S 2516E
0=2
C
u:
U
hayQY
t�V
soya
F�Fu
CYC•
xx:
nplal(
m�pC
0
^E
to
z
zzz
Q
vC
ry F
OL
UZ
r]
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
RUILDIN(: DIVISION APPLICATION/PERMIT rl.unnurvc-nlsnANlcAI,
BI111. )ING PROJECT IDEw 'IC PION
PERMIT NO.
S 2516
IiUI1.DING ADDRESS:
`L
rj
SANHARY NO.
A IPPLICATION SUBMIVIIIALDnDXI'E
OWNhRIY� ItpYI
C(NTRACIOR'S NAMP�O?_6'O71(,W0yrLICNO:
NIC
❑
CONIROLa
ARCHITECTIENGINEER: LIC NO:,'
ADDRESS:
CONTACT �j PHONE:
w/01 -6'Z/.4
d -5-0,36,14Y
❑Consultant Eces Paid by Applicant
BUILDING PERMIT' INFO
BLDG ELECT PLUMB MECH
Lrf rY/
LICENSE[) CONE RACfORS DECLARAr10OFN
I hereby mrrmr mm I am licensed ander prookion, of chapter 9 Panarm terng
with Section 7XX)) of Divixina 3 arrhe Brniness nnJ Pref ..ions Cofe, and my license is
in full force and effect.
j License ClassLie.❑SFUWL
1 Dat.. Grmruumr
QFY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ KITCHEN REMODEL
❑AUDITION ❑PLUM B ING RE-PIPF,
El MULTI -UNIT [I STRUCTURAL
MODIIgCATION
[IINTERIOR ❑ CHIMNEY REPAIR
IMPROVEb1ENT E]SWIMMING POOLS
[IRATE REMODILREPAR 0DEMOLITION
[I OTHER
L
TSA
PER>11T ISSUANCE,
APPLIANCES - RESIDEMPIAI.
ARCHITEC'CS DECLARATION
1 understand my plans shall M used a. Public records
PANELS
Ut'TU 200 AMPS
Licensed Prafe,amm'I
OWNER BUILDER DECLARATION
C 1 hereby affirm nut I u t xcnpt (nun the Contractors License Law for the
following a -at (Section 70315 eBwirmss and Profusions Cn& Any city or county
which require, a permit ms consumer. ager. impmv'e. demolish, or repair any samerme
13cor'lo its ismance.also nyuires the applicmn forsuch Perini[ o fileaa,riedd.hanem
_ that he is Gceroedpumuum m thepro.urans of the Canrmcan''e Licurcc I... (Chapter 9
(commencing with Section 7Q*) of Division 3 ofthe Business and Professions Code)it
( that he is exempt marcfrom and the basis for Jm alleged wtion, ion. Any violation of
• Section 7131.5 by any applicant rant permit snnjens the applicant ton civil pnwltY of
t more than Eve hundred dollars ($50a,
C I. as owner of the n.or err Inas with woes as their sole coat moan,
v ❑ proart, pc YentP Y g pen
will Professions
C d e: The oat is not s Licenses ora ply ]) an 0W11 ncss
Code: The Ctntmereo Lianwe Law, tau nm apply s an owner err
and progeny who
• propcny who builds or improves tMreon, and nbn Jaz e h work himself or through
his own unrpinye "pmviJed Lha web Intpmvemmeus arc nal imendeJ or offered Inc
wale.IL he huilAing or impm Id within one year ofmmpletivar the
I v ill have the M of prm'ing that he did not build err improve for pur-
e nc uf. nl
K1, m mpeny, am cxdmivcly contracting with licensed contractors m
onsuuct r ¢n (See 7MJ. Bu-cincw and Ihatessio ns CMe:) The Contractor F Li-
Jrxsirfpplylmnnr col pmpcnywhu builds orintproves thorcnn, and
wee
who,ond fo can jaa wirh.cnntmcaats) F,,nwd per uunnol he Contmctafx
Li0eR" °
pl r0 r If & P C for this reason
Owner Dale
20I-EXd AMPS
OV13R IgX)AME'S
SIGNS ELECI RICAL
SPECIAL CIRCUFUMISC.
TEMP METER OR POLE INS'1'.
i
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TP.NANT ❑FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS-SWITCHES-1§XTUItES
NEW RI4IDENTIAL ELECIR SQ IT.
SQ. IT.PLOOR AREA
USQ. Fr.
TOTAL:
QTY. PLUMBING PERMIT PF.F
PERMII' ISSUANCE
0
ALTER-DRAIN&WATER (EA)
BACK FLOW PN .E
VALUNHON
WORK l., aaalt, of sjor en DECLARATION
1 hereby allinu unJor penally of perjury one of rhe RdlowmgW ken Ci..
�Ihave unJ will inainlain uCenifcmeof Comenuosel(innuru (err WorAels Cnmpen-
scoot, as provided for by Section 37 (10 of the Labor Caste. for the performance of the
work far whichmix pc or is i ... ed.
