30465 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
APPLICATION/PERNHT PIA)IBING->IECIh\SILL
PERMIT NO.
30465
BUILDING DIVISION
BUILDING PROJECT IDENTIFICATION
BNLDING AUD FSS: , - -
SANITARY NO.
APPLICATION SUBMITTAL DATE
i 70 6 ✓d� 2
8 Z7 q G,
NE' �;:�� PHONE. ONTRACfOR:S NAME_' CNO:
7 3
NIC
CO OL 11
Col"
41?
it (� /J /
f�
❑
ARC IIItiCT/INGINEER: LIC NO: IlRl54NO
Co LT: P PHONE : v s�
/ 41
BUILDING FO
BIL�DG E PLUM MEC
/ LTJ �� ❑ Conwlumt Fe's Paid by Applicant (Initlal
' I
LICENSED CONTRACTOR'S DECLARATION QTY' ELECTRIC PERMIT FEE
I`''mo
JOB DESCRIPTION
D00
I hccby elErm that 1 ran licensed mdca onvi,iom of Chaper 9 (Lmuneocing
Section]ngpof Busirexs l4ufcadom.. Cotde,ual
O
wiN ninnlnf the aal mylkcnse ie
PERMIT ISSUANCE
R SID NTIA
y�C
V
i i full fence end ended. �
License Class liar. M
❑ShDWL - ❑KITCHEN REMODEL
QF CW
Unc Gmlranm APPLIANCES- RPSIDPMIAL
DITION ❑PLUMBING RIiPIPIi
❑M I-UNIT ❑STRUCTURAL
hQL
Fly
' ARCHI'I1:CTS DECLARATIONPANELS•
p�Z
IuNmtaod my dens shell beu.sud.s public records
MODIFICATION
I Z ^ p
u]
UP TO 200 "I's
LicenuJ Hof¢vi«N - -
101-1000 AMPS
RIOR [I CHIMNEY REPAIR
IMPROVEMEYI'
iy�
C Q
OWNER-HUILDER DECLARATION
1 hereby af0rm that 1 am exempt from the Conlorttw N OVER F)D)AMPS
's IJnLav for e
BATH REMODEIIRFPAIR ❑DEMOLITION
3 a U
following rwwn. (Section 711311, Irconavn and PnRessi us Cale. Any city «cowry SIGNS ELECTRICAL
El OTHER
LL
which requires a Par t to comdera t. cher. improve, demolish. m rap r my %recome
ti
•=C
nmrb, in imants,elw the cant f«wch t to Man si� statement
rnryiro pili Irani g SI'ECIAI. CIRCUIt'/MISC. .
_
I�N
.yp0
K
OalWi,liwnw with
tpmcond to the70(m positions of the eBusiess dProfnse lawsCcln)9
Second tof hebai icor orthee dancend Professions sCade)or 'TEMP. METER OR POLE INST.
than he is the basis do Any of
zany
9�y
e
^
esens,th
a mn.od .Meted exemption.
31c b and _
vimmepenalty
Scmilm]WlS
Sec uppliuntfor C l whjoelahn upplicwnneCivil penalty of POWER DEVICES
❑ NIIV BLDG/ ITION' �/l DF OSERVI
^nn
F Z y
sae ben rn($X0tnil
m maxc Wen five hwdred Jdlen (5300).
❑TENANT, � O'�DSERVICE
IMPROVEMENT
Q
G
I,nuwerurthe
❑ haaemy,«myemdoYcen wiWwegesvathcirsok c«nprnsiness SWIMMING PIXII. ELECTRIC -
will dnthawmk. nrn.don, ml
�JrLIYo ..V
OTHER
enolhof Cocle: he Comisnrinmmhd
Cal c: The Cwtnerues Li Lewdos wt .piny toff owerof OUTLETS -SWITCHES-FIXTURES
apply.oano necof
Mb w
who oyids pr irtlrove, wtu docs such trek m thmogh
his own
his own t mch impr ded! or
pmvklW that ,uch impmvemcnw an, noton intrndN on offered f« NEW RISIIIENTIAI, EL[CIR SQ 6 '
SO. FT. FLOOR AREA
LSO. FT.
owaser. the Wil ding «irapovcusi. is wd without oroplcliw,We
eilclL Wwer.
ill
avncf Wilhr will hove de W rdm of povimg N.t he did rot hold «improve fm pw-.
Ihold oni
pose of We).
❑ 1, u ower of the p contracting with licensed cOnlNo«S In
am sere,, r
. 70d.
crnnruct the pojat ISre. ]UL1, Btuinecs end Profeasias CodcU The Conlrxtols IJ-
ad
«me Law doc, net apply In w owner of Mrsc ty wlm Wild,« impnives Hereat, rad, QTY. PLUMBING PERMIT FEE
wlw cumr.cts f«,uch pmjmts wiW a convu'mKs) hemsed punuwl m We Conlnam'.
�S
K`wT
U. Law. PERMIT ISSUANCE
AL
I.m enemp under Scar. ,H&P C fon this resam
Owner Due ALTER-DRAIN&VENT-WATER(EA)
VALUATION
"I�'J
WORKER'S COMPENSATION DECLARATION HACK II.OW PRO�ECT. DEVICE
ereby atfrm Cder pcwlty of pmluryoe of the following dom: cclanti
ho
' _
--1
❑ IWscetdwillm.inWnaCrnif tcofCmucntwlf-imwcfwWa ces Camper, DRAINS- FLOOR. ROOF. AREA. CON).
