S 2048 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PI!SITND, 2048 0 4 8
HH11.DING DIVISION APPLICATION/PERMIT ru)nIBINr..Bo-:cunlvu;nl. J
BUILDING PRO PCT IDENTIFICATION
BUILDINGADDHISS: SANITARY NO, APPLICATION SUNMI'I'TAL UAIIi
I4'-g6 'aM�s tows 0I-v 13 -2— Y`V
s,A lrk��ejMli I v. I'll(lN �d a 0 CON'1'INCI'OR'S NAMH. LIC NO.
� ,,srrr tt NIC CONTROL,
1 ARCHITECTIIENGINEER; LIC NO: ADDRESS: ❑
t
CONTACT: PHONE: I BUILDING PERMIT INFO
ZConsultant Faces Paid by Applicant(Initial) It1.DG IEI.ECT PLU�MB// MECIi
/ o o E] F-1El❑
LICENS1IDCONTRACI'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under,.visiom of ChapTnr
P100 with SfOusn'7M1(BofD......n3ofthe BusinessinJ .fesdonx Code,unit mylicce,ris PERMIT ISSUANCE RESIDENTIAL
FW- in full Pone mind elk0.1_ ZZ/3 ❑SFDWL O KITCHEN REMODEL
Out License Clusi J P Lica APPLIANCES-RIESIDENT IAL ❑ADDHION ❑PLUMBING REd'IPH
Nab Dem Cammeior
Dtn ARCHITECT'S DECLARATION PANELS El MULTI-UNIT OSTRUCTURAL
F
Z p y Z 1 undemmoA meat y plshall brood!us public records MODIFICATION
OZ�n-0 _ UI'TO 2lN1AMl'S F1 INTERIOR [I CHIMNEY REPAIR
-u1 Licen...I ProfessMad 201-1000AMPS IMPROVEMh:N'I' CSWIMMING POOLS
••l OWNIER-BUILDER DECLARATION OVER IIIDIIAMRS El BATH REMOUF.IJk1iPAIR DEMOLITION
C st 1 hereby affirm that 1 am Osempt from the Cntnmcmrs License Law for the
x1x1 O d U fnllowing spawn.(Section)031.5,Itminess and Professions Gavle:Any city or county SIGNS ELECTRICAL El OTHER
which regnirea a permit.cnnftnmt,vheE improv,denadiah,er repair any.manure /
prim la llx is+umu'c,nlw requieOs'the applicud for ouch pennll.fleusigned a...mint SPECIAL CIRCIII'IMISC,
that he is licensed pnnaanuo the previsions of the Counselor's License Law(Chapter9
W qpm leann 'R
encing with Section of Division Sof the Business and Prnfccsin )m ns CwOI HMP.METER OR POLE INST COMMERCIAL:
d c C 'hill be is exempt therefrom and the basis for the alleged exemption.Any viNminn nT 0 NEW BLDGIADDITION ❑DEMOLI"PION
�y Section731.B ve hundpplicatlaapMlkmit.ruljcal oat applicant m a civil penalty of POWER DEVICES EITHNANT CFOOD SERVICE
SeauaT Pml s n
F z 1+ IMPROVEMENT
a O [.asnwncr of the properly.nr my emPloyeev with wego ns their sole compensation, IMMING POOL ELECTRIC
W will dothe wOak,uldthes¢uewmIsom inam,cdoraffered fnrsale(S..90fJ,Business
11 Of
Cpm
S a and cry who
Csle:The Contractor's I.....I w law Jaws nm work
hi m ll owner of Bt-EETS-SWITCHES-FIX'1'URES
pmpeny who huilAs nT'imp mvev Ibercon,Boit who doer ouch work hinmxulf nr Ihmugb
his own employers,provided lbs such improvements arc not intended ar of1OmJ for li SIUI!N'I'IAI.BLF.Cra SQ Pf.
sale.IL however.the building or improvement is sold within oneyear ofcompletion,thc SQ.PC FLOOR AREA $ISQ,F1'.
ownerbuilder will have the burden of passing that he did not Is M nr imp.ve for pur-
pove of Yale.). -
❑ 1,os owner of dte properly.vn exelusively contracting with llcetued cnnuactots In 'T(TInL:
cnmlrucn Ne projccl(sw.",,itusiness and ProfessionsCode:)B'e GmoactnT's Li ceme an owner of properly who builds or impraves thereon,unit QTY PLUMBING PERMIT FEE
whe Animals I'or such projectswith v cnnvamor(s)licensed pursuant to the Contractor's
Limn.se Law. PI!RMI"f ISSUANCE
O I I exmn,I under See. if k P C fin'no,
rerun
ALTER-DRAIN A VENT-WATER(IEA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
I hereby utfr underpcndtyol'pap,oneoftbe I olldwingdcabTnlionv.
