S 1797 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO 131111,DING-ELECTRICAL PE TTNO
BI111.1ING 61 VISION APPLICATIONFPERMIT PING PROJECT ICBANIcn1. 1 7 9 7
I1IJILDINC NR(1JDCT IDb:N'11F10A'IION
BUILDING ADURILtiS: � ��31 �� �� � SANITARY NO, APPLICATION Sl11fM1ITAI,DA)
OWNIi
"!;AZT
PHONE CON'I'RAC 11 NAn1E; LICNO'. /
�� }Srr N. NIC COM1TROL
/ N
'�ARCI2ITELT/ ,NEER: LIC NO; V AI ) ❑
r CON'T'ACT: 1 PHONE: BUILDING PFRMFUINFO
oA •-�`�1/f�zYLryN/ _j17q -(;M ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�VryGWI �V `"1.7VT_ 4•� ❑ ❑ ❑ ❑
LICENSED CONTTRACI 012'5 DF.CLARRI']ON Q'rY. EI,ECTRICPERMI'I' PEI:
1 hereby affirm Thal I..n nm
licensed lel pmvislom,d Chapter 9lconttncndrg JOB DESCRIPTION
WOO with Section 9000pJ Disown 3ollhe Bnsine,sand l'mfinvim,Codeandrn,]or enxeis RESIDENTIAL:
ILL-O- in full force and effect. PERMI'1'ISSUANCIi
�W� ❑A D ITL ❑KITCHEN REMODEL
Zw License Class Court APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PII'Ii
u,Z� Dam Conlmdnr
F-5y ARCIII"TECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
ZOO1ZI understand my plans shall IN,used as public records MODIFICATION
O Z'4 UP'10200AMPS [I INTERIOR ❑CHIMNEY REPAIR
F�FC'W LicensJ Profesiomll 201-101a1AMPS IMPROVEMENT ElSWIMMING POOLS
OWNER.BUILDER OIiCLARA'DON OVER 1000AMPS ❑BA'I'It REMOUEIJREPAIR ❑DEMOLI'T10N
C C d I Imreby alllirm That 1 am ux 111,from the Conuucmis License Law Inc the
xL i U following rosea.(Section 7031.5,Business and Pod e..mot Cote:Any city or a,army SIGNS ELECTRICAL ❑OTHER
LLl�+LL in which requires a permit to mnuwq.Amq impmve,demoli,h,or repair any sautime
d priorto its issuance,also requires the applicant for such Permit o file a signed,mtamem SPECIAL CIRCUI TMISC.
'-1 that he licoma,l pnraualat Ac onitlsiotw of the Comranm"sllccse Law(Chapter!)
LL 00 (contmencingwilh Section 9000)of Division Sol the Bluims,sd Pod..it ata Cola)or 'TEM It M 13'1'F.R OR POLE INS'I COMMERCIAL:
a a c W that he is esempt therefrom and the basis for the alleged exnnptim,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section 9031.5 by any applicant for a Petmitsubjens me applicant to a civil penalty of POWER DEVICES
m nounnm than live hundred dollars($500). ❑TENANT ❑FOOD SERVICE
IMPROVEMENT
2 d do hvwmk.flbepmpnmylnr lisnotmrmado,lbeedfi stheirtale cangmn,inno. SWIMMING POOL ELECTRIC
Has will duthewons Cook, he Contnm,lcmra pots License
Law,
apply
to
water ss ❑O'TIIEIt
3 m and Professions C,Jc The Contractor's License law dos not apply m on owner of OIITl.lffS-SWI'1'CIIGS-FTXTURIS � � T_
pmpmy who builds or improves thereon,and what docs such work himself or through
his own employees,provided That such impmvcnmnta are not!.,ended or offered for NEW RESIDENTIAL ELFCYR SO 17L
soft lL however.the b..films or iinprovemenl ie,old wiminnue year of eomptell oty the SQ.IT.FLOOR AREA $/SQ.FT.
mrballot,will have the harden of proving that he did no lauld m impmve for pur-
Pose of vale.).
❑ 1.as namor of the property,um exclusively contracting with licensed troust arsot TOTAL:
,ourounut,the p jc,l(Ser.9014.Business and ProNssiors Cyte:)The Contractor's Li-
wcLuwdoe ml apply town owner of pn,lsnny who ballon,improve,there..,and Q'rY. PLUMBING PFRMI'F FEL?
