26614 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL)IM1 -ELECTRICA L PERMI'TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIIING-MECIIANICAI. ^ � r�
BUILDING PROJECT II 'FL IFICA'I'ION iV1 4
BUILDING ADDRESS: o SANITARY NO, APPLICATION SUBMITTAL DATE
> p
t o �GJI. G-2o-9�P
l
'Rg NAME: PHONE: COEP4AjZrOR'5 NAME: L1 NO:
• a eV El-lar-1-au
xG N/C CONTROL#
A CIII'11iC'I'/IJJCINEI?R: LIC NO: ADDRESS: ❑
�' 041 C L
CONTACT: PHONE:
QTY. ELECTRIC PERMIT 17EE BUILDING PERMIT INFO
BLDO P.HCT PLUMB MliCll
Q Jt PERMIT ISSUANCE / ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTIONrxyy I hereby affbm that l um licensed underprovisions idChupter9(cnmmencing with
uF 00F Section OW0)of Division 3 of the Business/ands-Paro..Posio ri.and my license is in PANELS
g<.2W fullcnse Clntl ellen X10 Lic.1 Seo! UP TO 200 AMPS
y7m
to Comon 201-IOMAMPS
�OyZ ' ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ,IT.
O Z�O 1 understand my plana shall bc used as public records.
1:,yt-.j SIGNS ELECTRICAL
Licensed Prnlcesinnal
XOyUd' OWNER-tlempt fi no the CRATION SPECIAL CIRCUIT/MISQ
1 hereby..firm that I am exempt from the Icaimmt.Ps License law for the
m34.y which espon-aTormiion]O31tract. he,,i pr ve,deaionaCWe:Any city Stcounty TEMP.METER OR roLF.INST.
L-fSa� whrtoitsussanpermit mlaim,t claheq improvgh perms h.ore a shred staucmm p E ® I Tia
prior to its issuance,also rcynires the applicant for such parotin to fileasigned statement POWER DEVICES � � IIIA I' a\VR
a�O that he is licensed pursuant to the pmvisiotts of the Comrncmr's License law(Chapmr
d Xo 9(commencing with Section]0007..DivisionJnf the Business and Professions Cade? SWIMMING POOL ELECTRIC A ON
onhat he is eaempnhercfrom aodthe hsis(a,the alleged emailAny,mationof OUTLETS-SWD'CI1GS-FIXTURES
kZ4 Scctinn]03 LS by any vpplicam forapetmit subjects the nppliconu.ecivil penalty of
nm more than five hundred dollar(SSW).
E S p NEW RESIDENTIAL.ELECTR
CFp ❑do
wrk.anheestructturormycmpended oro emd forstheiside Sec.70m1,Becomes, —PQ PT DATE STORKS Pf3 CONSTRUCf1ON
will drnhewom,ands:'I he Cufeianm's License
La a does i..I upply town vine,ss
and Professions Code:'I'he C.mfocmr'e License Law does not apply m an owner of
property whnbuildsorimprovesthercon,and whoJ«ssuchwak himaelf.rthroughhf.
cmploycembefng ori that suchimpmvemenban:not ourdcompltion,theoe.lf, OCC GROUP RCS.UNI,'S
h older will have
the burden of pmartinsisthold e did
limit or improve
urposer-
builderwillhtrvethebuNen.f that he dlJ not build or int rove for f � L
proving p purpose.
