TRAP
W'arkm'ComprnsatianlmwaneeaaacnificJ copy thcrtOf(Scc.Jg00,Isb C)which PARK FRE Y N
mem all berto yeei w/er l�pmrlje,� GAS-G.SYSTEM INC.d OUTLETS RECEIPT#
Poliy0 UJL-/i CJ �A'G�� BUILDING DIVISION FEES
C1mposeY ,4 d, GAS-EA.SYSTEMOVER 4IFA) PLANCHF.CK PER
❑ Ccnifed copy ix hereby furnished.
Q}�CrcnifkJ copy ie BlM with the clty lrupxliun Yvlwn. GREASI INDUSTRLWASTE1NfERCEPfOR GRADING FEE
CERTIFICATE OF EXE1,IPIION FROM WORKERS GRFASE'IRAP SOILS IEE
COMPENSATION INSURANCE
(Thieaction nrzdrct W<mnpleld ifthe pemulufororlehurdled dollen(flIXl) SEWER-SANITARY-STORM EA.2WF7. ENERGY FEE
a IcvJ
I certify that in the perfmmanc of the work for which this pemul is i.wtd,I slash WATER HEATER W/VEIUF/ELECIR
rot employ any person in any maneer w as n beware subjeel to the WoArn' PAID
O COmpemmimlrw,MCalifornu Date WATFRSYSIEMOREtTING Date Receipt
A
pWicpai
O NOTICE TO APPIJCANT:If,after nuking this Ccniflrnuof Excmption.yw sMWd NEW RPSIDB:NI'IAL PLMB. SQ.FT. TOTAL!
V) beconu:.uhjccl t.the Worker',Cmmpenurirmproio.of the labor Cudc,you mum
> fides suh comply with auch pmvisiom or lot permit abut be deemed re,cld. BUILDING FEE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hertq eff ttuu them is a muwnim kding agency fm the pMurmare<or
the work L.which this permit Ia h.cct(Sm.209),Civ.C.) TOTAL: ELECTRIC FEE
U Op LenJc/.Nome
0 U Laule/s AJdmu QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LULLao�I ratify halt here ted this.'Remon and..-r.Phu dee Wove infemulm ie MECHANICAL FEB
t.Ivgrte ro cmlply with eB city and cuvuy adnurcn eM....laws rtlWeg to PERMIT ISSUANCE
Cobuilding ceutnuction,ud hereby mffiarine repecnutivea of this city to enter upon the
(j alnv-mertioed property for inspection ormaI.. ALTER OR ADD TO MECICONSTRUCTION TAX
(We)agree to vave,indemnify aM kccp berm eo;the City of Cupertino against
tabilitie,jvdgmrnu,cosu mdcaprn.xa which my in any way accrue egeiw add!City AIR HANDLING UNIT(TO 10000 CFM)
N cornrylwee of the gsmtting of this permit.
AIR HANDLING UNIT(OVER 10.000 CFM)
Sipahere of ApplicanoVoulmctor Dote F,XHAU.ST000D(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE RE STING UNIT(TO Mi,"BTU) Due Repi 0
Will the ayplicant w future baiter,ocapwl pea or handle luavdaw material
v deftnd by the Cppenim Manic Code,Cheprer 9.11 and the Health and Safety HEFTING UNIT(OVER 100,000 BTU) TOTAL:
Cade,Seetioe 25532(a
❑y,,, VEMILA'ITON PAN(SINGLE RBSID)
No
ISSUANCE DATE
Will Once epplicengarfwurcdtildingottvpantlueequipmcrR osdevicewtich emit BOILER-GGFIP(JHP OR 10),000 BEV)
baadoua air mnwninanu a dped by Ne Bay Anes An Quality Marm
utgeenl BOILER-COMP(OVER 100,000 BTU)
❑Pec Nn
DistrinT I,•JS/
NEW RCSIINiNUAL MliCll.—,SQ.
1 have read the harparl ca emila reyulrcmcnts leder Cnapho 6.95 of the
CdifornJa Heath&Safety Code.Seniaa 25915,25533 and 255k.I understand!that
if the building doe not avrmtdy have a Tenant that it i,my mpomibibly to edify the vQl
Occupant t,which muv W and prim m ia.uarre 5.Cenlleate of 1 rep
gsyfr Dem TOTAL ISSUED BY
OFFICE