S 1818 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY rIiy\y�IT NO.
CITY OF CUPERTINO BUILDING-ELECIRICAL V 1O - O
APPLICATION/PERMIT PLUMBING-MECHANICAL O O
BUILDING DIVISION Bl11LDING PRUJIiCT IDErvR'IF'IL'ATION
SANITARY NO. APPLICAI'[ON SUBMITTAL DA'fC
BUR,DIN 1 RES,.
OWNERS r E: PI ONE. CONTRACTOR'S NAME: LIC NO: NIC CONTROLN
s�ao Jq ❑
,ARC 11 t IIiNGINEELIC NO:
R' ADD hS:
CONTACT: PHONE: f BUILDING PERMIT INFO
❑ Consultant PceS Paid by Applicant(Initial) B1:1LDO ELECT'
PLUMB CMI!-H
LICENSED CONTRACTOR'S DECLARATION / QTy, ELECTRIC PERMIT FEE JOB DBESCRIPTION
I herehy affirm heat 1 am licensed under,11,111111111 of Chapcl9(comomocing
OCz with Section WXXh.fD'l,'cmm 3ofine Businessand Professions Cole,and my license is RESIDENTIAL:
w o F m fall force enA e�ec a/ PERMIT ISSUANCE I 0 SFDWL ❑KITCHEN REMODEL
�UU Licrn.e CL,, (.� hic'N APPLIANCES-RESIDENTIAh ❑ADUI'I'ION ❑PLOMBING RE-P1PIi
r~ir Z Date Qmtmauor ❑MULTI-UNIT OSTRUCRIRAL
~ l ARCHITECTS DECLARATION PANELS MODIFICATION
OZ�Z I unlmomdTy plansxhall m m,depuhde ren.uls UPTO 20K)AMPS ❑HIT ERIOR ❑CHIMNEY REPAIR
r idzli"� Licmtud l'ndcsional 2111-KC0AMP$ IMPROVEMENT ❑SWlhihflNG POOLS
abE I OWNER-BUILDER DECLABAH
' ON OVER 1000 AMPS 0 BATH REMODEUREPAIR ❑DEMOLITION
C < 1 heeby ulBnn that 1 um exempt from the Contractor's License Law for the ❑OTHER
followin
g mann.(Section]011.5,Business and Pard,sons Cale:Any city or county SIGNS ELECTRICAL
lit a m y ouch myuires a pernth m enmwm,idler,improve,denmdish,ur repair any m ualme
F 1-06 ,11111x,as issuance,not respire,the aPplicam booth permitm lile.ourcd stamment SPECIAL CIRCUITMISC.
9�{N'� Thal he is licence pmmmt.the pmviaons of the Co.......e,License Uo,(Chapter 9
apo (cammenoing wlm Seetion700(dof Division J of the liveinels end l'rpfcaiuns Code)or TEMP.MIiIER OR POLE INS'1'. EW BLDG/ADDITION ❑DEMOLITION
Ibut he is exempt Ihemfrom and the basis for the alleged exemption.Any violation of
^m Section 1031.5 by any arplicnt for a rod,timbers me ap,liennt 19 a evil Penalty of POWER DEVICES T ❑FOOD SERVICE
not more than five humlreddcll...X500). I VEMENT
=Q ❑1.asowmerofhe prepcny.1,r my employees with wages-their sole compensation. SWIMMING POOL ELECTRIC THER
F will do the w:trk,and menrunure is not intended 1,r offered famlel Sec.]IW,Business D
W and['ratessiom Cole:'rhe Commetus,License Law does nm apply at an owner of OUTLETS-$W1'ICf1E5-I'IX'1'I1RES
pmpeny who builds or lmprons,thereon,and who does such work himself or through NEW RESIDENTIAL HLECTR SQ FT.
his own an,Ioycee,Provided that such a,awcmcros ore nm intended or ofercd for S sAOR AREA SISQ.FI'.