ale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as the project
(See 704 ttm Business and onnfinsa gwiCWe:)Ths,Contractor's
ljons,tthe pcs not(See ]044,Nus and ywho siom Cale)The thereon,and
License Law dace not apply manownerofpmperty who builAs or improves thereon,and PERMIT ISSUANCE
whoccalmets for such projects with a cominclor(s)licensed pursuant to the C.ntracmlx
License Lw. ALTER (EAT FEESUMMARY
❑ 1 am exempt under Sw. ,B&PC for this reason BACK FLOW PROTECT,DEVICE
SANITARY Y_N
Owner Dote RIiC131PTN
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Ihembyafr=thailbaveacenificamofconsenttoself-insum,oracertiRcateof FTRECEIPTM
Wnrkerd Cnmpensedon otsumnce oruaertifiuleopy therwf(S.c.38g1,Lnh CJ which :B,_ Y_N
coven 01 employce's under this permit. OAS-FA.SYSTIiM-1 INC:4OUTLFTS RECEIPT N
Policy M BUILDING DIVISION FEES
Company GAS-EA.SYS �OVER4(EA) KFEE
[ICenlfedcopylsheruhyfm iOmd.
❑ CenificJ copy is flet with the city inspection division. G EASU .INTER EPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WOR GR AP
COMPENSATION INSURANCE SOILS FEE
(This sectmanced not be completed ifthe permit is for one hand dollms($100) SEWER- Y-S RMEA.200I - ENERGY FEE
or leas, v
I cenify that in the performance ofthe work for which this parent inissued,lshall WATER IIS B W/VENT
n I employ any peons in any m as m become subject n the Workers' PAID
z Compensation L.wauf C.lifomio. Dote sa WATER SY' G Dem IteceiptN
O O Applicant
NOTICE TO APPLICA M:If,after mokingthia Cenificac of Exemp on.you should LP B. SQ. TOTAL:
huwme subject m the Worker's Compensation provisions o.the Labor udq you must
Fes ; fonhwin comply with such....Iliamor this permit shall be deemed r voked. B LI 'E
WCONSTRUCTION LENDING AGENCY SEISMCP.
z JLfi
5 Iherchy affirm that There is aconstruction lending agency for pe tormnceof
1..) O tR� — sll�
he work l'nr which this permit is issued(Sec.309],Civ.C.) 101-AL: ELECTRIC FEE
1<ndces Name
OF Lender's Address QTY. - M HANICALPERMIT FEE PLUMBING ME
V I certify that 1 have mad this application and state that the above info tion is
u^ correct. l agree m comply with all city ondcounty oNhancesond smtehmmmla'ng m PERMIT ISSUANCE - MEET IANICAL Is E
�- building construction,and hereby aathdze mpresemativesofNiteirymemerupo the CONS'IAUCTIO TA%
O ,2 above-mentioned progeny for inspection pafpoua. ALTERORADDTOMECH.
(We)agree m save,indemnify and keep hematites the City of Ci penin.again
ladilitin�,judgmerm, ...is andexpenses which may in any way acemeugainst said City AIR HANDLING UNIT J'TTO IO,n00 CFM)
in corse of a mmi of parotin.
6 �o iyOMEB- ,
ignaw n Applicant/Contrndor Date [MiAUSTHGOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant or fumm building occap:mt score or handle hazardous material
m dcftned by the Cupenino Municipal Code,Chapter 9.12,and the I halt it Solely HEATING UNIT(OVER 100,000 BTU) TO AI.:
Code,genion 25532(e71
El Yes EI No TILVENATION FAN(SINGLE RPSID) /a
Will thea applicant or furore huildin / ruse BOILER-COMP(31 IT OR 100,010 BTU) ISSUANCE DATE
pp gorcupar equipnmmor devl.es which emit
hazadous air conmminmtts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 11100,000 BTU) PAID
Nstrictl p
Yea El No NEW RESIDENTIAL MECH. SQ.FT. r Q
I have mad the himardous materials'reyuiremems under Chapter 6.95 of the JUN 1 7
California Illatil &Safety Code,Sections 25505,25573 and 155M. 1understandthat
Hthe building does not curremly have a mason,that it is my responsibility mainly the
occupant of the fequiremants which must be an,prioa 1.innanca of a Cenifiwm of
Owner or amhofized agent Date TOTAL: ISSUED BY: VL�IJyf�'e(� 11Tj
OFFICE