S 1523 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CLPERTINO BU I LDING.ELEC9'RIC.AL 111' 1'1'NO
BUILDING DIVISION APPLICATION/PERMIT vING P IMG E IfIDENNIFIC 1523
� nuu.mnr.v1:o,lEcr InBNru'fcAnoN '
BUILDING ADD1RESS'. SANITARY No. APPLICATION SUNMI'TIAL DATE
NBR:S NAME' PHONE C 'IRA 'S A I,IC NO:-
\ N/C C�OxNTROLp
IRCH'I'h T/CNOC EER: Off
: RUS
❑ y� /��
I • V/ G
-oNTpCT: ['HONE: BUILDING PE RSIIT INFO
Mike Vierhus �p1"t5QU ❑ Consultant Pees Paid by Applicant(Initial) ELECT PLUMB MECII
LICENSED CONTRACfOR'S DECLARATION
QTY. ELECTRIC I'IiRMI'1' (FEE
1herebyarummat1 3liem Inlandered Proar.afehtmmr9(om:�llnenseis - AL: DHSCRIPTION
Cmz whh secnnn 9fXlB)a,T oidsmr3nfNe Naxmexa and Pmfe..inn:epde,:ana,nr license i.. �-y1 RESIDENTIAL
�fs PERMIT ISSUANCE V
F,0 in full force and cl `N '�' Drs / ❑SFDWL ❑KITCIE REMODEI.
UV License Chrsv Lica APPLIANCES-RISIDEN'I'IAl. INJOID11ION ❑PLUMBING BE PIPE
a hale e:S DECLARATION
4 AHCHITECT:S DECLARATION [15h1U171-UNIT ❑MODHESTRUC`TURA[.
f-hR [understand my plunsshtil bcuvedic,ablicrcaads , INNEIS MODIIlCAI'ION
.Zoiz-O UP TO 200AMPS Z1 ZQ ❑IN'I PRIOR El CHIMNEY REPAIR
Licensee 11 mwinual 201-HKRAMPS IMPROVEMENT SWIMMING POOLS
f') OWNER-BUILDER DECLARATION
C W W Q I hereby affirm that I am exempt from de,hCommons License Lew far the OVER KROAMPS ❑RATE]REMODEIM711AIR (]DEMOLITION
O following masof[Section 9111 L5,Business unJ I'rofesrions Cwle:Any city or cnuntY SIGNS ELECTRICAL ❑O'rfIER
(i5$0 L
I+:LL O pxj which myuires a permil to consumer,ahec impmvc.demolish,or repair any structure
pp w� prio t as ars resimm,th ,,l uninf such Isearna 1file SPLCI A L C IRCIIIT/M ISC.
A p+ that l licensed Pan It II provisions ft C I 'm, � Low(Chapter9
C�a�C (commencing with Section 7000)ofDnsidor3 afthe Buricesecandl 1 ions Cade)or II:MPMETERORPOLEINS'E COMMERCIAL'
C.6 c C mal he is exempt therefrom and the basis future alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^'W Section'I03IS by any applicant for u permit subjects the applicant m a civil penalty of POWER DEVICES
�y pt more than five hundred Jollura Sion) ❑'IMPROVAN't ❑FOOD MiNYIGii
_<Z i+ o i mERVIiMENT
wiLothe worofine propeaoure myot mended with wagesrsale(See.coo,Buri ien, SWIMMING POOL IiLECTRIC
C will do the work,and the srucmre is s Li den{of offered ilJ h,r of apply to air Rosiness ❑O'INER
W�m
and Pmlee.inne Code:The Cummnar's hleenne law dmv not apply to on owner al oil'I'LP:'I;S-SWI'[CAIS-FIXTURES
pmpeny who builds or improves memos,and who does such work himself m through
his own employees,provided that such improvements are not intended m offered for NEW RESIDENTIAL ELEC:R S
.sale.If.however,the todding or ifpfvcomon is cold withinonc yeuroftml,li,fon,the SQ.19'.FLOOR AREA $/SQ.FT,
nwner-huilder will have the burden of prnving that he did not build or Intprovc liar For-
Pose
❑ Las nwner tar me pmpeny,am exclusively contracting with reem.ce comranars m "A:
,c) t... the pmjcel[Sec.91144,Busincxe onJ Prafcsinm CMe9 The Cemmnnr'e cont,Law does not apply to an owner of progeny who buildsor improves thereon,and QTY. PL IN B
who contracts for such projects with a comranar()licensed pursuant it)the Contractors stilt
License Law. / PF ISSUANCP` f O
l am exefpt under Sec._.B&P C om m,,reason
Owner Uatc .TER-DRAI V)&-WA VALUATION
WORKER'S COMP17NSATION DECLARATION BA1,R F I PR 'VICE
I hereby affirm under Penalty of Ptrapa com oflhe lnllAhichlhkpv�tll
