S 0191 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'1'INO BUILDING-ELECTRICAL PERMIT Nn.
BUILDING DIVISION APPLICATION/PERMITrLuanurvc-.+tecxnNlc,u, S 0191
BUILDING PROJECTIDENTIFICATION
SAN[PARY NO. APPLICAI'[ON SUBMITI'AI,DA]E:
BURA)ING ADDRESS:
7 /exon Dint
OARNAME: I'110N1r: CON'I'RACI'ONS NAMIi: MIC NO:
N/C CONROLk
a c ❑
ARCHITECT ' 'INEER: MIC NO: ADURIiSS: tt //
V r e- ✓V
CONTACT: PHONE: BUILDING PERMIT INTO
49,f'Y717 ❑ Consultant Fees Paid by Applicant(Initial) BLDG IX PLUMB MECH
1:1 '1F
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm thin I am Iimawd under provinion<nf Chapter 9(commencing
Oa'Z aim Simon. Divisioa3ofthe Husms,,ond Poom,,ime,Cone,and my liml RESIDENTIAL;
WOO � PERMIT ISSUANCE �gFpNrl [I KITCHEN REMODEL,
CWF in full Once and eLyet. 3 T G/
V Licenm Cl.-s Lic.H APPLIANC6.S-RI?tiLDIiNTIAI. ❑ADDITION C1 PLUMBING RIiPIPIi
Z Z W Dare Centra /� /0 / 0 MULTI-UNIT 0 STRUCTURAL
ARCHITECT'S DECLARATION PANELS
~hZI undersand my plans shall lee itself as public records MODIFICATION
oy
ZO m-aO ❑UPT0200AMPS ❑INTERIOR CHIMNEY REPAIR
OZ-
1=.4)~u] Licensed Pndeuional 201-I00AM1'S IMPROVEMENT 0SW'IMMING I'001.5
OWNER-BUILDER DECLARATIONoVF.RI(NtAMPS
❑BATHREMOUe R IR EMOL " N
C 6 1 hereby intentional I am exempt from'be Contractor's License Law for the
dx O d V following rcau'n.(Section]03 r'5,Rosiness and Professions Crile:AnY city of county SIGNS ELGCfRICAL ❑OTHIiR
u1'31+,Hwhich requires a penin mons,cotime,improve.demnlish,or repair any structure
¢
prior in its issuance,also requires theapplicam fmamil pe..if o file.signed statement SPECIAL CIRCUIT/MISC.
�}•] that he in licensed panand to the prnvisiom ul flaw Comnnmr's License Law(Chapter 9 ('OMM DIAL.
A;�7 Icommen<ing wins Scuinn]0(Ily of Divisi�n3ofthc Business ami Professions CeNelor TEMILMETEROR POLE INS'['.
6 6 p C than he is exempt therefrom and the husis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION DE}f01,11'ION
^y
Section 7031.5 by any applicant for a peninsubjecns the applkanuo a civil penalty of POWER DEVICES ❑TENANT 01'001)SERVICE
t more than five hundred dollars($500). IMPROVEMENT
SSC ❑ I,as owner of the praised,or my employees with wages as(helr sole compensation, SWIMMING POUT,ELECTRIC ❑OTHHR
will do the work,and the structure is not intended or offered for sale(Sec.]10,14,Busines f
3mand Professions CehJe::ITw Coulracrorn License Law deals nm aPPly m an'owner of OUTL[TS-SWITCHES-FIXTURES
property who builds or mproves memon.and who dxsmch vocal,himselfoa through NEW RESIDENTIAL[LLCfR SQ Fl.
