S 2858 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'PINO BD u.DwG-ELECT RICA PERMIT No.
PLUMBINGIECH
BUILDING DIVISION APPLICATIONA'ERMIT BUILDING ERtojFc1IUFNH'IFIC
AI'ION
BUILDINGADDRU_SS,. SANITARY NO, APPLICAI'ION:UIIM 'I'A.DATE.
OWNERS AMI: PHONE: ACTOR'S NAME:ALIC NO;
T�^ 7 TR ,1 I f NIC CONTROL p
tCfll l'IiCTIiiNGINF.IiIt; LIC NO: ADDRE.S: -S+ r ❑
/02--9-7 S jP.A.`I=t
CON'IAC'P PHONE. ;BUILDING PERMIT INFO
25 3—0(0 18 ❑ Consullanl Fees Paid by Applicant(initial) HLDG ELECT PLUMB I'
�Mi MEC —
LICENSED CONTRACTOR'S DECLARATION QTYELECTRIC PERMIT FEF: rLLLi"JJJ�
1 hereby in.that 1 am licensed under provisions of Chapter o Rmmacur ng _ JOB DESCRIPTION
popwith Scallon]IXHH of Divisinn}of the Business'and PonfessianeGde,andmylicaroolx PERMIT ISSUANCE RESInENT7A1..
In full tires and died. PERMIT
❑KITCHEN REMODEL
aF.UU License Class Lich APPLIANCES-RESIDENT AL ❑AUDI
TION
N<L Date Conwetor
ARCHTI'1iGT$DIiCLAHAI'ION CMUUI'[-UNIT ❑S'1'RUC I'URAL I'ANI:IS
zcNz I understand myplam shall be medaspubliamcmds MODIFICATION
Ooz=O UP TO 3011 AMPS C1 INTERIOR ❑CHIMN17Y REPAIR
F(: W Licensctl i, m"ional -OWNER-BUILDER DECLARATION 201-AFRO AMPS IMPROVEMENT SWIMMING 11001-SC C Q 1 berchy affirm that 1 am exempt from the Corlmcmr'z License Law for the OVER 10100 AMPS r f1 RGMOUIiUREi'AIR DEM01.1TION
7OyI 0.W,U follnwinyreason.(Section 7031.5.Raciness and Prnlineiunc Cod,;Anydly nr dmnt, SIGNS ELECTRICAL. ❑OTHER
to a 2 Na which cognac,u Permit m consumer,eller,improve•deauthhh,or repair any stratum
f-LL O..1 pnortoio lswarec.abn requires the applicant forsoch permit n file a signed statement SPECIAL CIRCUIOMISC.
y
but be in licensed pursuant lethepno,kim soi the Cummemds License Lan,(CWtpmr9
woo Oomrammg with Start on9000)of Division 9 of the Business and Pocassinns Cmle)or TEM It ME'I'ER OR PULE I NST. COMMERCIAL:
a F c that he is exempt thercfmns snit the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ Seeman y any apptorn 70315 by ped,subjects the applicant m a civil penalty of POWER DEVICES
y m ❑'i'ENAN'I' ❑FOOD SERVICE
F
nm Inure than five hundreA Aullorx(5511tH. IMPROVEMENT=O ❑Las nwneznf lM1e pmpcny,ormy,mployces with wagantheirsnlearmpcnsmion, SWIMMING POOL ELECTRIC
F will alwork,andlh,sarc
baatr nm imm� or
Jedoffewd fnnale(So6 x
c.10,4, in.ss ❑OTHER
32 and Prn.,,ions Code:Thu Cannadors Limns.Law Joe.nal apply to ua owner of OU I'LETS-SWI'rCHVS-FIXTURE
property who builds or improves thereon,and who does such work himself or through — — _- a
his own employ,..,provided that such imprnm .
vecal,ere not intended or offered for NEW RESIDENTIAL ELECTR SQ 1
,dr,11,lame... lot muldin,orfntprocurnal is.olA within one year or oulplctlnn.the SQ.FT FLOOR AREA Sady ITL
ownerhuilder will have the burden of proving that he did not build or improve for per-
pose of tale.).