iAd (�
u lhm,,andwill ntainmina Cenihefeof Conum mself-insoffer- r1A
LOOR, P,AREA,GOND. STORIES TYPE.CONSTHUC'1'ION
Ballon,,,,),,,aided liar by sedion 391X1 A he Lahnr Code,tc art C
work for which his,)emit is issued. PER'I'RAP
❑1 have and will maintain Workers Compensation Inationeor
391X1 ofmc Labor Cole,forthe performance of the work lin wwed. SYSTEM-1 INC.40UTLETS OCC.GROUP APN
My Worker,Co pensatiu ins mer and Policy numSY$TEM"OVER 4(BA)
Cameo C. I- I i. %=notion
Policy Nn:
CERTIFICATE OF EXEMPTION FROM WOR KHRS
COMPENSATION INSURANCE DUSTIRI.WASTE INTERCEPTOR y ,
(Thissecrionnecalmd hecomplcteJ lfmo pemait is for one hundred dollars($100) AP 11 NO VISIONFHES
PLANCHECK IT I emify that in For erfnitomme ofthe work nrwhich lhi.vpenmit is i....d,[soldANITARY-STORM EA.200 Ff
oat employ any Persian in any sumer so as m accofo subject m the Workers'ComPem ENERGYFEE
stainniaws ofCalifornia.oafrHR WINTVEIELECTR GRADING FEE
NOTICz Applicata
H he,..i TOct1. he Work II:altCo makingthisCkiturrofof[Labor es You should WATER SYS"1'EM/I'µl!ATING
R', > become scompl o the Worker's Compensation ..it
bol of the LaMar Code yon mus SOUS FEF,
�
forthwith comply with such provisions onhis permit.hall he deemed invoked. WATER SERVICE
1
UO CONST RUCTION LENDING AGENCY
NEW RE51UEM'IAI.PLMB. SQ.FT. PAID
1 hereby affirm that mem is a construction lending agency for the performance of Data Receipt,)
ry
ilio work for which this permit Is issued(See.3097,Civ.G)
C) F Lenders Wane 'TOTAL:
U Lender's Address T AL
F 6Wi 1 certify that I have sad[his application and slate mat the above infommtion is BUILDING FBH
. h correct.I agree In amrply will,aB city and county nrdinenecs and amts haws all.6a.m QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby amhorimmprew'rmrives ofthis city to enterepon the SEISMIC FEF.
aharce-mentioned pmpeny for inspection Puq.rza' PERMIT ISSUANCE
(We)agree it,save,indemnify and keep loonies,the City of Cupeninn against ELECTIRIC FEE
2.
liabilities.judgments,costs and expenses whichnnay icon,silly evefcaguinst,aid City ACHIRORADDTOMF"CH.
in nseyuence of the granting of this Kurt. PLUMBING FF.0
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO 10,00)CFM) ^
sou �Gul TI s.
I, MECfIANICAI,ITP.
4
C/i el AIR HANDIANGUNI'I'(OVER IB,M)CPM c CONSI'NUCION TAX
.ignatum(iApplicunFCentmcmr Data EXHAUSTHOOD(W/DUCT) J NS HOUSING MITIGATION FEE
HAZARDOUS MAI FRIALS DISCLOSURE
Willtheappli... (more building aecup:mt sore or handle humrdous material 1[IA'HNGUNIT(TO100.Ot10RTO)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the[Health and Safely ra„n••�
Code Seth....2553200' I(HA'I'I NO UNIT(OV HIR 100.0i)t1 IIT[ Vt v'
L3 Veit El No VENTILATION PAN(SINGLf!RISID)�T PAID Data Reeeiptp
�
Will the air conn (It panic building by tiro B aseeaAir Miryn in Maccswhich
emit hw�prdous air contaminants as defined by the Boy Area Air Quality Monugemert BOILER-COMP(3HI'Ok 100,000 Bll)
District' T r
❑Yes C]No BOILER-COMP(OVER IN),000 BTU)
I advertent tire motors,motors,ma¢rials quimarmnts unacr Chafer 6.95of rhe Cali- AIR CONDI"I IONER ISSUANCE DATE
fnmia Health&Safely Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT. ,'Jx
IF do"I've.wolaar...dyhavcnteranklhal itismyraaptmsihilitymnotifymaawapnta d" /-K — ?S'
or therequirements whichmusbe,netpriortoissuanceofa Ceniticaleof Occupancy.
owner,,anham'sk"' l Dam'- T AL IS6UI3U 13 V:• ' u� I4
OFFICE