las n,mmns f r such projens with a conuacunlsl licemvd pnrsunm m the Commnm's
License taw. PF.RMI'I ISSUANCE
❑ I am exempt under Sec .B&P C[ar Ihis reason
Owiwr ❑um ALTCR-GRAIN&VEtND-WATEk(HA) VAWAI'ION
WORKERS C(1MPHNSA'1'ION DECLARATION BACK FLOW PROI HC'1'.DEVICE O
1 hereby iffin...der Iwmolly of perjury one of the following dedumtiom:
❑ [have and will maintain aCenificom of Conant to self-insure for W'isi Compere DRAINS-FLOOR,ROOF,AREA COND. STORK. TYPE CONSTRUCTION
union,as pmvid,d far by Station 3700 of the labor Code,for the perinrnon re of the
work lin which this permits is issued, FIX'I'U RIiS-PER I RAP
❑ 1 have and will i main Wnror"Compensation Insurance,as required by Section
3700of the Labor Code.for the scrformamormche work for which this permit is issued GAS-HA.SYSTEM-)INC.4 OIfl'LETSto OCC.GROUP AIN
My Workers Compensation Insurance carrier and Policy another art:
Currier: Policy No,: GAS-HA.SYSTEM-OVER 4(EA)
CHIG IFICATB OF EXEM VI PON FROM WORKERS'
COMPHNSMION INSURANCE GREASVIINGUsirfuL WASTE IN'I'IiItCCI'TOIt
(This section need nm b+mmpleteJ iOhe Mnnit is fo...clo isreddollars($100) Allilos BU11. INC BVISION FEES
or less.) GRFASIi TRAP PWRACK E
I certify Eal in the performance ofthe work fmwhich Ihis permit is issued,I shallf
SI?Wlilt-SANITAIIY-STORM PA.211f1 FI'.
not enryfoy nnY Pelona in anY mm�nermusmhucutne subject mthc Workms'Campnt- UU 111111 IP FF.Ii
station Lawsof California.Date WATER I MATER WN17NT/El-EC'IR
Z Q Applicant GRADING ':Ii
N NOTICE TO APPLICANT:If,attar making this Cetificate of E,man'tion,you should WATER SYSTEM/TREA'I'ING SOILS PEE
a banana suhjml m the Worker',Compcnsatimt prockn m of the Labor Code you must
forthwith comply wile such prs.vls.. or lhirpefnn,shill bcdccmedmvnkeJ. WATER SERVICE?
a0
Ciel isCI'IONLENDINGAGENCY NEW kGSIDE,Nf1A1.PhA1B. SQ.17, PAID
5 Z )me Recdpl a
V I for whaffinn tnavnere iemrn (Sec.3nlendingagencyfm the ry:rinrmnnce of
W � 'he work far wh'mh thi,permit ix issued(Sec.91199,Civ.C.)
lsnJcrs Name
V IsnJcrs Address 'TOTAL:
y1 certify that 1 have mad this application and state that the ebrve admonition is BUILDING iii
.H. h correct.I agree tot comply with all city and county ordinances andstae laws relmiagto QTY. MECHANICAL PFRMIT FEB
V Z buddin,comtmalinn,andhemhyaathnrizerepresentativexatl lhiscity 10-cr,nothe SEISMIC FEE a
above-nicndoned pmpctY for inspection purpows. PERMIT'ISSUANCE?
(We)same to save,indemnify and keep Intrude.the City 9f C.pvmnn ugdod ELECTRIC PER
liahilitics,judgmems,costs and expenses which may in anyway accmeagainst said City ALTER OR ADD TO MECH.
in asequence of the granting of this Nomil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILI,COMPLY WIDI AU.NON POINT AI R I I A N DLING UN I (TO 10,0010 CUM)
SOURCE REGUTA9'IONS. MSCI AN CAL PHE
AIR I I A NDLING UN I'T(OVER 10.000 CFM) CONSTRUCTION TAX
Signature mf ApplicanuConlmctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
IIAZARDHUS MATERIALS DISCLOSURE
Will the hppllam ar fwwn huildingoccupum storeor bundle humMous ntmenol BEATI NO UN I I G 01 do poN)N'11IJ)
as deQned by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cola,Section 25532(a)9 BEATINC,UNIT(OV ER I(in"BTU)
E]Yet F1 No PAID
VENI'ILA'I'ION FAN(SINGLE RIiSID1 Uwe Re<ciptq
Will the air containment,
m nt,a building occupant use e9uipmem nr devices which
t huzanlous air eomaminanls as JefneJ by the Hay Arca Air Quality Mnnogenmm BOILER-COMP(3111'OR IIXI INNI BTU)
district? 'I to,
❑Yes Fl No BOILER-COMP(OVER 100.000 BTU) to
,
AIR CONDI'TIONHR
I have mad the the Cali- ISUA C1i DATE
fomin Berlin&Solely Cade.Sections 25505.25533 and 25534.1 ondersmnd that if the NEW RESIDENTIAL MECH. SQ.ET.
m N
1 � pA
building Joey ncurrently have a tenant. m it is mre
y icspoibility to notify the occupant 0 —/ f vo
ofine requirements which must he met prior it)issuance ofa Cetilicam of Occupancy t 'S //���
if
Owner or authorized agent Doc TO'1'N.: ISSUED BW /�
OFFICE