B 0602J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE,RTINO BUILDING-ELECTRICAL ,�/��-.�71y(�,)�I'iR//M�111�NN7711c. �.�.
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING PROJECT IDENLAICAL SOOO I `�.30 RM " kms " " " "
BUILDING PROJECT IDENTIF'ICA'TION
BUIhDING ADDR4\� tiANI'1'nRY NO. APAI S'1114h11'I'f\t. AI'
OWNER NA L: �Y CONTRACT'OR'S NAME: LIC NO: NIC CONTROL#
' e r/ Ncl 'eeR: 1 ". nunRlaS: 3� r
COMI'ACf: �H({y��'I'�" BUILDING PERMIT'INFO
IC-L-FA&/r, ( L// O / ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELC❑:r PLUMB MECI{_
L�� �(�L.�V!(/ 6r rLIJY I[Jy LrJ�
LICENSED CONTRACTOR'S DEC ATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby aHinn Thal nm IiareeJ under,mvixions of Chn,nr 9(cmm�mneing
�aZ oid,S Section
000)olDecision3ol'the Business and Professions Code,and my license is R• I F TIAL
mp0 1 PERMITISSUANCE pDWL ❑KI'I'CHFN REMODEL
aUU License Chex Lie.# APPLIANCES-RESIDENTIAL OADDFHON ❑PLUMBING Riz-1111117
vFi6a
Gare—Comrmmr OMIII,TI-UNIT ❑STRUCTURAL
ARCI 111 ECT'S OT;CLARAI'ION PANE ti
F v=i Z I understand my plans nhvll be used as,ablic records MOUIITCAI'1(IN
z C,OZ-0iz UP'1021X1 AMPS El INTERIOR ❑CHIMNEY REPAIR
LimmcJ l•rofcssimml 201.1000AMPS IMPROVEMENT' SWIMMING PDOLS
1IWNIiH-BUILDER OECLARA'I'ION OV
IiR Iarth 1YS ❑BA'T'H REMODEIBEPAIR El DEMOLITION
IY C Q 1 hereby vlfinn that I am exempt from the Contractor's License I.aw for the ❑OTHER
X 0 a U following tcamm.(Section 7031.5.Ituveress and Pmfessiom Calc:Any city a,cmnty SIGNS ELECTRICAL
W 3 LL Ha which Requires a,noth to eameaet,slree missive.demolish,ar repair any duras
C) Factto its isamnce,aim)requires the applicant fm such permit o file a signed statement SPECIAL CIRCUITIMISC.
E to Nat he is licensed paam
nato the previsions of the Contractors license Law(Chapters COMMERCIAL:
Ia1�00 (commencing with Section 70(10)of Division 3 of the Business and Professions Codd or TEMP.METER OR POLE INST.
61 e C that rte is eaampt donefmm a+d the had,far Ne alleged exemption.Any violation of C]NEW RLDG/ADDITION ❑DIih101.IT10N
��
Section 7031.5 by nay applicant for a permit subjects the applicant a civil Penalty of POWER DEVICES OTENART C]FOOD SERVICE
tat more than Eve hundred dollars(5500). IMPROVEMENT
b- ❑I.as owner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC [I OTHER
F., willdo thcwork...d lhestmnum is not imaddefirmfered for uto(Sec.70,14,Business
W m and Professions Cnlc:The Contractors I.Icmec Law does not apply to an owner of Of1TLETl-$WITCHES-PI%TURLS
property who builds or improves thereon,and who does such work himself or through
his own rtnple,nes.provided that such improvemenn are not intended or olfereJ Inr NEW RIiSIDLNTIAL ELECI'R SQ FI'.
sale.lf,howuvcg the huiklin nm int Ile sold within one [completion,the I SQ�FT,FLOOR AREA SItiQ.l9'.
n�mer w'tn hard he Women of,roinvfg that he cid lint.dad or improve Int,Lir-
puna vnle.l.
I,as ower of the See 704,stn o one, sly c,fessi in,Coot Ilcmmral cmollersdenn h l0 1 F
se I the,,+jccl idly.]Baa,one,ni and Prof scions Cwlca'I'ho Cs shoo, lir rand
/ a
scl.uw Jac nm applymnn,wncr ol'pr+,anY who buihlsmintpmvcs lharaon,and QTY. PLUMBING PERM IT PEE Li{Y1 i 4
cause
h acts for such projects with a eontmeter(x)licensee parnam n+Ihe Conone"" s
f.tca r , PERM I'T ISSUANCE
yrlew ,B&Ps.C fa this reesnn
y�I���� nu I •c.
