S 3322 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ER'1'INO BUILDING-ELECTRICAL PE Tr No.
ISIlILI11N1:DIVISION
API I'LIIh11HNG.MECILWIcnI. 3322
14kIaDING pill
it F,CI'IDF.N'1'IFICA,PIN
BUII.15 AgRESS� ^ ` SANI'T'ARY NO APPLICATION SUIBMMI'PIAL DATE
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OW. . .nME: J L.V,ONL.�J�^,� CO.TH CIO@':NAAIE: \ n� 1ICNO'
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�1RCHI6?CAINGINEER: LIC NU: A DRESS: ,^ - ( 1 anS �OCV ❑
CONTACT: PHONE I1 , J BUILDING VLRMIT INFO
❑ COnsultum(Fees Paid by Applicant(initial) PLUG ELECT PLUMR SUCH
❑ ❑ ❑ L
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEL'
L hereby affirm that I am licensed under provisin,N,+f chapler 9(cvmmrm9ng _ JOB DESCRIPTION
MWz with Section 7000)of Division J of the business and Emulators Cole.and my licenses RESIDENTIAL:
W 00 PERMIT ISSUANCE
F W_ in full force anA caeca ❑SI'DW L ❑KITCHEN RI?MGOC
<-U Licca Lich APPLIANCES-RESIDIiN-HAL ❑ADDITION EJ PLUMBING RE-PIPE
N a 4 DJIe Cen19c10(
NtCHI'I IT I DECI.A T 1N ❑MULTI-UNIT' ❑STRUCTURAL
F,0 w PANELS MODIFICATION
Z O'^Z I uadentnnd my d....hall R used-public records
UP T0200AMP5
OZ-C El INTERIOR El CHIMNEY REPAIRLicense/Pndc.aiomJ 201.1000
AMPS Ip1PROVEMI'vNT 0SWIMAfING POOLS
OWNER-BUILD12H DECLARATION OVER IOnoAMPs [I13ATIJ RE OFF JI FPAIR [IDEMOI.1'IION
C C 6 I hereby affirm thm I nth xemVt trainthe Conirac,m's Llemhm Law fur the
,K 31 U fallowing reason.(Section]NL.1fiviness and Profe,iom Cade Any city or county SIGNS ELIiLTRICN. ❑0111FR
ywmeh ra oust,it permit to s anmmt,alter,horn ve,denedid,ser mpmr any structure
prior to hnissuance,alw requires the applicant for such Permit file usigneA sutamm SPECIAL CIRCUI DMISC. A
than he is licensed punnunuo 0e pro,kion-Ohe Commnar's l.iecloc Law(Chapb,r9
marl y50�0 (eantmene ing with Section 7000)of[)ivixinn3ol'the Business and Profesalo,Cmk)or TEMP MET I7R OR PULP INSI COMMERCIAL:
a a tY that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDI'IION ❑DIiMOI.II'ION
S,a.on 70115b liaant foo tsub,ms he applicant lu ac'n'II II f POWER DEVICES
4 ynnyopp pond i pP Penalty El*1 ❑ADDU SERVICE
and more afoe hundred dollars($500).� I,ns owvner r u(thc pntpcny,onny cmpinycu with wngmmtheir sole mmp+cnsminn, SWIMMING POOL ELECTRIC IMPROVEMIiNT
willdo lhework.nnd thestucture sold intended oroffeted forsule(Sec 704cl,Business ❑Ol'H:R
L'i ao and Pndcsdons Code The Comramh Lkaliw Law docs nol apply m an owner of OUT LETS-SWI'I WHEN-FIX'I GRES
pugwov who builds or improves thereon,and who does such work himself nr through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sal,If.M1owevup'he building urno tnaiau is'.vold withinone Ycm of onl,lal.o„,the SQ.IT.IIAOR AREA S/SQ_FI'.
wneclailder will have the Auden of proving the he did not build or improve for plIF
mou of sale).
F11,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
m,ma,the project(Secs 7(94,Business and Profession,Cndc)Die Comrnctor'e),I-
nc6owdacs not apply man owner.1 property who bind-,improves thereon.and QTY. PLUMBING PERMIT FEF.
