S 1415 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEIrFINO BUILIIINC.-ELECTRICAL PEt IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1415
RUILBINO PROJECTIDENTIFICATION
BUILDING ADDRESS: SANITARY NO. Ali'I.ICATIfIN SUBMI'PI'AL DAII!
OW 'LR:S NAMIi: YIIONF,: (ib8'- C(INTRACI OR'S NAME: LIC NO: NIC CONIR01.g
2CHITI:9'/ENGINEER: LIC NO: ADDRESS: Q�9541.15 ❑
CONTACT: 1111ONE: BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG lil.l3ef PLUMB MIiCH
❑ ❑ g ❑
LICENSED CONTRACfORN DECLARATION QTY IzTECfRIC PERMIT Frill
I hereby arfinn that I am licensed under provisions it Chapter 9 anmmencing JOB DESCRIPTION
O with 5cealnn]Iplp of Uiv kion 3ufthe Bu,meea.ndProfesool"C'sle,and my liesmse is RESIDENTIAL
W O PEI2M1'I'ISSUANCI!
Fs, n full farce and eller -Ip ❑SFDWI, ❑KITCHEN REMODEL
aUl- I.icenaeClass 31A Lie.X 3�US
Q, U APPLIANCES-RESIDE1,fIlAI, (]ADDITION ❑PLUMBING RE-PI1'li
F z•W Uadc C..ntmOnr
NQ6
IA
AR(HI'IGC'I"S DECLARAHON PANIi1S ❑MUIThUNIT ❑MOLIVIAlIO
OZ=Z Iuakrsmndntypitir,fall beusedm public record. MODII'ICAIION
UI"10200 AMPS INTERIOR ❑CIIIMN17Y REPAIR
N4taj1 LitvnscJ Prol'msiwnJ 201-IIa10AMPS IMPR(')VEMEN'f EJ SWIMMING POOLS
r•l�J OWNFR-BUILDER OF LARA'1'ION OVER 1000AMPS ❑15X'111 REMODELIREPAIR ❑UFM(ILI'I ION
6 1 herebyafhnn that I am exempt from the License LicenLaw for the
X 3 d U fallowing reason.Section]1131.5.Ha,or,,anm d 1'rafic,ioCode:Any city or enunty SIGNS ELECTRICAL ❑Ol'Hlik
W W t; which ,rcefan,a permit m con,bro .Iwo intpmvc,dcnmlish,nr repdu nay atrncmtc p YA.�tr l }�
F"t='OQ� prior mita issuance.also.,quirs the applicant for such permit In file a signed ammnenl SPECIAL CIRCUIT/ML'
EST,,, that he is licensed pursuant the provisions of Contractor's License Law(Chapter 9 COMMFRCIAL
WE4QO CO laonmenting wish Seclton7000)of Division 3nOhe Sothic„and Pmt'esaiod,Cude)ur 1EMPNIM'IROR ILEINST.
a a e C that he is exempt therefrom and the basin for the alleged eaenrprion.Any violation al' ❑NEW ItLDG/AUDITION O DEMOLITION
��ySection 70315 by any applicant for a permit subjects the applicant o a civil penally of POWER DEV .S ❑TENANT ❑FOOD SERVICE
n more than five hundred doll...($5W), IMPROVEMENO
ESC Q I,as owner ol'ILepropnri arm to with wu ms as their sole cum tion, SWIMMI 11rc1OhIiLELTRIC
y entp yces wi 6 Lica, ❑Ol'l hilt
E. will Jn the work.and theumaum lis not in¢nJcJ Or offemdfar sok lScc.)IW.Husinesv
L,3 m and Professlnn.Code:The Contractor's License law does not apply to an Owner of OUT/TS—SWITCHES-FIX I UJI
p,,,puny who build,or Impavcs betem,and who docs.streh work hi..zsdf or through
his own cntpleyecs,provided that such improvemmi ,are nm intended..r I.Fees]for NI, kF.SIUI!NDAI.IiLEL:'k SG FT.
sale.If,hnsevhe building or impenverneol is told within One Year ofrompletion.Ihc SQ.I'I'.FLOOR AIi I!A 31SQ.PI'.
