S 2072F
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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC'IRICL PI7W`d.ITNo.
I1D[1,DING DIVISION AI'I'LICATIONAPERMIT n rr,Lunl IIING-MECIIANICA6 V .2072
Vo flualle.1111N.H.1'A'GON
0/8a Pt0-/e7' diad'.
I ar-09$ 3,7,7
"7 PA I ❑ Consultant Fees Paid by Applicant (Initial)
1 hereby affirm that 1 am Iicenwd under provi.vioms of Chapter 9 (commencing
with Sttuian 7000) of Di,i.um B of the Business and professions Curie, and mY license i.
in Gall forceand efea O 3,5 7
)at, C' Lic.p
Date / sJ Cnnlrua�
ARCHITIiCI'S IyEC1.ARATION
1 understand my plans shall be ured as Public records
Licensed Professional
OWNER-I11111.UER DCCLARATION
I hereby af' am that It exempt (tuna Ibe Cnanraam" Li[lTe Lw fill dt,
following re'sudon
n. Tse ]I i15.Business and Prof sane, ode: Any city or enemy
which r quinex a pcnnfl to construct, u1r, improve, demolish. nil repair nay anworm
prim on, isxuarace. also receives he rNpliman rowel, parm..to plea\ignelnlmcoval
that ha is licensed pursuant to the provisions of Ibe Convector's License Low (Clepler 9
(endmmncing with Section 9(X10) of Division J of the BusNcss and Prdri%ionsCmle) ail
Ihat he is e,cul therefrom and the basis for the alleged esemplion. Any violation of
Section 7031.5 by any applicant fora permit subject, the applicant to a civil penalty of
not more than rive hundred dollars (5500).
El I, as owner of the property, or my employees with wages as their sole compensation.
will do the work, and the adware is not intended nil offered for sale (Sec. 7014. But no.
and Professions Code The Contractor's License Law does not apply to an owner of
property who builds or impactors therein, and who down such work himself ur Through
his own employees, provided Ghat such improvcancnp arc net intended nil off d fou
safe. 11, hn,e,v, the building or Ual m .,rem Is sill wRhin ono ycarof eemplelinn, he
ovotirtbuika, will hued the burden of proving abut he did an build or improve for pill -
Five of sulc.l.
E] 1, : ,,air it the ropch,. man d.el.kedly contna'ting wish hectored conv.dor, to
consumer thcprajed (Seri. 7144, Business and i'mfessions Ctde) The Convaeor's I.,
crouse ]saw does
. -
mlawdoes not apply to an owner(fprnpexty who builds or improves thevnn,and QTY.
who contracts Inrwch projects with a commclon v) licensed pursuant In the Contmdar.
License low%
lam caempt under See . B& P C for his reasnn
Pine, Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declamtmro:
I have and will maintain a Ccnipcum of Consent n self -inure for Worker's Camped.
star en, ;is pmvisled for by Section 37N) of the Labor Cade, to, the pedamminee of the
ork lar which This pcnnfl is issued.
151 have anal will anaintain Worker's Cnmpensmlon In,wnance. as respired by sccdnn
]7q1 of the Labor Calc, Re he FMbmuumc al the work or which this pernut Is i_ssaad.
My WSJ��d C Pe a In....a pei...er and Polleyt naberg
canicaVof:-may�%�yi Parey No.'.-16�/00
CE RTI FICATE OF I!X13MPIlON FROM WORKERS'
COMPENSAIION ENSU RA NCI:
(ThissWdud meld not be dnnpled! if the permit is flat . mundred do)[. ($ 1(0)
orless)
1 certify that in the penormative of the work fail which his permit is issued, l shall
not employ any person in any manner w as to hccoane subject to the Workers' Camped.
salla. Lw, of Callromie. Dore
Applicant
NOTICE 10 APPLICANT: If, after making his Climactic of Exemption. you .should
become subject m the Workers Computselinn provisions of the Labor Code, you has
loo r, all unnply with ,such.:.... inns nil this actual 4ha11 bee, deemed r,,liked.
CONSTRUCT ION LRNOINO AUFNCY
I hereby effort (hat here 1. a umstruclion lending agency for the pdro n ion, ill
the walk for which this permit Is issued (See I(Xlt. Civ. C.)
]sodas Name
I cancer's Address
I ready that 1 have read this application and state that the above information is
amt. I agree to comply with all city and county ordinances and state law, Mating to QTY.
building construction, and hereby chat ... i repreanlalive, of this citym enter upon the
abrv'e mentioned property' for inspmlinn purp,ses.
(We) agrte to save, indemnify' and keep handless the City of Cupertino against
.I
judgments, costs and experees uhichnay in any way revive against said City
in courecarda. of the graining of this pcnnfl.
Amu tCIN'r' ONna RSTANDS ANU Wild, COMPLY WITH ALL NON -POINT
sigatal arca 'n.Fhdait nmramo ante
ZAZI SMA'I'ERIALSDISCI,OSURE
Will the ill lantmfm cbuilAlnpracch,elan m dor hands hit aorder, nave ial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
Carlo, Scetion 2553200!