wfio contacts for such projects with a commaork)licenced pursuant in the Co nractor's
License Law. PERMIT ISSUANCE
I] l am exempt under Sec. .B&P C forthis reason
Owner Date r\Cl HE-DRAIN&V ENT-WATER(IiA) VAI.UNFION
WORKER'S COMPENSATION DECLARAI mg-ION BACK ROW PHUI'ECT.DEVICE
herby lllinn Iain a penalty ser perjury one of the following dcdmi-x Co
❑Ih J 11 t Certificate !C a self-insuref D, kr:C lI DkAINS M1I OOR,HIXIT.ARIiA.GOND, S'IONIIi$ 'I'VI'I;CONS'TRUC'TION
sot .I "IJf IYS 'i 37000d I'1 C th p f Idc
work for whichtti.M I is -und. TINT ORES-PER TRAP
I base Told willonuoudo Walk,Cli hourro,t,u,ua,car,lby S nn
700 of the Labor Cod.for the Nalonerammot the work lot
^which this remit a issued. GAS CASYSTLMIINCAOUTLETS OUP APN
M Workay Ct+mpen.atli In unny t',aerrand Policy
�(f1'y-�re � 1
Gurnee Ct-31 / X"Yb�'l�Y CAS-IiA.SYS'I'IiM-OVEHS(r:AJ
CERTH9CA'L'17 OFEXEMPTION FROM WORKERS'
COMPENSA'DON INSURANCE GR[iASrJ]NDUS'IRI,WASTE INTERCE141F, 11
IILUING DIVISION FEILS
(Thins section nc,J not he complied if th,permn is forma hmdreddollms(3 bn)
GREASGTHAP
or loss.) FEB 4 IiC I'
I certdy dost in the performance ofthe work for which this permit is issued.Lshall SEWER-SANITARY-SI ORM EA.2W
not employ any Penna in any manner w us m hca+me nubjeo m the Walker,'Cumpen- ENERGY ITt i
o z samm laws of CrIifinni;a Dan, WATER HEA'CER WiVENT/ELEC R GRADWO AEE
z O Applicant
y NUI ICE 10 APPLICANT:IL film making this Ccnilienc nl Excmpuon,you should WAI'1TS SYS'I'EMG REA'I'ING 8Y
C berme subject m the Workers Compenwdon p.,I...m,of the Labor Calc,you most -
forthwith eanmply ,,It s.all.......inns onbi.s pcnun fi:dl bu daemcd revoked. WATER SERVICE
a �
CONS"rHUCTION LENDING AGENCY NEW ItES1Ul?M'IAI,PLMH. SQ.FT. PAID
U0 Iherehynffimt thuubemtsuconammtimm kndingugency fiathaparf rmanea of Uatu p
the work for which this Permit is issued(sec.3097.Civ.C.)
F' Lcnde-Name 'I(IIAL:
O1, Lento's,Address TOTAL.
r a 1 certify that I have read this application and state that the aMwe infmmatium is BUILDING RITE
N cornua,l agree to comply with all city and county ordinances and state laws mlefing In QTY. MECHANICAL PERMIT FEE
V Z building cnnaryhormivcv
ctiuo,und hereby amveneprescmof this cityit,enter upon the SEISMICPEE
r-t abavomaulonal prolwdy lot in......lot]purpose. PERMIT ISSUANCE. �s /
(we)agree to save,indemnify and keep hamdess the City of Cupertino.,ain.a ELF.CI'RIC FEE
liabilities.judgnrema.as and cxpau.cs which they many way accmc agoing said City AUI17R OR ADD TO MECIL
an uqucnce of the gmmi.,of this,p:mIil PLUM BING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT A I R I IA NDI.I NG UNIT(10 10.000 CIT1)
SOUR I GULAI'IfINSa MECIIANIGIL PEE r
AIRHANDLINGUNIT(OVP.R 101N0CFM) CONS,RUC'1'ION'I'AX
Si na t AA,DiiJcaMCommemr Dam EXHAUST IIOOD(W/DUCT) I IOUSINGMITIGAIIONILE
HAZARDOUS MATERIALS DISCLOSURE
will the applicant or more building occupant stare or honJk hamrdo.,metrial 1111/31 NO UNIT(TO 100.00 B'I'U)
as refined by the Cullen inn Municipal Cade,Chapter 9.12,and the Ilealb an I Safety
Cale,Section 25532(0)? T
�/ HEAING UNIT(OVER Patina)0PTU) -
❑Ycs dQNa PAID
VEN'I'ILATION I'AN(SINGLE RES ID) Date Receipt#
will the applicant or future building swcupanl use equipment or devices which
,mit humrdo-61 eu uffemanta as A -seal by The Boy Area Nr Quality Mmmgmell I{OILER-COMP(31 W OR Wins)It'I'U)
Diarict? )1'
0Vn Na BOILER-COME(OVER 100.000 b'I'lll
AIR CONDIIdONEH
Ib ' lead the 1 '¢Tial 4 t.underCl pl 695ofthCali n ISSl1ANCI:DATE
0th HJI &ng coy( I \ t .2551152553} J 2551) 1 1 .t nJ d-t he a the NEW RISIUIiNTIAL MECH. SQ.h7. LC/J,of M1h , 1 I . t ' ,priot,t is y cauccof a C^ll,m fOc,u, )ant [[//t - Dan, TOTAL: SUED BY:
IS
OFFICE