(] I.its owner 01 ha property,am caul aslvely contructi ng will,hcemcd,onitmm�,in .F.(
instruct the project(Sec.71144,Hudness and Proressmas Cale:)The Contractor's Li-
cerise Law does not apply lnanownet ofpmpenywho mild%or improves thereon,and QTY. PLUMBING PERMIT
whow,nvuelx farsuch project,with a unractor(s)IIccased putsuam to the Contractors
Lovn®Low. PERMIT ISSUANCE
1 tan exempt under Sec. .II&P C for this rcmon
]).atOwner
ALTIdt-DRAIN&VENT-WATLR(FA) VAIDAI'ION
c
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I
Iherchy affirm under penalty of prjury ane of the following declbmnionx: ^^^���
❑ I have and will mainutin a Cerlificale ofConsenl In self-notate furWnkeu's Gnnlxro- DRAINS-FLOOR,ROOGARIIA,COND. STORK 'IYPECONSTROCHON
salirn,as provided for by Section 37M of the L.alwr Code,far the performance of the
work far which this#e.it,is issncd. FIXTURES-PER TRAP
1 have and will maintain Worker's Contpensatian htsumn,as required by Scdinn
37M of`Fitnee Labor Code.fur the perfomtamttof the workk to,which
this
-p�en—nit i.issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP ,\ N
Myanallsoli
Wo 'sC Cgso T,C1iRTIF CA'fE OIn+SY poON FRIM WONKERS' / GAS-1717Ai 'il.Ri aVF,1t 411:,y
COMPENSATION INSURANCE GERM NDUSTRL WASTE INIERChOR
H his.non nedl nal Munnplatest if to,permit is Tma
os hundred dollau.IS 100) BUILDING DIVISION FEES
or less.) GREM . P PLANCHECK FEE
1 certify Ilam int Ne perfomtance of the work for which this Permit is issncd,E shall
p y any Eason many manneran in j SIiWE S 1 .A.
not em la Vrhecomcnuhed lnlbn Wnrkcr,:Gmtnn- ENERGY
O z scion Lows of Califamia.1) c WATE , 'BRW/ 'NTd1i F R
Z Q Applicant GRADING FEE
0 NOTICE TO APPLICANT;If,attar makingthis Cenilicate of Ilxempnia r,youabauld WA'11h S P.M?IB TINq
a ; become mutest m the Worker's C(,,,, cnsadntt pfovl,non,of the Labor Cale,you meq � I SUFIS PEE
fonhxith complyxilh such pmvisiomnnhis permit shall be deemed revoked. WATER SERVICE
� z CONS'PRUCIION LENDING AGENCY NEW RESIDENTIALPI.MB SQ.1,r. PAID pill
U Ihcmby. irm but is a commuting lenditgagency fnnhe lreHnrmuntt of a Receipt#
U F the work for which this panuit is issued(Sar.3097,Civ.CJ rte'
p U Lenders Name TU'I'AL:
Lender's Address TOTN.:
I certify than 1 have mad this application and state that the uhove information is BUILDING P L
fr (0.L) correct.lattice R.comply with all tiny trod cuunty ordinance.and xtam I,Iw.relafmg In QTY. MFCHANIC AL PERMIT FEE
U z building consrucium.and hereby authorize representatives ofthisciry m enter up on the SEISMICI
above mentioned property for inspection purryrses.
(We)agree lo.iave,indemnify and keep homlasthe City.1'Cupatlino agaillst PERMIT ISSUANCE f1 FUPC rw >IJi
Iiahi lines,judgments,costs and expanse x hich may in any way acetas against said City AUT ER OR ADD TO MEC11. `z .1y
incan"tivece of the grad ting of rho,perom t PLUMBING �F.
APPLICANT UNDP,RSI'ANDS 1) .COMPLY WITH ALL NON-POINT AER HANDLING ONI'I'(To 10,000 Cl NO
SOU Ii REGULATIONS. Qo MECHANICAL FEH 70
Ant HANDLING UNIT(OVER 10.000 CFM) CONSTRUCT ION TAX
Signmurc c' n 'muucro CJ—
[)am EXHAUST HOOD(WIDUCI') HOUSING MITIGKI'ION FIiIi
suHAZARDOUS MATERIALS DISCLOSURE
Willtheapplicant or fume mildimgorcupim.tar,arimedle hazallou,cournal HEAHNO UNI I(TO I00,M0 BTU)
,is refined by the Cupertino Municipal Code,Chapter 0.12,and the Hedlth and Salary
Code,Section 25532(x)4 HEATING UNIT(OVER 1000)0 BTU)
#Yes Nn PAID
VEN'I'ILATIUN PAN(NINGLI3 RBSIU) Date Receipt#
Wil 1 the applicant or haute buide Wing by the B use equipment or devices which BOILER-COMP f3HP OR 100,000 RTU)
mit hazardous air ern. .....nu as defined by the Bay Area Air Qualify Alanag.mmat ITN
Dkhiao
(]Yes e}LI� BOILER-COME(OVER 100J00 BTU)
AIR CONDITIONER
1 have mud Ibn hoamdnus materials rcgnircmena under Chapter fi.J5 of dm Cull ISSUANCE DAT•
formic Health&Safety Cedc,Sediure 255 5.25533 and 25533.1 unduntund thin if tire NEW RESIDENTIAL.MECH. SQ.Ell
buildiagda,ronvumfly amm sit is my resrymsihilirym anlifyamoccupard U
'them, un,a, prior cotaC Ificu�fOacupancy. ,
Ownerar Ihadzed agent Dote TOTAL 111 F70 ISSUGDBY:
OFFICE