AI,TFik—DRAIN&VENT—WATER(EA) VALI].\TION /
war Darc 6 W'
ORKER:SCOA))'H SATION ECLARATION BACK FLOW PROTECT EVICE /
IhaehyaNrmunderpenmry of,maryo ofthefolhwingdeclaotionn:
,-J thea#anti will maintain aCcnificae ofConsem to self-insure Ga Workels Compem DRAINS-FLOOR. RG,CONU. MY)RIPS '1'YI'Ii CONSI'RUCI'IU
avian,ah provided far by Section 371X1 of the I.ahor code,for Ne pedarname of me
work for which this permit is issued. 19STURCS-PER TRAP
1 have cad will maintain Workers Compmention Insurance,as Iequieed by Senior GAS-EA.SYSTEM-1 INC.a OU . S
3700ofbelaborCalc.for the performance of lire work for which this permit is issued. OCC.GROUP AI'N
My Warkci.s Compcasuron Insurance carrier and Policy numMrare: GAS-EA.SYSTEM-OVER4(: i3
Cameo Policy No, 7�
CERTIFICATE 017 EXEMPTION FROM WORKERSGREASMNDUSTRL WASTE INTERCE
COMPENSATION INSURA BUILDING DIVISION FEES
('this section need not he completed ifthe pamlti arent, Lind of I E PLANCHE EE f .�
lemony that in the
nar,fonmaoacoltht weekfar me mit i. Court I W _SA _STORM .21N ENERG
not mnploy nny person in imy mm�nerm nx to become eWor 'Carol t .I ��
Z cannon Lam—I Cnlllimria.])all A'F .E k GRAD lE
C
Atp,heml I on.
NOI ICH 10 APIVIJCAN'1':Il:afire making this Cert sl d A'1 SYS' "ATINC
[� beeon+c subject In the Worker's Com Iiunfauviston,ofte a ,Cale. nt 6UI1,, i?
^� j ,coxa
�� fonhwilh cnnply withsnch Provlsiotan,Nis,ennitshall he deanvJtcvnked. OAT+ SHR
�] PAID
a
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.PT pair Receipt#
UQl hereby arum that there is a construction lending agency for the priforeave,of
[L the work for which this pe.,it is issued(Sec.3097,Civ.C.) '1 f
O V leaders Name 12-0} U lre,Address BUILDING FEE
a 1 cenify that 1 base read this v„BCaion had state that the above information is Q
F y '.real l agree my ply,with all city and county ordinances and nate laws informal,m QTY, MECHANICAL PERMIT PEE SEISMIC FEE
V Z ouldingeonswctian.and baebyauthorize re,reumatives of this city to entaru,an the
aMnx"mentioned par, it,for inspection puaposes. PERMIT ISSUANCE ELECTRIC FEF.
1 Wel agree have,indemnify and keep harmless the City of Cupertino against 4r%
Ends ibex.judgments.masunJexpenseswhichmayinanywayaccrueugainnsailC'ny AITERORADD'1'0MECH. PLUMBING FEE ` 2�
+ m.wquenceof the mining of this permit.
w
AINLIC 'ONI 'RS'I'ANDS AND WILL COMPLY WI'Fit AIA, ON P01 M' AIR HANDLING UNIT(TO I0.000 CFM) MECHANICAL PEE `L
SGB G d.
G AIR HANDLING UNIT(0111 IILIXX)CIM] CONS"TRUCTION'1'AX
m'
'it 14 Uatc EXIIAUS'f H0OD(W/OUCT) I IOUSINGMITIGNI ONFEH
IIA%ARUl1US MA11ikIAL$ CLOSIJkIi
pli
11
C,Jallval„v1259321::)linnlMnniaPalllC aloe Chapter 9r.12ronA(he tl{aallh mtA Salary ttl IIIiA'ONO UNIT(TO I(IO INN111T111
/' DEAL INC,ON['I'(OVER 1000()III'U)
p Vox26'5-
PAID -Ly t+T.J7
VIiN'I'ILATION FAN($1NGLIi RIiSIO) Data Receipt,
WII Nc ap,licum or Tatum building wcurym uses equipment or dcvicc�whl<n HOP.ER_COMP OR 100.0 BTU) A
ly harumoux air contaminants as defied by the Bay Area Air Quality Management '1 UI'AI: L
s.evicY! —/ Bo11.liR-COMP(OVER 100.000 BTU)
Alk CONDITIONER Cr DATE
1 hare t ':edeas materials requiremenn Linder Chaplin(eta of the CalBlue
humin 1 N sty ale.Sections 8505.25533 arid 8531.I understand that if the NEW RESIDENTIAL MECH. SQ.PI'.
bail ' Ir avtenant, at- - xpnnsibil'y"On, fy tnaneeapent
of e I u- act a Canlit f 0c attcy.
r or aahorned agent �� ” ISSUED P
OFFICE