S 0796 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
0`117ITY OF CUPERTINO BUILDING-ELECIRICA]. 11151T NO, 0796
BUILDING DIVISION APPLICATION/PERDIIT PLUMBING-MECHANICAL
IfUILDIN'G PROJECT'IDESI'IFICATIO\
IIUIhIIIN�UHF_SS: N��. � If � � � SANI'I'AHY NO, APPLICATION SUItMI'ITAL[)ATI
1,Dn/MVy b 4
I OWNG 'S NA EA 1'tE NE: NTNA I' (5 N Mli. 1 C U:
seq � ��`/ a •CrJ (0NIC CON'I'ROhX
ARCHITECT/ENGINEHIE: NU. �+ IRF,.5: _CWC.� QI ❑
CONTACT: PHONE: HUI NG PCRMITINI'O
❑ Consultant Fees Paid by Applicant(Initial) HLD ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT' FEC JOE DESCRIPTION
1 hereby affirm that 1 an licenced under pull Uiom nl Chapter 9(nnnmm�cimg
Z widt So Ion V(XX))Cf Divislnn 9 oohs Thromcs,and l'mfesslnn,Ctde,aodn+y license is RESIDENTIAL
Won withS t
W p Z PERMIT ISSUANCE
FW
in force and effect. ❑SFDWI. ❑KITCIIIiN RIiMODEL
IY H Lica APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RE3PIPE
Hzw Uatc Comraam e
bnsata� ARCHI'FECPS DECLARATION PANELS El MULTI-UNIT El STRUCTURAL
Z O t�'Z I unders and my plain shall M uscd m public¢cords MODIFICATION
o UP T02(NIAMCS ❑INTERIOR ❑CHIMNIiY RENOIR
Licensed 1, essinall 2111-1(XXIAMPS IMPROV' ;N'I' SWIMMING I'OOIti
�,yJ OWNER"HUILDI?R DECLANAI'[ON B IiMUDHIIk BPAIR QUEMOLI PION
4C .`al OVER IINXIAMPS
6 1 hereby affirm that 1 am exempt from,M1u Connocmrs Limns,Law lin,hc OTHER
XX13 a m billowing mason,(Seel 7031.5.Business ins d Propeason,Code:Any city or county SIGNS ELECTRICAL
which req Permit I construct, Ile P demolish. pa y structure
pgprior to it% ee.alw,MqUiMsIM1e spirituel fsuch Permit file a signedstatement SPECIAL CINCU ITIMISC —
E }
that he is licensed pursuant tthe pervisions of the C I tors License Le (Chapter9 COMMERCIAL 7 '` ._
WC:C (commencing with Satind7000)of Division l of the Business and Professions Code)or TEMRME11iNORPOL NST.
'LE c that he is exempt therefrom and the basis for me alleged exemption.Any violmion of ❑NEW BE DGIADDITIO. ❑DEMOLI'T'DON
WmV, Section 7031.5 by any applicant for apernit subjects the applicant to a civil penally of POWER DEVICES (-I TENANT . . FOOD SERVICE
not mate Chun five hundmd dollarsIS5s)). IMPROVEMENT
1.axuwncr of the Tn n employees IL ware,a,drelrsule Tom lien, SWIMMING )LETLECI RIC
a�p ❑ P m lme i. P yerxwl 6 Iwnv:+ El OTHER
ad ea
will dothework,and O: he ConCIsnot,License Low
a(Sec.](H4,Easiness
0. ono property
who b Ctde:The Conlreaors Lice me Law s such
but apply m an ulnen h OUTLET. -SWITCHES-FI%T URILS
his own whin builds or impmvro themh improvements and who tsuch work dei or or through
his own employeese building Thal such ensisw thin not intended- or aRcmJ fm NEW SW
his ELECTk SQ F .
salt.If,however, building or improvement is mlJ within one Year o(complainn,the SQ.I'I'.PI. AR. ASQ.14.
