27108 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUB. -ELECTRICAL PERMIT NO. 0
APPLICATION/PERMIT BUILDINLUMBINGG
IDENTICAL
FICATION
BUILDING DIVISION BUILUING PROJECT IDENTIFICATION
BUILDING ADDRESS: ,r SANITARY NO. APPLICATION Sl1BMfITAL DATC
UNITN LOT
O ERS. ME PHONE:. CONTRACTOR'S NAMEWC O'. I_l l
0 6 7 N& CONTROLif
• R GIN LIC NO: ADU S ❑
ONTACT: PHONE QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFOO
-
�y PERMIT ISSUANCE BLDG EIFLT PLUMB MECII
❑ 7t ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAI, DESCRIPTION
WyZ I Mscbyeftirm that l am liccrosWumlcrpovuioosof Chnper9(commendngwilh
t+100 Scciim]tXp)of si 3ofthe B..e,sand Pmfea inn Cak,andmrlic.,in PANELS
Fy�k+ full forty and e[fcm. Q� UP TO 400 AMPS
44ZZUU hicarcC ��K Lic.N
yQy Dere Conustm 201-11100 AMPS
H ClilW=S DECLARATIONSQ.FT,Ell AREA S/SQ.FT.
ZOami.3 lunh tmtlm plan..shallMu� es ublic vxdc. OVER IOOO AMPS
OZ—o
SIGNS ELECTRICAL
LiceneonJ Pmficommel
ER- U115B51 T SPECIAL CIRCUII'/MISC.
OyU 1 he da,affirm that I am cxcmp from Ibe,Contncon"Lice.Lw f«do
W3Wy following oasnn(Secum]031.5,Burma.road Pmim,iim,Comic:Any city or county
TIME,METER OR POLE INST. �^
tc.° which mquinew a permit to cowtuct,eller,improve,3cmoliah,or repay any suucmm
EYE Prior to iw,mumoce.also requites the applicant for such permit to rile a signed statement POWER DEVICES
%0<0 tot be is lircnscd pursuant to the provisions ofmn Contrecmi s Licatve law(Chapter
9(commend,with Section]000)of Divuim Sof the Business and Pmfewions Cad)eSWIMMING POOL ELECTRIC VALUATION
or that Mieexempt iberefom and the baric for tin alleged cxempimr Any viAlmonof
lb. Section 7031.5 by any Vplicml for apermil eubjnm,the aWlicatt to a civil prnalty of OUTLETS-SWITCHES-FIXTURES
0 not momtban five hundred dollma(S5W). NEW RESIDFNIIAL ELECDt
Ho C1I,asowoxrofNeprrapertY.ormy mnPloYaswiN wages eslMir,olecompcommim, -SQ.FT, STORIES fT
yam wdl do tad wark,arad this c,.rcisa.imendcdoraHam for salc(Ser.70,0.Bosici
End Prorei" w Cask:Tlx Cmtrosctols Lic.Low does not apply m N owner of
popcoy whoboilds mimpmves Ihomnm,and who does such work himselfmthmughhia
ncnTloyca,povided Not such innprovcmcnts arc not intcMed moffcnd for mlc.If, OCC GROUP
Itowcvm,the building or impovmnnrr is sold within tine ycvofcomplimon,tad ti., !�
builder will h.ve the MNen of guying lira he did and build or improve far qupme of
L]
❑ I,asowromoftM propcmy,am cxdudvdycomnding with licmwcdcintrecton to Qom' PLUMBING PERMIT FEE FLOODZ NE
otm tic the pojcut(Sec.7(iLL Bu.imco,and Professions Cock)TTN Cantraetar's
Licence lxw doanut apply to an m,mercfpro envy who build,a improves therein,Brad PERMIT ISSUANCE
who convems fmsuch pmjc,.with.comonnon,)lircri pu moomm Ne Contrettor'a
Li,m.lax, ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 em exempt under Sec. ,B&P C for this nasan
BACK FLOW PROTECT.DEVICE SANITARY YN
O m net Rare DRAINS-FLOORR TEA.COND. RECEIPTM
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ IMrebya Nallbeveecmifitaleofwnxnttoalf-iw ,mncmiri teof EIXTI3 TRAP RECEIPT#
Wrxkerx'CmryenmiUilmurarxvaacertified copy Nrmof(Sec.JgW,fab CJ which PARK FEE Y N
errs al I employee,uMer this pemut. AS-EA.SYSTEM-1 INC.4 011'ILEIS RECEIPT M
PolicyN BUILDING DIVISION FEES
❑n,,eryCtmori orgy is Mmby(umisMd. GAS EA.SYSTEMOVER4 CA) PLANCHFE
ECK F
❑ Certified cupyb filW wiN Bre dry inNm.'lim divi,im. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREkSETRAP SOILS FEE
COMPENSATION INSURANCE
(This,ec0m need not be completed ifthe permit is for cox bundml dollars(51W) SEWER-SANITARY-STOR ENERGY FEF.
