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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -El ECTRIC\L PE RM]TNO.
BUILDING DIVISION APPLICKI'ION/PERMIT rll,-loujkNiR lla" Eaisel 1. S 2638
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❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACrOR:S DECLARATIONQTy ELEC"I'RICPERMI'I'
Rirm
I hereby an that I am ficend under provicinm of Cnapter cin
4 commeng
withSection]IXXIpd Dtvi.ionJnflhe Eucincss and l'mfe...... Code.. d uylicensciv PERM] I' ISSUANCE
in full force mid cffcct.
Lian,e Class Lick APPLIANCIES- RESIDEN IAL
Dale Con.. con
ARCIII'I'1iCI"S DECLARNION / PANIEIS
I unde,%roud toy plens shall be .,ed :a public record,
UI"f1121N1AMPS
hivenuJ Pmlkssinnul
OWNER -BUILDER cI mei from
DECLARATION
1 .Cathy affirm that 1 um c u%in from the Cordmaors License Law for the
following rcama (Section ]II3I.5. Itusiot, and Professor Code: Any city ns county
which m%issuance, permit re conamet, uhue ntf r su h Permitdemorit ur repair any .uumurs,
prior u, %l reCdprsu requires the rhe applicant rat such permit m icesle a Law (CUPt em
that he Iseir, ,Ill Section
mtheut INvmo of of Commdoh License Luw(Chope) 4
,ho ingwnb Section aX11 of Div' mrnRMeged t,csunJPmfAnylis CtNd or
rent heel, esempt merdmm ann le, usis lin me alleged exemption. Any violudon of
5enlmrt nuts by env nnpbeam for i�pa, nh.rnjaetn the applicant araemll penalty of
Tun :tune lout five hundred dollars S.11X1).
I, is owner of the Property ...any euop oyrec with wages u, their s demmpe orflrr.
will do the work, and the structure is not intended or offered for svlc(.So'. 70,W. hussar.
and I'odccsoms Coda 'Me Contractor's License Law dors not apply it, on owner of
pmPsny whit builds or improves thereon, and who tines such work himself or through
dor—
his own employees. Provided that such impmvnnents are not intended or offered for
sala.If. hnwcw% the building or inipmvcment is sold within one year C, completion the
iter -builder will have the burden of pate ing that he did not build or implies, for pur-
pow, r sale^)).
C(� f the property, lu, ly cuourecong % do l' J contractors to
construct d p j m (S 7(H4 R ss 1 1 f n c d) IT ( t '1 h
u 1 t reply r r rl p nY h t E ,, inpoloc, fl .aid QTY
who ,�oTu�rc.i--lot i /pp/J1 t' ill t ( sur u
ttu tile ci rt ctur9
-1 i.(e,�a,nJ�„rtfaCtiee. .1 C for sic rea.on
SIGNS EL1ECl'RICAL
SPECIAL CIRCUI VMISC.
Zt
TEMP. MEI ER OR POLIS NST.
BUILDING PrRMI1 INFO
POWER DEVICES
BCEO / CIA:CP
SWIMMING VOOI.IEI.IECrRIG
SOIISITIF
OUTLEs15-SWI rCHES- FIXTURES
JOB DESCRIPTION
RESIDENTIAL
❑SPDWL ❑ KITCl IFN REMODEL
❑ADDITION 111'LUMRING RF -PINE
01,101a'I. UNIT' ❑ S' I'RUC 'I'URAI.
MOOIVICAI'ION
0IN'IFR10R [:1CIIIMN1EY REPAIR
IMPOVEhthIsT E]SWIMMING POOLS
CI FIAT RP.MODEII EPAIR ❑DEMOLITION
❑0THER T
l ,
NEW RESIDENT IAL ELECTR
SQ ET.
taS;P% - Date
OR KI°RIS COMIll NIATION DECLARATION
1 hereby vine. under penalty of perjury ane of.hs, fellow tag declrutions:
Hocclm wlllmainmina Cenihcateof Cun.mnuoself-insumhnWorker'sCompen-
saion, as provided for by Section 3701 of the Labor Code, for the Irerfornwnce of the
work for which tld, permit in issued.
I have and will maintain Worker's CouTcroution Insurance, as occulted by Section
3701) of Labor Code, for arforonance of the work for which this permit is Issued.
MY W .. kers Contpcnsat on, hrvnrance carrier and Polley number use
Cions: Policy No.'.
CER'1'IFICATII OV 17X EM PFION FROM WOR KIERS'
COM l'ENS A PION INSURANCE
(this section need mol be. ... it rhepcnnit is fn mac hundrcJ dnllurs 151(X1)
orI... .I
1 ernify that in the 1'erouncnveof he work for whale his hermit is issued. I shall
nor employ any pram in any manner a) as to become subject to the Workers Compen-
Z mion Lawsof CalifoDoleiu. Da
ZO Apprca.r
yNOTICE "r0 APPLICAN'p IL mter nmking this Cermficme of Esc ouinn, you should
the cmno cobject to the Winker, Cmnlrcncntam pmvieione of the Labor Colic. you mor
LLI turd ire comply with such pmvio..nv or this pernd shall be deemed mvnkcd.