his awn employees,provided that wch inhpmvcmems.am n'o(intended or offered fm S .I .(R)R AREA E/SP FT
h
safe, howcveF,the building m improvement is mid within one yea of completion.the
r-builder will have the burden of proving than he did not Mild or improve for pur-
p1 1,as ownslcls 'TOTAL: J O REM
❑I, f owner of she pmpeny,am exclusively womneung with licensed cemmqun to VVN ���iiirrr v
construct the project(Sec 7044.Business and Professions Codi)Too Comnmev's L,-c se Law dws not apply to an owner of property who builds at improves thereon,and QTY. PLUMBING PERMIT FEEJ La
who contracts for suet,projects with a conutelons)licensed punlan ('the Control f LVNEI 11 IlvU
License i PERMIT ISSUANCE
I um uamnpt audit Sew. ,11&I'C for this reason
ALTER-DRAIN Se VENT-WATER([A) VALUATION
Owner Dae
WORKER'S COMP12NSATION DECLARATION BACK FLOW PR(IFECI'.DEVICE
I hereby affin under Penalty of perjury one of the following declare ams:
�Ibnve and will mtimuinn CeniOculcol C'onscm hh nelhinwmfer Workrs Ccmpcn- DRAINS-FLOOR.ROOF.AREA.COND. STORIES T'YPEC[INSTRBC`HON
.cation,as provided for by Suction 30011 of the Labor Code,for the perfonanm of she
walk for which this permit is Iswcd FI%'FURE.S-PER TRAP
WC� have ad will maintain Worker's Compensation Insuranm,us required ft,
Sm,ion GAS-FLA.SYSTEM-1 INCA OUTLETS
J]IXmfthe Lahti.Code,far the paterearecaf the work toE!!,
penin islssuM. OCC GROUP APN
My Works{{'s CnmPe ti'oy.lnsunnce carrier and Policy nS/
loan 6/{A/��'(L/( Policy No.: 4 09- / GAS-EA.SYSTEM-OVERi
GER)'IIsIGATE OF E%EMITION FROM ' GRRASETNDUS'I RL WASTE IN'I'ItRCEPIOR
COMPENSATION INSURANCBUILDING DIVISION IsElis
CI'his mtics need not be eontppeod it he pcoal'is fed dollars($I IXI) GREASElRAI' PLANCHECK IEE
or less)
I certil y that in the Belltamma of the work lir which this penitis isocad,l shall SEWER-SANLTARY-STORM EA.2W FC IiNERGY FINE.
nm employ any person in any manner m as m become subject ,,me Weaken'Campania
C) Z satin Laws of Calilimhii.Date WATER HEATER W/VENTIELECfR GRADING FEE
Z Applicant
= NOTICE TO APPLICANT:If,after making thin CcOrdicate of Excerption.you should WATER SYST[iM/IRGTINO SOILS FEE
(-' became subject to the Worker's Conhpcnstnuo provini'ons of Inc Labor Code,you mos(
J ro
forthwith comply with such provisions or this petit shall be emitted revoked WATER SERVICE
0. Q
a
CONSTRUCTION LENDING AGENCY NEW RUMDEN'FIAL PLMI. SQ.IT. PAID
s7 z Dcion
't pt9
T Meeby mfinhh tont mare is a wonstmmi'on lending agency rte the perrnnanew or
W. 0 the work for which this permit is issued(Scc.Jin].Civ.C.) TO'T'AL:
O lander',Name TOTAL'
,r U berdels Address BUIL-DIN(UJ
iL
0. 1 certify that I have read nova application and atm that the above information is
F' tq current.l agree m comply with all ray and.many ordinances and stem laws minting to QTY. MECHANICAL PERMIT FEE SIESMIC PUB
V building construction,and nerebyroominc representatives ofthkcity menterup(m the
above-mcnni'oned prnpctlY lie innPwwinn l urrallIx P12RMIT ISSUANCE ELEMRIC Flt
(We)agree to save,indemnify and keep hanks,the Coy of Coupon...against
I'mbilities.judgmems,cases and expenses which may in any way accrue against said City ATTER OR ADD TO MECH. PLUMPING EE
Aconsequence ND gaming mixpetit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.fXX)CPM) MECIIANI:AL PIiG
SOURCE REGULATIONS.
AIR HANDLING ON[r(OVER 10.000 CIM) CONSTRUCTI TAX
Signature of ApplicanlContmmor Date EXHAUST HOLD(W/DUCT) 110USING MI HO )N FF.E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuure building occupant store or handle mundous material BEATING UNIT 0IWOM IT U)
as formed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Ill'ATING UNI'P(OVER IIXLLXXI RTU)
Cw1k,.Scninn 255J2WI'!
❑Yet ❑NnVENTILATION FAN(SINGLE RGSID) PAID
Dam Rs •ipl p
Will the applicant or future building occupant use equipment m devices which BOILER-COMP(1HP OR 100,001)BTU)
emit Wool air Cinnaminson;as del'mcd by the Eny Arca Air(Bnada,Management AL:
Ldmxate
BOILER-COMP(OVER 100.001 RTU)
es �No
e lead the Il snrJnus materials ren under CM fi 95 of(he Cali. AIR CONDITIONER ISSUANCE DATE
ymmmen 'p(axa&Salary V505,n533 uinnifyti snmifthe NIiW RPSIDI?NTIAh MCI{, SQ.F1'.snm currency h.a s,be,manL(bon it is ua res-1-Crliry umenify eawmpamnnnts whi h must be nwt prior m issuamx of u Cenilicme of Qcupancy, Lgesx— ) T(YfALISSIBi)BY:
nhonreJ.gem
OFFICE