sale.11,however,the building or improvement h sold within one year of'clandt fon,the
ncnbulmer will have the buNen of proving that he did not build or improve far per,
rose If In). t'
I,as owner of the proPeny,um exclusively contracting with licensed contractors m
onstunct the project(Sec.7041 Business and Professions Calc:)The Conlmemrla Li-
ecitse Law does not apply loan owner ofpropeny who hnidds or improves Barnum and QTY. PLUMBING PERMIT FEE
who contract,for such projects with a commmodx)licen,ed puroom m the Contnntor',
Luciano,law. PERMIT ISSUANCE
I not en,nt,umdcr Sec. ,It&P C fill thismilon
ALTER-DRAIN&VENT'-WATER EA) VALUATION
Owner Die
WORKER'S COMPHNSA'I]ON DECLARATION BACK FLOW PIR ECT DEVICE
1 hereby ill mai under pcnahY of pence,one of me imare ung Wo,wetions
❑ (have and will nuinmina Cenificmc of Con,entwelf-111111th for Wode(s Compen- DRAINS-FTOOR,BOOR ARE NO O STORIES TYPE CONSTRUCfI(J
sation,as pmvlded for by Section 310()of the Loftin Calc,for the performance of he
work fpr which Bis permit is issued. FIXTURES-PIiB TRAP
WOIonicand will maintain Worked Compensation Insurance,a,examined by Section
of Bc Labor Cade.for Bile wfamumcc of l he week for whidt,hk,cnnil i,i.,rcd, GAS-IiA.SYS'IEM-I INC.41111716fS OCQ GROUP APN
My WorkaOI Core mar Insumncecunicram PolicY6n•m�txrj}-'se" -gyp GAS-EA.SYS9'EM-OVERd(B
Caniec / - /ER
11F1 A L EXE FROM WOIEKFRS' GkFASE/INDUSTBL WASTE IN'TF.RCEI'TOR
COM ENSATTON INSURANCE BUILDING DIVISION FTFS
(TIONwaian need not M completed ifmc permit is future hundred dollars(SIM) GREASE TRAP PLANCHECK PEE
or In,,.)
Loy any ma.the in perbmmnceofinewok for which this Permit iaissued'Coloen- SEWER-SANITARY-STORM IiA.2IX)FT. ENERGY EEE
not employ any penmt in any manner so as l9 become suhjecue the Worker:Cnmpen-
0 ,Z saldnn Laws of Culifmmna Date WATER BEATER WNENTiLLECFR GRADING FEE
Z Applicant
NOTICETO APPLICANT.If,n0er making his Cenbicate of Exemption,you.m aid WATER SYSTEM/TREATING SOILS THE
I--t become subject to Be Worker,Coutpcnmlion provisions of the Lobar Crude,you must
LYi fonhwim nrnpty with such provisions or this pcmlit shall he deemed evoked. WATER SERVICE
QPAID
CONS'FRUC'I ION LENDING AGENCY NEW RES IDEN'IIAL PLMB. SQ.Irl'. Do Receipt#
0 I herehy affirm that isiantawclinn lendingasency lnnhe performance of
V
U0 the work fell which this former is isowd(Sec.11191,Civ.C.) 'TOTAL:
0 nc
Lender's Nae MAL:
LUTJ Lcndce.AJde,s _ BDILDI I H
I ceeily that I have mad this appdicean:md,ume that the above information os
�h ,one,rlagree m,otnply won au ety and eoamy 11rdiaam,es atm na,law,remingm QTY. MECHANICAL PERMIT FEE SI71SMICF
I U Z building construction,and hereby auhorim representatives of this city it)enter upon the //•�•� s O
I amoi,-mmelomed Poocify for inspection pmpo,e.. I'IiRMir,ISSUANCE V IihliCl' F i
(We)agree m save,indemnify and keep harmless the Ed,of o ag Ind
holdnin,,judgments c.samdexpeme,whichmaym n 'againl .a lty ALTER OR ADDTO MECIi. I'hUMI11N ''H
nmeyuenec of the gmming a(this permit. ��-- '''�''''
APPLICANT UNDERSTANDS Al�jl TC.Cry,ptL\WWI'TII: .NON ( F AIRHANDLINGUNI'r LTO 10.000CF10) MECHANI AL FEE
SOURCE REGULATIONS. [,/�
AIR HANDLING UNI'1'COVER II),IXIO CFM) CONSTB TION TAX
Signature ofApplicammCnmmcmr ((]] Dae EXHAUST HOOD(W/DUCT DOUSING IGATION FEE
HAZARDOUS T' Ar3lf TpLOSIINE
Will the applicant or finum buil 1,a,tpat sone or handle hnaardual nettlei9l II HATI NO UN I'I'(TO IlXkodO It'FU)
as defined by the Cupenino Municipal c,Charter 9.12,and the HcAth and S HEATING UNIT(OVER I00.007,BTU)
Colic,Se,lion 25512(a)7
❑Vias ON. P VENT PAN RFSID) PAID
J Uam kecciptp
Will the arPlicuntor faBre buildi in use esaipmemnr delicts which BOILER-COME(311POR RX1,000 B'I U)
emit hmanmet,air comami..ms as defined by the Bay Area Air Quality Mmagemen TOTAL:
Dialict? gITIONER
OMP(OVER 10,(XX)BTW
❑Ven ❑Na
IS$ DATE
1 have read the CecNo a tions 25505.25533
ls resuiremcnt.under .1 and b.95 of the Cali /a �S
buddi Flenlih&,cure dyha Sections t.that.is my %,Ssibul I undcmmnd that If la° DP,N'I'IAL MECII. SQ.FT. Y .- Y
huildingdoms no curtendy have a mount,that it i,my mponsihility m mnily the occupant
n(there i terns whicM1 mai Fe met pn1,nnirsuonaofa Cenificnm of cupuncy.
Owne o ummic agent m ISSUED BV:
A � %J
OFFICE