S 2704APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING. ELECTRICAL PI!RMII'NO.
BUILDING DI VISION APPLICATION/PERMIT nun, ol�uMBING.mecunNlcnl. S �i70 n
-uuUIVIT rOF1N'1'IFICA'I'104 V L �F
CONTACT. PHONE:
Zz'c- 161"lf yy b / 2ly
El Consultant Fees Paid by Applicant (Initial)
I hereby affirm but I am licensed under provisions of Ch peer 9 fico urramo ng
yupw!in Scetio l700()o1'Di,W,,.3ofmc Bavincss cep lip IsiopnCie,i lay Beense lv
W In full force and effect. (TJ(� l/O Y
<U U Lieene, Class Lic. N
l- z W Dutc Coil or r
ARCHITECT "S DECLARATION
Zy Z I undersand my plans shall 4 used us public remrds
41 � Licensed hurcasional
OWNER -BUILDER DECLARATION
5 Q 1 hereby official that I vm exempt from the Cono-umor's License Law fnr the
Oy U following reason, (Section 7031.5, Business and Professions Cadc Any city or county
Z O F which requires a permit to mnouroU, viler, impose, demalieb, or repair any smucmm
prior m it issuance, also requires the applicant for such permit to a signed statement
�� that he is licensed pursuant to the provisions of the Contractor's license Law (Chapter 9
'QC) (commencing with Section WERE of Division Sof the Roines,: (Prof sions Code)nr
thin he is exempt flim from and the basis br rhe alleged eselnprior, Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant In a civil penalty of
0rn more than five hundred dol las (5500),
1, as owner of the pmpeny, or Ty employee, with wages as'her rsolccomperemimr,
F�is it l do the work, and the structure is not intended or offered for sale (Ser, 70,14, Business
W and Profession, Code: The Crearacmr's License low does not apply to an owner of
pmpeny who builds a, improves Iherenn, and who dues such work himself or through
his own employee,, onvided don such hnpooemoots are not intended or uttered ler
sole. If. however, the building or improvement is sold willim one ye rrof cmnderon. the
owner -builder will have the bunted of proving that he did not lwild or improve for pur-
pose of eate).
❑ L ns owner or the Sec. primery, . Business excessively cantmcting whb licensed utruct les to
instruct thees net pplyo an wnei:mdrty who bus Cede:)The Contmaon, nd
Li -
cerise Law does applyman owner of pmpenywM builds ori on to
thereon, and QTY,
whn convncre fnrsuch projects w'uh u eonvumor(s) Ilecnmd pursuum m the Cnmmemr's
License Law.
❑ 1 mor esampl nide, See. . B& P C for his crucial
Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
❑ I Invariant will malnain a Cedificate of Consent ln self-inaum fnr Wiss is Cmu,u-
salinn, as provided for by Section 37W of the Labor Code, for the pedbmnmce of the
work for which this pemnit is issued.
C1 1 have and will maintain Worker's Compensation Insurance, as regnimd by Section
3700 of the Labor Code, Ba Thu performance ,I be work for wblch this perm'd is isaaed.
My WorketAC wnsalpnlysmpncecamierand LWI utlWr e:-2/' (21 'J
lsC Cartier: fill �O /L.I` Pnhc¢@o/ Z�f -f •" r
(� CERTIFICATE OF EX AIMION FROM WORKERS'
COMPENSATION INSURANCE
(Thin secti.... d not be completed if permit is for one hondreddollas ISI(X8
or Ices.)
I ccolfy the( in the prounance or the work Iia which this permit is issued, l shill
t1ol employ any person in any manner ser as m become subject fit the Workers Compere
,Z ":snot Lawn of California. Dale
.01 tApplicanl I
all
NOTICE 10 APPLICANT: If, afar making this Cennicate of Bncmplion, you .should
F �become subject to the Worker's Compensation provisions of the Labor Coale, you must
Wfanhwim comply with such provisions or hmi
is perl shallid
be deemed resided.
Oki�%
CONSTRUCTION LENDING AGENCY
U O l hereby Ofirm that mere is a connElection lending agency for the performance of
Ba Fthe work for which his petrail is issued (Sec. 300, Civ. C.)
U Lender's Nona
}W Lender's Address
y I retify aha I have rcud this application and slate that the above information in
nFi 0 correct. ) agree to wmnply with all eily and county ordinances and state laws telling to QTY,
U 2 building conswclion, and herchy nnthorizo representatives of this city to enter upon the
aMnve-mentioned papery for inspection pugwecs.
(We) agree m save, indemnify and keep harmless the City of Cupcnino against
7',,1 es. judgments, come and expenses which may nnny way accrue against send city
jilliss
i in
crimes of the Granting of Ibis permit.
