2549 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
I APPLICATION/PERMIT
PPLIC�A�TjIjnO�N�}\/P/teErR_MIT^ PLUMBING-MECHANICAL c•;,v'j: .;.! . 2
J / J
_IuuamncDrvlsloN JL1:gBUILDING PROCIDENTIFICATION
UILDING ADDRESS SANITARY NO. APPLICATIONSUBMITTALDAI
44S
LOT, C� J
. ERS NA F �� prM PHONE CONTRACTOR'S NAMI : LIC NO: N/C CONTROL N�•
il
"RCHITECf/ENGINEER: LIC NO: ADDRESS: ❑ I J
CONTACT: PHONEY '+.`1°Kta r eta - - . ;<;, . + ',:e;BUILDING PERMIT{/INFO. .J „?
/,gyp tic TELECI'RIC PERMIT,-:-, a. r�4 FEE,e,i-
I`•M:L -,•• B LE ECf i MB M i
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Z.z Iherebyuffi—m,l l art llcen.Xd under pmstactrsol Chapter9(commemem,,vith 10B DESCRIPTION
Section 10001 of Division Jol the Business and Professions Cade.and my license is in PANELS
full force and.ffen.
License Class Lice UPT02W"PS
Uma Cottontail., 201-IM AMPS
ZCyZARCHITECTSDECLARATION OVER 10(10 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Z—= I understand my plans shall be usetl m public records.
='i"= SIGNS ELECTRICAL ��/\
s^ _ Lk
LLIPCOd Professional
Licensed OWNER-BUILDER DECLARATION SPECIAL CUSCUITMISC.
�•��U 1 hereby affirm that I am eaemps from de Commicam,License Law for the
,3 err,, followingfeoaon.Section]UJI.5,Business and!Professions Code:Any city car county TEMP.METER OR POLE REST.
which requires is Permit to consomi alter,improve,demolish,or repair any structure
yT� priorto its lssumce.also raccoon,the a Iment fmsuch pemdO.filcasignedsyummt POWER DEVICES
X1<0 Ihot he is licensed pursusant to the Pasua rsof be Contractors Licmue Law(Chapar
ton. 9(coranencing with Section]OOOI of Division J ofthe Business and Professions Code) SWINMING POOL ELECTRIC
iCm— VALUATION—y
ty_,� nnhm heiseaeby n,it'therefirommd Nemail t s Ncallege aWlic;don.Any violati..f UILETS-SWITCHES- !� w� fJ/
PrZ�• Sec on]dord byymndred do[].( pemit xubjecu she applicant,.#civil penalty of FIXTURES `� W
n Nan five hundred dollars(53007. J L��fJ
z F_— ownuofNe tmpany,mm em Io aswishwe esmsheirsolecom NEW RIESMENTIALELECfR _SQ.FT.
y p y g ,Buedon. STORIES TYPE CONSTRUCIIOM
a3=
tilde Newark.ancitCame swetureisnottorsLmlelm awdosno, (Son.by ral. roci n
ness
and Professions Code:The Contractors License Law does not apply w m owsler a( It ^
own am w,ces.provided!
Nereogandwhodocssuchwoh himXlfor Nmugh his 11 I
cmployaca.pingor improvement is
earrtdedmo(feted tfroarade.he
owner-
builder - 'OCC. ROUP L� L . ITS
however Neave theg omm�of prncmrshat he id not build of complexi on,po —
will have the burden of proving put he did not build or improve for porpoise,of ,r
sale.). Q7'Y- .} g PLUMBING PERMTi/'c+- :�. FLOOD ZONE
❑ 1.tu owturofNe pmpcny,amexclusivclycmmcungwrN hcanredcontrecturst yr Zx jw,.. oc .k,.,-,i.c.r. y .a''x+ a. `L's'I DATE
comwet the project(Sec.)014,Business and Pmfessiou Code:)The Ctrnvacmrs «
LianX Wwdmsnos apply,.mowncrof propertywho buildsmimpmvu thereon,and PERMIT ISSUANCE
whoconcracrsfor such Projects with a comractids)licensed promantmshe Contymo's ALTER License law. I6 aft�IjG. '4- 'FEE SUMMARY;(;. rate
❑ I am exempt under Sec. ,B @ P C for Nis won BACK FLOW PROTECT.DEVIL[ UNKII-Iri FEES
SANITARY Y—N
wear Dare DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT at
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y__N
-❑ Ihcrcbyaffrrmonimu eacerla=mfi copyme Xf(SM.38 o.Lrificmeof FIXTURES-PER TRAP �' RECEIPT#
i Workers'Cositti dsml this permit.