or IHQ
I cerrily Nat in perforrmence of the work for which this .it is meed,I shell WAIER HA"W
not employ any person it tiny mumcr,w. to ter.mbjea to the Wmken' PAID
O Z Comptim lows of California Dare AIER TIN Da¢ RaciptR
z NOTICE TO APPLICANT:If,after outing Nis Cmificateof Exemptim,ym should EWRESID AL SQ.FT. TOTAL
^� V] Mcomc sabjccr m the Worker's Compensation pc,isicm.f the labor Code,you no.
a ; fonhwrh 1 nS,oco this t.bell be deemil rerokW. BUILDING FEE
rompYwa pnvaridw or prmi
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z 1 Mreby affirm torr tbere B a amnruction lerding agency,for the perfmramce of TOT ELECTRIC FEC
U O IM work for which Nis pcm .a3119]
uI is ised(Sere. ,Civ.C.7
ro [cedar's Name
u"
U LemleO,Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify Nm I have read Nis Bpplicetim and,wte tot the aoom information a MECHANICAL FEE
comon.Iagree tocomply with all city enirmn)ordirumccs and Sowclaw,oehrng 10 PFJLMI SSUANCE
F^ bolding wn.wetbn,old hmcby euthorDe mpmmra0ves o(Nis city toontm upon the CONSTRUCTION TAX
U above-mrntiansl progeny for iroapw0on pupa . ALTERO ADDTOMHCH
(We)ugae to save,indemnify and loep hmoi Ute City of Cupem o,egmnet
Iiabiliumjudgments,cnvks mdupewer which cony in any wry DnpvnrsaidCity AIRHANDLGI1NIT IO,cco CFM)
race of Ih of Nis I
AIR IIANDLINO UNIT(OVP.R IO,tX10 CPM)
,opo IicenUCmmemor Dme EXHAUST HOOD(W/DUC7D PAID
IIAlARDOUS MATERIALS DISCLOSURE
IIBATING UNIT ITO IO(id00 BTU) Dare Receipt#
Will the ilic Cupm or ertino me Mildingd CaNcr9 2,bandhe Health
rt and Safer,
HEATING UNIT(OVER 100.010 BTU) L:
rit
es dr,S..by tad Cupertino Municipal Calc,C'oper 9.1;vd the Hcalrh and Sefcry
Code,Secum 255J2(ap
11 ye,, 11 No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Wi0 there licenl«ruwmbuildin occu BOILER-COME(3HP OR IW,(gp BTU) �� q
pp 6 Penluxeyuipment nrdevicu whim emit
haninkina air,wnwninenta vs defined by the Bay Aoea Air Quality Mam,croml BOILER-C1OMP(OVER 100,000 BTU)
District]
❑Ycr ❑No NEW RESIDENTIAL MECH. SQ,FT.
1 bare read the hie, w materiel,regrimrcnts under Cho ter 6.95 of thearta y,e ,11 4 1994
California Health&Safety Code,Scttimm 25506,25533 25534. I malentmad Ln r
ifthebu Wm,M imcmm:mly neveetcrmnt,IM1etitumYrulvcaMlitymaMily lne 9. (:r t.ur
ocmpant of the oegrirement,which moet M trot Prim to iaua ere of to Cemificate of Ch I�N4
Oew�ey.� .
Omar or amhoriu agent Date TOTAL ISSUED BY'.
OFFICE