s ' ❑ I hmcind will failed.aCerifemeof Consennueelf insure for WorkeTfs CompOm DRAINS-FLOOR,ROOF.AREA.COND' STORIES TYPE ONS'TRUCTION
smlon,as provided for by Seeman 3000 of the labor Code,for the performance of the
work tic which this permit is i since. / FIXTURES-1-1!R TRAP
❑ 1 have and will...ainmin Wmkur's C iipcnvanion Inwnnce,ns required by Secdon
37(m of Ilio LGm,Cade,for be ptanneopecot'(he work far which tulslwrmlt is i...nai, CAS-Ia1v SYSTEM-I INCAOU'rLiUS OCC GROUT' APN
My Workers Cunperosa m.loonno ce clinicians]Policy moomm arc:
Carticr. Policy Nu: GAS-EA.SYSTIEM-OVER J(FA)
CERTIFICATE OF EXEMPT ION FROM WORKERS' <;RIEASEIINUIISTRL WASTIi INTERCEPTOR
COMPHNSATION INSURANCE BUILDING DIVISION FEES
(TM1i.eeellnnneednon recompleted it licpennit ix fnronchundteddullursSIM) GREASETRAP'
or less.) PLANCIIECK FEE
Icerify that in the,erfmmuneeofac work farwhich this permit icissued,ishall SpWER-SANITARY-S'IORM EA.200 IT.
net employ any Tenon in any number so lis m become subject.the Workers'Comped. ENERGY FlEIi
Oz 'Od...l 'nws of Culllnrma.Dlnc WATER H17NI'1!It WIVHN'I/ELI!CTR GRADING FEE
z 2 Applicant
F^ ^ NOTICE TO APPLICANT:If,after making this Cervical,of Exemption,you shnutd WATER SYSTTM/I'RFATING
become subject to the Wooer's Compemation provisions of the Lahr Cale,you must 50115 PEIi
.�j forthwith comply with such provisions or this permit Aill he deemed revoked. WATERSERVICII
YYJJ
:Dz CONSTRUCTION LENDING AGENCY NEW RESIDI!NIIALPLMB. SQ F. PAID
are M
U � Ihertny affirm 0athere ixacnn.vtmnion lending agency for the performance of ---
the work for which this permit is issued(Sea.3091.C1v.C.1
0U IN'nleis Nan. TOTAL:
Lender's AJdrcss
} 0. 1 cerify that 1 have read this application end shale Than nbe above information is 'F,
Fir ran cmrrtco lagreenm comply withallcity unJ county nNinances and state laws relaingm QTY. MECHANICAL.PFRn FE
(.Jz holding construction,and hereby authorize representatives ofthis city toemer upon the SEIS
SWI I.
ahovonicia iul property for IneTenanPurposes PHRMII'ISSUANCE.
(We).gree mm save,indemnify and kevp M1armlexx the Cily of Cuponino egninn ELEJIR11'
4d!
Iiabilitics,judgments,costs and c"mes which may in any way ecce against said City AI;TER OR ADD TO FIIECII. PL•F.AL U Z 419
in meq.ence of the ramin,of this permit.APPLICANT UNDERSTANDS AND W11,1.COMPLY WI Hi ALL NON-POINT AIR HANDLING UNITHO 10000 )SOURCE REOULA1'IONS, MEAL PHY.AIR HANDLING UNIT(OVER ITO OB ) COTION TAX
Signature of ApplicaMCoureacmr Date IEXHAUSTHOOD(WIDUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will The v„Beam or future Building twenpant susre nr handle hairdos material I IIEAfINC,UNITG0 I Ix),0(x)11'I'Of
as defined by The Cuperino Municipal Code,Chapter 9.12,and the I leahh and Safety
Cri Second 25532my I[HATING UNIT(OVER I091100 B'i'U)
❑Yes Fl No PAID -
VEN'I'ILA'TIONVAN(SINGI.I!RESID) Dam Reeoipng
Will the applicant or future building occupant use equipment(ir devices which
emit harmijus,air contaminants to defidttl by the Bay Arca Air Qtahty Management BOILER-COMP OUT OR 100,011 BTU) T
DTatrmet( BOILER-COMP(OVER 10(h(MID BTIH
0 Via, ❑No
AIN CONDITIONER
(have read theh ode,Section,25505,
2uls 553 ats n2553Chapterf�95tl st it tic ISSUANCE LATE
hsmiagdoesroSa(rry Code.Sectionst,that.2553]andmiloli T to addend thatifnine NIEW RESIDENTIAL MF.CII. SQ.FT 0 - .ix / q•,ITf-J�(J
hnilNngJces nm currently have uTnnant.that it is mytswpnnsiniliq�to notify tiv:occupxm Q Y
of Ilia regnhemeTmlx which Inn he nest poor no ibaa.nce m'a Cerlmean of Oeeupabcy.
Owner at authorined.,car Date TOTAL ISSUED BY: s� A /
i OFFICE