SIURIFS
TYPE CONSTRUCTION
ewion, m provided for by Section 3100 of the Labor Code. for the Tadao of Nc
work lar which thin Imnnil i, issued FIXTURES -PER TRAP
❑ 1 have sed will maintain Worker', C.,nvtiw Immo . u rcquiml by Seen.
-
37W onita Labor Code. for the penf«merc'e oftha work for which Ni, pemdt is irwed. GAS- G. SYSIPJ.f-) INC. d OUTLET
OCC. GROUP
APN
My Worry ',�n},y _1nny.ylGi 1.»od Policy nwnMr am:
%
Gorier [IRI/ hIEX PTIOcy O GAS -EA. SYSWN OVER EA)
CERTFlCATE OF LXFJ�PGON FROM WORKERS'
tlU11.U1 IV ION tFyS
COMPENSATION INSURANCE GREASNINDUMI. WASTE INTERCEPTOR
(This section need not be completed ifthe pmnit u for oe huMrtd dollen fSlW)
«lav) GREASETRAP
PfANCHECK TIE
I certify that in the pndororce ofthew«k for which thin ferrent i, issued, I JWI SEWER - SANITARY -STORM FA.]UB FT.
nor employ any pawn in any manner Cara, to Ivs.Stim: subject to the W«krn' Comprn-
ENERGY FEE
O Z
�
w
�
Applzam lutart sof C.lifoinu. 0.B WATER HEATER WHEN 1111-EC R
GRADING FEE
v)
NOTICE TO APPLICANT: If, after making do% Certificate of lacmpion, you,lwukl WATER SYSTEM/IREATING
SOBS FEE
f•" 5
becmrc subject to than, W'orkrn's Cmnpcmarian pmvismn of We Labor Code. yw mon
�-
rmhvith comply with such Praviu«u orlhis Permit Imll be deemedrevukM WATER SERVICE
� z
CONSTRUCTIONLENDINGCAGENCY NT:N'RF_SIDE,YTIAh Plh1 N. SO, FT
PAID
V
ieounmswclKKO.Cing agency fmthe Pedortmrce of
Due RecelptN
W F
work
me [«which this pemth i. iswed (S«. XM. Civ. CJ
W.'C'i
TOTAL
U
1e
leadctI Addrean
as
,Add
1 crnify IWt I have read Ihir .pplkdllon aW none Nw the above informLlian ii
UUILDING FE 4
h
carrot.legrtetocomplywiWallcitywdcnumyo imnl.'eendw lam mWl gm QTV MECHANICAL PERMIT FEE
CiZ
b Wingco nry tinedh reby euWa v<rtp nutivcs of Nis city to cater opo W
SEISMIC FEF
abe
ova-nntmead prolan, for inspectionpurposes.
ELECTRIC
PERMTf ISSUANCE(We) agree la leve, iWemnify vol kaeP hmmkss Nc CitY olCupertino ag.imt
Inbilitin,judgmcv,. cone and expenses which may in any way wmue.g.imt said City ALTER OR ADD TO MM
kk
on mw9eec of me B.arm, of thin parmit.
PLUMBING F!TF
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIO 10.000 CFM)SOURCE
REGULATIONS.AIR
MECHANICAL FEE
HANDIJNG UNIT(OVER 11,000 CFM)
CON,STRUCITONTAX.
Si sere WApplic. n nm Data EXHAUSTHOODIW/DULT) r
HOUSING MITIGATION FEE
/TMZARDOUS MATF.RIAIS DISCLOSURE
Will the app emo or future W ilding ecupwl shoe m hullonvvdws malarial HEATING UNIT TO 1oU'fg1U RM
es dcfoeal by Na Cupertino Municipal Cak, Cluper 9.11, and the Hat milSafety
-
Code, Section 25532(.)9 THDOIN'G UNIT (OVER Hp,HW BTU)
❑Yer E] No
VENTILATION FAN (SINGLE RESID)
PAID
Dao RacipN
Will the
us airc me or future cefinog by me, D use et Air u «devices which
t hezaodnus air c«mntinan¢ as oktimd hY the Day Arca Air galip' Mavgcmrnt BOILER-COMP (JIIP OR 11p,00 BTU)
DiwicR
TOA:
❑Yes FI No BOIL9t- COMP (OVFR IMill BTU)
I have nal the hexadma macaronis rtyuirtnnvs tendo Cleat ex 6.95 ofthc Cali- AIR CONDITIONER
ISSUANCE DATE
fmnn Hedth & Safery Code, Reno s 25505, 25533 and 25514. I utdavatd Wu if dte NEW RESIDENTIAL MECH. SO, FT.
gdi a.. menlywhich have. that it in my rtnryinsiMlitytommifythe «ivpwt
,ifthe ,nere,
mfddi n,dortnorc which muse.t metprimm iavwecnlaCmifuateofoa„fcecy.
ISSUED BY: Vag•_ , ,
(F.vxnr wthorincd agcm DataJ\
OFFICE