1 have and will maintain W'orkds Compensation Insurance, as required by Section
37X1 of the labor Code. for the performance ofthe work for which this permit is issued
My Worker's Comia pensaImumnm conic, and Pnliey number are:
Cartier. Policy No.;
uRE tFicATE 01: EX FMITI(IN FROM WORKERS'
COMPENSATION INSURANCE
(Thiswatiom nctfina bu Csm.pleM if IN permit is I enc hundreddoliFts($1W)
err less)
1ecnify that in the perfmmanr.la, twork forashichthis permit he W..ers'C Fnell
not entpiny any pcmon in any nmmwr_ar usmbcmnncnthja't to the WnrAcrv.'Cmtgpen-
scion laws of California. Date
Applrant
DRAINS -FLOOR. ROOK. EA, .Il.
STORIES
(KC. GROUT'
TYPE CONS'IAUCTION
AP��
'Y7 -/M^
Q
PIXIURE5-PER TRAP
GAS-EA.SYSTr:M-I INC.J OU .ff.'
GAS - BA. SYSTEALO1 q[EA)
CREASI]INDUS FRI. WASTE IN PER
BUILDING DIVISION PIi1S
GREASHTRAP
PLANCHECK PEE;
SEWER - SANITARY - STORM EA. 21%IPI'.
ENERGY PEE
WATI7R HEATER W/VENT/ELECTR
GRADING ITE
Nl)l'ICIi TO APPLICANT:IL after making Nis Cenifical-f ExuatptimU you should
become suhjeamlhe Wodeiw Grmpenwlion pmviainns o(the labor Crxle. you cwt
forthwith cnmPly wish such pmvisinac err th'ry permit sh.Il6e damM revokM.
CONSTRUCT ION LENDING AGENCY
I hereby affirm that them k a construction lending agency hit the performance of
the work far which this permit i. isenM (Sas 3097. Crv. C.)
Lender, Name
Former', Address
I ecnify rhzt 1 hove recd (his upplleation unJ sm a Ilial the above information is
cmrea.I.gree mcomplywimalleityindcnumy latinanccc:md.1.1 I.—telmin,',
building conswctinn, mod hereby amnome represenmtis<s of this city m enter ulsm the
alyI" men lntit d pmpcs ty Ity inspection Int Polls.
to save, int mnify vnA keep hamlcss the City of Cupcnino against
liahilities,judgmems. cons expenms which may in any x'ay acerae agaiml,vid Cay
ncyucna n(Ihcgn" i gal this permit.
APM'ICAN'1' BIND NUS AND WILL COMPLY we ED Lf. NON -POINT'
SOURCE R[G
1
WATER SYS'FEM/fREATING
SOILS HE
_
WATER SERVICE
PAID
Doul Rcceipta
NEW RESIDEN11'IAL ('LMB. SQ. FL
TOTAL.:
qQ�I
BUILDING IT .
QTY, MECHANICAL PERMIT FEE
SEISMIC PGG
PERMIT
PERMIT ISSUANCE(W'c).gra
ALIERORAUD'IOMBCII.
PLUMBING Flit
AIR HANDLING INTI (70 I(Loin CPM)
MECHANICAL PEI:
AIR HANDLING UNH (OVER IILIXX) CFM)
CONSTRUCIIONI'AX
-6 en ApplirnnUComucho Date
MATERIALS DISCLOSURE
Will the ,li,ma in Pomre huildingnccu.art.amrc or handle hemNnusnorenal
av defined by the Cupcnino Municipal Code Chapter 9.12, and the Healthand Safety
Com. Section 25532(a)7
CI Yes D
Will the applicant or future building occupam use equipment or devices which
carr lurOduus air Crna r tsdefined by the Hay Area Air Quality Management
Dismier^ n rim urn its /'/
yes
ad the hvardous materials n . p under Chu
gammen pmrr!)S Dram Cali-
totalsSafety Gds Smi ms85(15. 25533 a 2553q lunderstand Dal if the
V,dotlmnonh,ha,c
hadilin�lC�antenhmakaryrc msihil
ofthccwhi s�cei,oi,r Io ounc of, 'cr h eupancy.
HXHAUSI' 1 IOOD(W/IIUC'1)
HOUSING MITIGATION ME
HEATING UNIT (10 IWJXX) BTU)
HEATING USE r(OVER IIX%NX) BTU)
PAID
VENTI IAI ION FAN(SING LH RES I DI
BOILER- CHAD OR IWJIW BE U)
Dare R-6pt a
T��fAI'
Q
BOILER-COMP(OVER W,0001ITU)
AIR CONDITIONER
ISSUANCE, DATE
ISSUED BY:
NEW BESIDES '1'IAI. MECH. SQ. F'L
( mieM agent ):nc
TOTAL:
OFFICE