ifiMcopy Nerrof(See3g00,WbC.)which PARKFEE Y_N
Policy all emploYaiue.ar Nispmnie GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPTN
Commpaopalicy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA)
El Certified copy is hereby hammed. GAS FEE
❑ Ccnif¢d cnpY is filW with the city inspection division. GREASEANDUSIRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE MAP SOILS FEE
COMPENSATION PISURANCE
This aerionneW trot be,completed ifdac permit u fmmehumdred dollar PIED SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or ltilless.)
I cannily Lal in the prefommmce of the work for which Niapemdt is inured,i shall WATER HEATER W/VENT/ELECTR
not employ any Person in any mama,so u to become subject to the Workers PAID
Z CAompeantcion Wws of California Data WATER SYSMNLTREATING Date Ree ipl ,
pplic
Z Q NOTICE TO APPLICANT:If,after nuking this Ccreficme of Eaempdon,you should NEW RESIDENTIAL PLMIL,.NSQ.FT. TOTAL:
— V) become Subject to Workers Compensatimn pmvuitrru of Ne Labor Code,you must
Yfonhw rk comply with such provisions or this permit shall ba deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
7) Z 1 hereby off Thu Nene is a caruuvam Irnding agerry fm able ill- ---of
Q the work for which this pemdt is issued(See.1097,Civ.C.) TO ELECTRIC FEE
Landers Name nvr �y
.J U
Lander Address QTY.jry,-,-it(MECHANICAL PERMIT a+"""' ;FEE}' 4 PLUMBING FEE
1 lentil,Na 1 have read this application and state that the above information is " ^""•x`,w_ave..acre✓. a'v.+:,,+.rCitSd
1 correct.laeree,.complywithall city and county ordinanm aM sum lawsmlatingm PERMIT ISSUANCE MECHANICAL FEE
_ r , building Ponsuuetion.und herebyauNndu reprea mtiveaof Nis city,.emerapnnthe
V Z above-mentioned Properly for imon pu TER OR ADD TO MECH. l• CONSTRUCTION TAX
el a o sal indent `md kap h les_ a Ciry of Cupertino against
liabi i ,jus nyy anile ch yin weyaccrueagaiutsaid Ciry IT
AIR HANDLING UN (TO 10."CFM)
so o Ibeg ingo it.
AIR HANDLING UNIT(OVER 10.0))Cl
Signor o p icor cm c EXHAUSTHOODDY/DUCTI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW."BTU) Date Receipt it
Will the apPlicam in future budding occupant store or handle hazardous material
as defined by the Cupenim Municipal Cola.Oupu,9.12.and the Health and Safety HEATING UNIT(OVER 100,001)BTU) TOTAL:
Cote.Section 25332(a)?
13 Yes 0 N VENTILATION FAN(SINGLE RESIDI
Will thea licantorfunum building BOILER-COMP CHIP OR ift"BTU) ISSUANCE DATE
PP gby the uy Area Aire Quality
Management
uzarl air contaminants as defined by Nc Buy Area Air Qmliry Manngemem
gsNet r Yca 11 No BOILER-COMP(OVER I W,pt1U BTU)
❑ NEW RESIDENTIAL MECH. SQ.IT.
I have read the haammux materials requiremenu unJer Chapter 6.95 of the
Calilomia lladdl&Salary Code.Senium 255115,25533 and 25514. 1 mWersm!W that QCT 12 g
Jdtchci"I l;tlrx.nme..ols llyhav rrunt he Nmiiis my mance of
sty to modify the 9 9.•1
"Llmallhos di ed es not ncnn wha:h mut tic met priors m nwm.�of it Certificate ircam of
he 1 3
jD..narnrawnmr.ed agent
Mme V ISSUED 119: