S 2759C
1-
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C
L
AN
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING, - ELECTRICAL PFRMIT NO.
BUILDING DIVISION APPLICATIONIPFIRMIT PLUMBING -MECHANICAL S 2759
BUILDING PROJECT IDBINTIFICATION
rNH.DINII ADDRESS'. SANIIARYNO. APPLICAII)NSIJBMII Al, DATE
PHONE:
❑ Consultant Fccs Paid by Applicant (Initlal)
1 Mrthy uflirm shop 1 um IicunseJ under provlxions d Owrytt Y lamtmncing
4'ith "ace
]Ig0) nl IHviaitm J of Ills Nuaims vrd Pmfcssians Cde, erd mY lianas is
in full form and cI
Liunw CI s. I.ic.0 �oLs
Uatc Carumcu
ARCHITECTS DECLARATION
I uncler loml no, plunv shall he ..d os "able, W ands
OWNER-IIIJILIIER DECI,ARAfIfIN
I heathy mrien tbar I um ecem, Boo Ne Cmfnet«a I.1 (e Law fof the
fMlow'ing Gran. (.4ctkn 70313. Puaireu erd Pmfeaicna C .Any city tv rounry
which of,m a p iron in con., rust, ultra, improve, r1m,oh, .repair any Mmalure
prinnniu ixworcc. also rcyuirts NcaEElicanl l'unmblar fo f ileao,or, nwrcnem
I�C�l
e ki lken4d purswru lntM providomvaftk Cam ,«eficrose Lew (Cltytttt9
mercing%ffi. aaa 7(00) of Divisiml 3 offM f a and Profxsim Ceac)m
M ie' cxcntpl IMrclmm and tla hcvis for IM1c cgal cacnllion. Any vlaltinn of
on ]NIS by any applkvnt ten a pentdt s IttH fM opplicunno a eivll Isnulty of
tmc Nun fvc hurdnd ded (53110). aetwner oflMmapenY, ormY el nyccx wiN wageamlMlr mlecalEenvthn.
a the work and lM strm'wrt is mtewlN or olletN few alc(See.](W, 6uvimr
Prnfci.silm CUs: lle Cont 'or's Ix r Law duty rvg yply to un rwrcr M wM Wilds or improv thcrtin, and wM dres nosh week mmrclforIhnwgh
lLmiytloyux, Ext flml such improv cn(r c nal intended n n lEod! for
Mnrcecr. the boi sl g ar impnrvertrat is rukf within arc 1. ofeempledon. Be
r-huildcr will a me hmdcn of pawing thus he did nmbuildof or,owforpu.',n omrcr tM proRny a,o mclmivdy utntrMlin, voth tomsatl comriam. tofm,l jen l5¢. ]0141. Bnsines: erd Prafeas'uan Cede:) The Cugrrct«s 11l ,4as nnutpply ht un nwno of pmpcny who hWQTYmets Oxsuch prrjettO with acomracntd.) littrxt! p roonttodw Contact«aLaam exempt under S¢. . P & P C for Nix re of
1
Owner Dom
WORKE!R'S COMP NSA HON DECIARATI ON
I bemhy ellen under reel,ofperjuryane of Ila lolls -on, dwlara. am,
❑ Ihave mad will maintain aCerdfinfeof Conwrit lowlt-insnmImWorker'xCrmpen-
mtiml, as provided far hr Section 3700 of Be labor Cdc, fu Ne pfff rna.c M the
whkIn Ihia Perron ix i—c.
wart hmx and will maim. Work,- Co eperrofivn ro mncc, ev rtyuircd by. ten
1700 of tM Lahor CNc. for IM perf^rrrvrue of Nc woe], for which this permit k upaucJ.
My W«ker ram Inwnrce....ramp Porcy plrary''Ip u-' [g
n ms4 SXX TT DDI [O
Cvricr q'TETIF -TATE OF TION ROM
CERTIFICATE OF S EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(IhisxYtitn nmvl lax M canplacd it larmil ix fnrww bmdml dollars ($104))
efrRYs.)
Foy any Matin Nc performer of 11 e4Mfm oda Nis,erne,-i.a . sMB
gremploy err lanwn in any Inner or of In heal,«. aankYt .The fin rr eampa�.
an l awa nrcal'�fnmfi. dam �
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
VANI;IS
UP TD VIII AMPS
K)I-IfM0AMPS /
SIGNS ELECTRICAL J
SPECIAL CIRCUI'FTMISC. 1
TEMP. MITER OR POLE: INST.
POWER DEVICES
SWIMMING ITR)I. ELECTRIC
OUTLETS -SWITCHES - FIXTUR[S /
NEWRP-SIOIiN'I'IALELI!C'FIT SQ FT.
PLUMPING PERMIT
PERMIT ISSUANCE
ALI'HR-DRAIN & VENT -WATER (FA)
HACK FLOW PROTECT. DEVICE;
DRAINS- FLOOR, RWF, AREA, COND.
FI%TIIRIiS - PER MAI'
GAS-I:A. SYSTEM -I
IN( '4� I1'+J3!IS-
GAS-VaiS�'IW )VAW )
SEWER -SAVARY WFORM EA. 200 IT.