er-builder will have the burden of proving that he did not build or improve fill pur-
ptn1ofsaleJ. TOTAL: 98 I
I, rude).rof,n,pmpcny,um exdusivcly contnmting with LecnscA cnnlruaurs¢+ DECV the
m,Hlocl the project(SCC.7844,Hosineas mod Proi ..inns Code:)The Conlmaur's Li-
r. .w Law dols nm applym an owner oToolnny who builds or improves dremon.and QTY, PLUMBING PERMIT PCIi
who contracts for such projets with ucootrucmr(d licensed pursuant w 1h,Comruaors C11 ur wr'tH�1 0
Licen.m law. PERMIT ISSUANCE
1 oro exempt under Ser. .H&P C for This reason
ALTER-DRAIN&VENT-WATER(PAT VALUATION
Owner Dam
•
WORKERS COMPENSATION DECLARATION PACK PLOW PROTECT.DEVICE OD�
1 hereby affirm under pommy of pujury one of the following Jaluretions
❑Thole onJ will muimvin nCenlBcm,ofCnnxnn lu self-insnm fm Workrr'x Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. SR RE is TY PIT C(INSTRUC'DOD
a lion.rte provided lin by Seaton l](Xl of he Llobar Cole.for in,perfnrou nI he a /I'
wank for which lhil,ennit lx issued. FIX]USES-PER I RAP V M
1 have and will maintain Workers Compensation Imurance.as required by Section
7]00ntlbc Labor Code.fit he pcAsrmancwdlbs work for which this Permit is i.oucJ, GAS-I?A.SYSTEM-IINCAOUI'1 ti OCC GH(ll1P AI'N
My Workers ComPenution lmumnce atrium and Policy numb.+are:
Carrie'. Policy No.: GAS-EA.SY$'DiM"OVERJI )
CERI'IfTCATE OF EXEMPTION FROM WORKERS' GREASE%INDUSTRLWA EINEiRCEPIOR (/
COMPENSATION INSURANCE BUILDING DIVISION FEES
('(Tic xedinn need not he completed hire Penni,is fibrotic hundred dollars/511X11 GREASETRAP
hr It".) I'hANCHECK I'lili
Icerli(y IMll in the perlimmincw+l the work for which thUpemlit is lx+ucJ,lxhull SEWEN-SAN'ARV-S'IONM HA.21HI Pf.
not employ any penon In any moon °(I hl a the Wnrkcrd CnnT,m ENERGY PIJi
O z .salion I-Or ft anl>:Yc f "' co n WATIiR H- 'LPH WNEST/f?LECIIi
0 Applicant �IYYt V�iM GRADING Rill
y NOTICE t0 LICANI'af,afar mal, this Certificate of Exemption,you should WATT+ SYSTEMITREATiNG SOUS PER
a7 become subject to the W9rker,Compensation Provisions of the Lebon Code,you mint
{LI forthwith comply wnhsuch provisions or this bem+it shall be,deemul revoked. WATERSERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PANarc Rcmipt N
I hereby uffimt that There k.corenuaion lending agency for the pmourmmmce of
IDL( O the work 1111h Ihix pram,k issued(Sac.91197.Civ.C.)
O F't TOTAL:lender,Name
V Lcm1mh Address "TOTAL:
>" W 1 certify that 1 have lead this application and,tarn that the above infnmwtion is BUILDING FEE
fa
Z Bane,. agree mcomply
and withall yaudiand countyordinancescsand stere lawsmintingupon
a QTY. MECHANICAL PERMIT FEE SEISMICFEF:
(.7 z building comwaion.and hereby authome representatives of this city to enter urymtM1e
above-mentioned property for inspection purposes PERMIT ISSUANCE ELECTRIC FIJI
(We)agree Oil vlov,indemnify and keep baroness the City of Cupcnimn against
landitiesjudgmens.eaan and expenses which may in any way actual against said City AL'I'17R OR ADD'TO MF,CH. vjFUMBING 8717.
in close quenee of the gnmllne of this permit.
APPLICANT Lt DERSI'ANDS AND WILL COMPLY WITH AL1 NON" OIN'T AIR HANDIANGUNIT(TO lq(XXICFM) MECHANICALI+Eli
SOU REG t.A"
1 90 [�/ AIR HANDLING UNIT(OVEN IIL(NXI C- H CONSTRUCI'ION'1'A%
Vbees
Signature of Applicun Cmmncmr CJD/ a EX IIAUST HOOD OYMUCI) HOUSING MITIGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will thcaPPlicamnr far..huilJing accubem comm handle hwrarJnusmumfial HEATINg1V
10.100 U)
as defined by the Ca,doo Municipal Code.Chapter 9.12,and the Health and Sufery
Code.Semon 25532(u)'I BEAT INUNIT HOVE at(XXIBTU)
�Ya E:1 No VF,N'IILINGLE RI?$Ill, PAN
Receipt aAm Will the applicant or future building tecupanl love equipment or device,which BOILER OR IWLgXI(ITU)mit harallous air contaminants ex defined by the Buy Arta Air Quality Management TOIAL:Di,Wcfl BOILT:kER RXLIX)0 BI'U)❑Yes ❑NoI nave read the hxsardous materials"ramnmms under Chapter 6,95 of the Cali- AI O ,T Ni DAT:
humin health&Sals,Coda Sce,ns 25516,25519 and 255)4.1 understand the'II the NEW RESIDI?N'I'NL MEC((. SQ.Ff.
nnild+n ��gJ drlltivnalal ,.mtnnis my re,pnndndnymnon nl,t 9yI(mv,a�m�
• `Ilnw he mdpdor u+isxllan„mlacrrti(r„t gcS+Nif
Owner or authonxedo col / Dal. TOTAL: ISSU
OFFICE