APDL 'ANT UNNnERS'VAN US AND WELL COMPLY WI'TII ALL NON -POI NET
IIA" DODS diIALS DISCLOSURE
W'il the vpplicum nr umre wilding cecupam score err hunAle hazardnns material
m defined the Captains Municipal Cade, Chapter 9.12. and he Health and Safely
Carle, Seclir n 25532(n)^
1 ❑Yen 0 N
Will the applicant or future building occupied use equipment or devices which
emit horrendous air cnntmommnt, as dermad by the tiny Area Air Quality Managetncm
dd"
❑Yes ❑No
I hmeread Is hunnNou.v mulcziuls lcyuiremenly under Cu,hn,fi95orlheCaf-
Iomiu hh ty Cads, Sections 25505, 25533 and 255]4. I understand Out it the
Imldia she- curmally have a renanl,ppt it is myNbinpgbility In notify the oc'cu1Nnt
ELECTRIC PERMIT
PER M I'1' ISSUANCE
APPLIANCES — RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCLE UMISC.
TEMP, METER On POLIi INST.
POWER DEVICUS
SWIMMING 11001. ELF.C'I'ItIC
OUTLETS — S W ITCHES — FIXTURII
NEW RESIDENI' IAL ELEC'I'R SQ1L
PLUMBING PERMIT
PERMIT ISSUANCE N
ALI'HR- DRAIN &VENT WAI 17K (VIA)
BACK FLOW PROSECT. DEVICE
DRAI NS_ FLOOR, ROOF, AREA, CON D.
FIXTURES— PER TRAP
GAS —IiA. SYSI FM -I INC.4 GO 1'LhI'S
GAS —IiA. SYSTEM OVER 4 (EA)
GREASIIINDUS'I'RL WAS 'I'If INTERCEPTOR
GREASP.TRAP
SEWER—SANITARY—S'IORM EA.2(XI FT.
WATER HEATER W1VEM71iLECIB
WATER SYSTEM/TREATING
WATER SERVICE
NEW RESIDENTIAL PLMIL SQ. FI'.
3 -
1'EE
PERMIT „I', FEE
UNIT (OVER
IIEA'nNG UNIT (OVER 100.000 BTU)
VENT ILATION FAN (SINGLE RES ID)
BOILER — COMP (311P OR 103,000 HE
BOILER — COMP(OVER Infant BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. EL
SQ,
s
BUILDING DIVISION FEES
PLANCHECK IPII
ENIiRGY FEE
GRADING PER
SOILS FEE
PAID
�ylk� ReceiplX
VSQ. Fr.
TGI'AL:
BUILD 1
SEISMIC EB S�
ELEC' ICFEIi
PLUM! G FET?
MECUAbkCAL FEE
CONS]TRUCTION TAX
HOUSING MIT CATION PCC
PAID
Date Receipt
ilffYT1]!A
ISSUANCE. DATE
3'—t, z_ —? %
OFFICE /
El
' BUILDING PERMIT INFO
BrL�Dr/ ELECT PLUMB MECH
L ❑ ❑ ❑
PEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
Fl MULTI -UNIT ❑ STRUM URAL
MODIFICATION
0INT17RIOR El CHIMNEY REPAIR
IMI'ROVhMENT CJSWIMMING POOLS
❑BATH REMODEL/Ill ❑DEMOLITION
❑ OTHER
S
COMMERCIAL'
Cl NEW BLDG/ADDITION ❑ DEMOIAI [ON
❑'TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ HER
1'EE
PERMIT „I', FEE
UNIT (OVER
IIEA'nNG UNIT (OVER 100.000 BTU)
VENT ILATION FAN (SINGLE RES ID)
BOILER — COMP (311P OR 103,000 HE
BOILER — COMP(OVER Infant BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECIL SQ. EL
SQ,
s
BUILDING DIVISION FEES
PLANCHECK IPII
ENIiRGY FEE
GRADING PER
SOILS FEE
PAID
�ylk� ReceiplX
VSQ. Fr.
TGI'AL:
BUILD 1
SEISMIC EB S�
ELEC' ICFEIi
PLUM! G FET?
MECUAbkCAL FEE
CONS]TRUCTION TAX
HOUSING MIT CATION PCC
PAID
Date Receipt
ilffYT1]!A
ISSUANCE. DATE
3'—t, z_ —? %
OFFICE /
L11/1N6 �e&m
pU3N . YIEIw
APPRp�►Ed
OR
IN ACCORDANCE WITH THE CITY OA
CUPERTINO GOCES AND DINANCES
OATE_�- s
SIgIyEU_;_.
(his set
he kep�'T -
avrfv! -
n same
Ile
.,e srm a'
of
OFFICE' cord
NEw.
OCT,4{,Onl
2'X L'
,V/J)7/o9 AW&,,f RATE
rN
)trZf/i9 T/ON lllF_ IN
MAR191g9
���u,ICT`I OF oUPEPjWOmUvt
._C,4- �P1lZZINI_ 1efjlz)Z4-1vff
qu AP RDvm BY:
/�Vp EIWMOY
N L.M.
DATE: 3>!Z / % -
cl:,. YM/L N0 DWG NUN9ER