I ❑Yes
Will the applicant or future building eveapmnt use equipment or devices which
emit hamrdnun air contaminants as defined by the [lay Area Air Quality Management
Dinky.'
❑Yes
I1 dth h urd 't 4 t. 1 CI pl b95 That Cal
h 11'10 &Sul- 1 S '-t 1 SII 1255141 nes r lahm fthe
h II 61 flyh a t y F bllyl try lhcecctrye
ill the...... must a at ssl. sec tl'I Cell befit. of
ELECTRIC PERMIT
PERAlll' ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP'102f0 AMPS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE 1
POWER DEVICES
OUTLETS - SWITCHES - PIX
NIiW R[SID ,NT'IAL ELIiCI'R
PLUMPING
PERMI T ISSUANCE i
ALTER - DRAIN & VENT - WATER (IIA)
RACK FLOW PROTEGE DEVICE
DRAINS- FLOOR. ROUP, AREA, COND.
1:1 VI LEES - PER TRAP
GAS _ HA. Sys 'TEM -I INC. 4 OU'I'LII IS
GAS - IiA. SYSTEM -OVER 4 (IIA)
GRF,ASFIINDUSTRL WASTE INTERCEPT R
GREASE TRAP
SEWER -SANITARYMIiA.2
WATI3R HEATER N'/V q, -1.
WATER SYSTEMORE '['INF a - [
WATERSERVICE
NEW RESIDENTIAL "MB. SQ. ri
MECHANICAL PERMIT
PE RIM F ISSUANCE.
ANTER OR ADD TO MECH.
AIR HANDLING UNIT (TO UMN)) CFMI
AIR HANDLING ONI'P (OVER I0.(XX) CPM)
EXI HAUS"1' I IOOD (W/DUCT)
HEATING UNIT O'O 100.01X111IUI
HEAT'ING UNI r (OVER 100,I1X)ENI
VENTILATION 12AN (SINGLE RISID)
BOILER -COMP (LHP OR iond Xl RTU)
BOILER - COMP(OVER 100,000 13'1'U)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. Pf.
F1d
FEE
SQ, FL FLOOR AREA I E/SQ, PI'.
Z
BUILDING DIVISION FEES
PLANCIIIECK PEE
ENERGY FEE
GRADING FEE
Sons 1 38
PAID
rte Receipt
-- 1 OTAL:
BUILDING Ilii
FEE SEIs MI B?:
IiLLCI'RIC P E
PLUMBING 'liir,
MECHANICAL.
'0...I..UCI'IUN'TAX
I IOUSING MITIGATION PER
PAID
Dale ReceiplX
)T .:
ISSUANCE LATE
BUILDING PERMIT INFO
B1LLDDIGS 1: _FC] PLUMB ME If
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDW'L ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING REPIPI:
❑MULU-UNIT' ❑STRUCTURAL
' MGllgd`ICAlION
'IiRIOk I�J.��MN/IMNISY RF:I'Alk
❑IN'11fAI
IMI'R(IVptdpNT []SWIMM INC, POOLS
❑ BA'I'I I REMOURIIREVAIR ❑DI?MOhI'ION
❑tinn:k
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLI'TION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
FEE
SQ, FL FLOOR AREA I E/SQ, PI'.
Z
BUILDING DIVISION FEES
PLANCIIIECK PEE
ENERGY FEE
GRADING FEE
Sons 1 38
PAID
rte Receipt
-- 1 OTAL:
BUILDING Ilii
FEE SEIs MI B?:
IiLLCI'RIC P E
PLUMBING 'liir,
MECHANICAL.
'0...I..UCI'IUN'TAX
I IOUSING MITIGATION PER
PAID
Dale ReceiplX
)T .:
ISSUANCE LATE
JONES MASONRY
1058 DELL AVE., CAMPBELL CA 95008 FILE
(408) 377-7512 • Lic. # 390359 • Fax (408) 377-7513
Inspection Report & Estimate
y Customer Name C t \q,-\ c, WO tires
Address l u'� -L
/
City l r State
7--2 90
Fax:
tove Type
i!� r i W Ava j Ai.
vU C�JC -mde
Firebox r_ll(_
�e Exterior Shell
C
u®
NOT RESPONSIBLE
FOR DRAW OF FIREPLACE
Shoulder
Throat
Cap Damper
Chimney Flue
Facing
Roof Line
Damper
Facing
Firebox
Hearth
Ash Dump
Spark Arrestor L1 (IV(P P
Other An P-4
J .(( o�or
Rel )�C`0 t-rc ) �di R.r52
�1tt�1�
d o'
Date: O f> >
Zip 435-0/ 1
� JUC
5U W
TO
Iwo
WED, WE
0
Total Estimate
Inspection Fee:
(NET 30) DUE 30 DAYS FROM DATE OF INVOICE
TO AVOID INCREASE IN FEES.
I,-)
1— -- - A 1
36262 /