N'ATI!R HFA WlVENf/ELF.CTN
NIJICIi TO APPLICANT: If, i fmr making Nis Cf,uln
ohf Inmion, p,m aMwmIA WAITR SY
h wbenm the Worlds Com,refirteG
tmhwiN comply with such l rov"i"" fermis stall M deceea rtvokM. WATER SERVICE
CON' (MION I,EN I)ING AC IINCY NEW RESIDENT IAL PLNI.
I thereby alb then Lv amnatmo:titm lending agency fm thcleRirnlwce rat
tM wM Rew' is lend, is ioaN LSa. 3d17. Civ. C.)
1 cmify that I haex read this aMlimicn anal Ihv tM abave inrormannon is
arm. I agree to comply with all city and cnunly ordinances vd sole laws refiring to Qry.
budder, canumction, old Inerehr alol orl', rtprtwnlNivcx of Thin city m anter, uptn the
afnvc .,.it pmpcny fm im'pcc,ion purry>•ea
(We) agree to uxc, ildmtnify and keep hartnleea the City of Cupmitc agarol
lool.ucx, ludgnanls. A,., and ..psoas whaTere, inary wey aoona agmool wed Cay
in onve unex of IM gaming of tok Per mit.
APPLICANT UNDERSTANDS AND WILL COMPLY Wall ALL NON -POINT
SOURCE H' S
3ignnurc of ApplicantlCnnlracmr L alt
IIA%ARDOUS MATERIA(S DISCLOSURE:
Will Nc apFliunt «fmurt building oceupant start or hatdk baaudtacr emmaiol
as defrN by ifc Cap ro Municipal Code, Ell 9.12. and the HeaIN and! Safety
Ctdc. Seen- 255320)?
❑Yes ywa
Will the aMlacunt or rotate Nlilding eceo,m t uan cynipmm�l re devlccr which
mit haradous air cwftatun s na d,fnN by 0M Bay Arita Air Vua ny Marmi Goa m
Diataicr! 1�r'
❑Yes
I huvc rad IM harankua mucnnla rcyuim , udcr Chapter 695 td be Cali-
xmia HeaIN & Safmy GnH, Smitten 255x5, 25513 and 215rVL I understand that if IM
huildingd�as rat ,ea,naaadhm it'wnty rxPnaibiNy In naifyllteecupmn
rf vita whim must M m.,,mar la iaruanc Ifo Ccnirlcac of O.Tulvfay.
NIECHANICAI, PERMIT
SQ, M
PERMIT ISSUANCE
ALLTR OR AD[) In MECII.
AIH HANINJNG UNIT (TO 10.000 CEM)
AIR HANDLING UNIT (OVER 111.000 CFM)
HEFTING UNIT (TO 100.010 BTU)
IMATING UNIT(OVER I(MlAC It I U)
VENIlIAT10N IAN (SINGLE RF'_SID)
BOILER -COM('(3HP OR 100.000 RTU)
BOILIIR - COME (OVER Ig),0f1(1 BTU)
AIR CONDITIONER
NEW RI'SIDENI'IAL MHCH. SQ. FT.
OFFICE
23
[D NEW BLIhIIADDITION 01)EMOIJTION
OTFNANT OFOOD SERVICE:
IMPROVEMENT
D OTHI!R
SQ, FT. FLOOR AREA VSQ.ET
FEE S !
W
PLANCHE!CK M!
ENERGY ITE
GRADING FEE
SOILS FFE
p0J
DIVISION
PAID
D Rccxipt N
LIIFAL
BUILD , FEF,
FEL SUIS C 17
ELE C EE
PLUMBIN' FEE
MECHANICAL Fl]i
CONSTRUCTION TAX
HOUSING MITIGATION II]i
PAID
De¢ H<aip A
ISSUANCE DATE
3- -�3-IT ?
El
I Yz3�
BUILDING PERMIT INTO
B1LL�IIXII ELECT PLUMB MECII
�S 9- iK N
FEF.
JOB DESCRIPTION
RF_SIDEZiEll
❑S19lWL D KITCHEN REMODEL
%QADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT []STRUCTURAL
MODIFICATION
D INTERIOR DCHIMNEY REPAIR
IMPROVEMENT OSWIMMINGP0CIfi
D BAl'll REMODELiBEPAIR ❑ DEMOLITION
DOUTIFR
' O
[D NEW BLIhIIADDITION 01)EMOIJTION
OTFNANT OFOOD SERVICE:
IMPROVEMENT
D OTHI!R
SQ, FT. FLOOR AREA VSQ.ET
FEE S !
W
PLANCHE!CK M!
ENERGY ITE
GRADING FEE
SOILS FFE
p0J
DIVISION
PAID
D Rccxipt N
LIIFAL
BUILD , FEF,
FEL SUIS C 17
ELE C EE
PLUMBIN' FEE
MECHANICAL Fl]i
CONSTRUCTION TAX
HOUSING MITIGATION II]i
PAID
De¢ H<aip A
ISSUANCE DATE
3- -�3-IT ?