efJ
ncrhuilder will have the burden of proving that he did not build or improve for pur-
Is—of anted. TOTAL:
❑1.100,ne,of he propny,and c,eir,orly noonaling with licensed contmanrs to
construct the project(Sec.7044,Bu,ince;add Professions Cade:)The Cnntmnnrs Li-
cosa low docs rot apply it)an Owner of property who builds or imposes themon,and QTY. PLUMBING PERMIT FEE
whnenntfucl,a fnrsuch pmjcfawitlt a..... n'(,1 he...ed pntsuu
annt he C..nmtcto.'s74b ,� /i,�
License Law. PERMIT ISSUANCE L/1 L�1\,
I am exempt under Sec. ,B&P C forlhis reason
A 1:1 HR-DRAIN&V HNT-WATER(RA) VALt1ATlON
w"" MAY 19 1999
Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTE(TE DEVICE
1 herebyuliirm under penalty of porjury one of thefollowing . ti..ne
u] IM1uvc amJwill ntaintuanaa C'miucumofCnnamnoµdhlosnrcfr Worker'aC..mpcn- DRAINS-PLOOR,ROOF AREA,GOND. STORIPS '1'YI'000 IC[ION
,dion.as provided f by See 3700of he I sa Cot I In,peduradwe of the
..,k far ti huh peranit .'. J FIXTURES-PER TRAP By
/�.1�II 11 ' t Worker,C p i 1 JbyS tun
iNI)of the LuMrt Code,for the perfmnance of worl,for�which this Td it i:issued. GAS PA SYSI EM-1 INCA CATTLE'IS OCC GROUP
My Wude�,���rt�p�ets�ia ce aaier and Policy W ra G98 rE
GAS-FA.SYSTEM SYSTEM-OVER carricc.. + r—Policy Nsn: 9/ nZLt l--
CI1MIFICRtEOF IIXEMP'I'ION FROM WORK17RSORFASIVINLUS'fRL WAS 11;IN'fERCEPI OR
COMPENSATION INSURANCEHOILDINO DIVISION FEES
(Thi,,ation ncednut beeomplcmd ifthe .it is foronc hundred and—(SIM) GHEASE TRAP
PLANCHIiCK Plili
lemony tomo I.anydeetancud'Ihcwurkbuwhbjeellli 1.11-1111 i kcr,' ornptol til!WER-SANI'TAI2Y-S'fORM liA,200 IT.
nm crop...any person in any ntannm aet as m become xuhkcl m the Wnrkeri Compo- ENERGY PGF;
Z .talon Laws of Cullfomia.Dae WATER 1117ATER W/VENT/ELECTR /d GRADING FEE
'z O AFFllcm l
NOTICE TO APPLICANT:IL after making this Cenifeme of Exemption,you should WAI"ER SYS II!M/I'READ NG SOILS THE
F" becotnc subject In the Workds Compensation provisions of the Lobar Cole,you must
(Sa rim livid,coloply with such pntvi.1 0,0,this,.nlitshnll be derne,doevokal, WATERSERVICE
i �
CONSTRUCT ION LENDING AGENCY NIiW RESIDEN1A.PLMI1.
SQ 17K PAID
U z are Receipt p
V 0 Ihereby whidlirotthat
11 orsthereit
ssued S,cbonlending agency for the prtimn'vnee of
L4 � the wnrA or which this goon ix Ixvnal fticc.1114],CO.C.1 TU'I'AIJ
Le de x Name
V Lender's Actin,, '1 OTAL: O
>' I trdi fy tour 1 have read this npplia 1111.and same Ihm the above inLmoa en is PUILDING FEC:
Flip correct.I agree tr comply what all<ity andcoud,ordinances and scam lows n luring o QTY. MECHANICAL PERMIT IsfiE SIiISMIC ItiE
V z building construction.and hereby aulhorize representatives of Niscoy treater open the
above roentloncd poppy for inspection puHarscs. PERMIT ISSUANCE ELECTRIC Fit
(We)agree to save:.Indenantry and Aoep harmless the City nt Cuperli al against
Iiuhilitio,juJgmm�ls.c".as and exposes which anayinanY soy accrue againm aid City AI:TER OR ADD'lO MISCH. 111.1JMBING FEE!
in consequence of the granting of this pe.I,.
APPI.ICAN I'UNDERS'LANDS AND WILL COMPLY WITH ALL NUN-POINT AIR HANDLING ON I '(T0111,Ilfq CFM) MECHANICAL FTSE.
SOURCE REGIL AHONS.
�3 AIR HANDLING UNIT(OVIiR III.q Il CONI RUCTION TAX
SagnomrcnfApph,am/(....true(... rate HXHAUS I'HOOD OV )UGI HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material IJEATING UNIT D 0 I IMNI it'I U)
as deli ad by the Cupertino Municipal Coe,Chapter 9.12,and the Hcallh and Safety ?1:N
MR�
ts.)RTU)
Calc.Scclinn 25532111?
❑Yea E]No R_Ufi D c Recupr xWilldtc apprutmof fmu.e bah lding..eetmanl use eepipmnm nr ocelot,whichl fin I1TI11it buzardoua Id,conmtninants as dcOncJ by te Bay Arco Air Quality Munag.mcnl 'I OIAl.:Dstrict( .1X16 RTIp❑Yes ❑NO
I have nadthe nindous tomeriols reyuimncm.under Chpter fi 95of the Culi- SSUA Ii DAfEfomi.Health&Safely CodeSimon,25505,2.5533 and 25531.1 understand that if theSQ.FE
building tine.,nod atrrmnly havca lenant,that It is my ne..amsihilily to notify the occupnnl
of the rafro rem,which tmia be..tet prior to issnnne,nfa Ccti tic to at Oceapancy.
Owner or umRtdscJ.gent
Uak TOTAL: ISSUED Bl':
OFFICE