CON STRUC'I'ION LIINLING AGENCY
C.1 I hereby effort and there is o consmmrion lending agency Ga the performance of
{k.l—thework for which this pemtit i, kstcd(See. 31))7. Civ. C.)
O 1- Lender. Name
} O.I Lender's Address
y 1 verify that 1 have mal his ipplic ition and .to than he above informsmom is
F` V) toren. I agree to comply with ill city and county ordinances and .crate laws relining to QTY.
U Z building construction, inti hereby mtlmri>c reprncnmtivesof this city w enter uptm the
obove-orentiored property in pc r m purposes.
(We) agm mc, imicloodY andA phirmlc,ccr Cty IL Pninu age nd
Buhl. J nt,, t I e. I Y b'r.a, i JC ry
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wff� %VW b t 11'; �lull
np nNr )HRSI US ANI) i )n .V v fill ALL NtINd'UINr
HA%ARUOUS MAIHRIAL.S DISCLOSURE
Noll the spipheanr or home huildin6 (ccupmr store nr handic hazardous material
us lefned by the Cupertino Municipal CWN ' Chapter 9.12, and the Ils,allh and Safety
Code. Section 25532(x)?
❑ Ys,,
Will the applicant or fuure building overpaid use e9uipmmn or deviaw which
Got hatarJans air cunmminum. to let! I Ey the he, Area An Quality Mintage Cut
l lisuictT —/
❑Yes G4
mps,r 6.95 of the Culi-
I undersized that if the
y to notify the occupant
PERMIT
ALIiR - DRAIN k VENT ->t`A n/O
RACK FLAW PROTECT. DE ' CE
DRAINS - FLOTIL ROOF, AREA,
FIXTURES - PER "TRAP
GAS - HA. SYSTEM -I INC. IS
OAS -IEA. SYSTEM -OVER d (EA)
GREASE%INUUS'I at, WASTE INr" Ra,E 11
GREASE TRAP
SEWER - SANITARY - ST"ORM EA.2001-L
MWEER HEXIER W/VF.NT/ELECTR
WATER SYS'I FMCTREN'ING
I N1FR SERVICE
NEW RHSIDEN'I IAL PLMB, SQ, Ir'.
MECHANICALPERMIT
PERMIT ISSUANCE
ALI ER ON ADD'r0 MISCO
AIR HANDLING HNI'1('1 O I0,IXXI CI'M)
AIR HANDLING UNIT ((EVER IB(XX) CFM)
EXIIAOST HOOD (WIDUC )
HEATING UNIT (TO 100,000 BTU)
HEATING UNI'. (OVER 100.000 BTU)
V EN'I'ILATION PAN (SINGLE RESIDE
BOILER - COMI, (311F OR 1009000 if'U)
IRLI EER -COMP (OVER 100.000 if l'OI
AIR CONDITIONER
NEW RE51DEN'I AL MECH. SQ. rE
FICE
FEE
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STORIES TYPECONSTR CI'ION
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BUILDING DIVISION FI'.E9
PLANCIIECK PEE
BUILDING PrRMI1 INFO
BCEO / CIA:CP
('LOMB MUCH
SOIISITIF
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SPDWL ❑ KITCl IFN REMODEL
❑ADDITION 111'LUMRING RF -PINE
01,101a'I. UNIT' ❑ S' I'RUC 'I'URAI.
MOOIVICAI'ION
0IN'IFR10R [:1CIIIMN1EY REPAIR
IMPOVEhthIsT E]SWIMMING POOLS
CI FIAT RP.MODEII EPAIR ❑DEMOLITION
❑0THER T
l ,
Q
tO
COMMERCIAL;
0N17.W BLDG/ADDITION
❑'IHNAN'1'
IMPROVEMENT
❑OTHER —.
❑DEMOLITION
C FOOD svRVICE
FEE
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STORIES TYPECONSTR CI'ION
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2 3
BUILDING DIVISION FI'.E9
PLANCIIECK PEE
ENERGY FEE
GRADING FI R
SOIISITIF
PAID
Dote Rsteipla
'rO'1'AI.:
BUILDING I'IAi
FEE SEISMICI9"
ELfCIH 'PE
1'LU 1 G i
M ELIAI ' I. FEE
CONS'-1ION 'IAX
HOUSIN MITIGATION FTE
PAID
Dutc Receipt N
ISSUANC17 DA'Z'E
IV
L 29 ISSUED BY.