NO PERMIT NUMBER APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY dU U'
CITY OF CUPF,RTINO BUII.I)ING-ELBC'1'RICAL Pli MIT NO.
APPLICATION/PERMIT rINGROJE"cr[DWI MECHANICAL
Q
ISUIhDING DIVISION I{1111,UIN6 uR(LIEQf IDENfIf'ICA'r1ON ^'000
$ANI1'ARV NO. AI'I'LICAI ION SUR I'I'1'AI.UAI
Ii1111,DINGAIIIIftD: 81 05 QP
r
0 ofc oc �1COR� I R,C �l6 3`0 7 ^�
T NIC C(ONI'ROh%
CHI'I'IiCr/INGINEIiR; LIC NO, {/y SS: yy!! •'fit ❑
/ G /�
NTACI': w \ P13UILDING PERMIT INTO
��� -f-E��S � Consonant Fees Paid by Applicant(Ini3ial) SLUG ELECT 1'LUMIi MI:CII
},--1}'tiG IT ❑ ❑ ❑ Lim
LICENSEUCONTRACIOR'S DECLAR =201.1�AMPS
FLECTRIC PERMIT hEE JOB DESCRIPTION
hereby dit.that Into licensed under provisions of Chapter 9(commencing
WIZ win Seniors ngpl ofniviaionJonnc Busmen and lto&saints Ghde.anA mY licenseRFSIDENTIAI'
SUANCE.
LLD in full fracc of lifssc—_ 0 —�1 ❑SFDWL ❑KITCHEN REMODEL
aUU License Class Liars IS-RISIDENTIAL -]ADDITION ❑pi.UAIBINGRCPIPE
yzw Date Comrnnor ❑MULTI-UNIT E)STRUCTURAL
ARCHITECT'S UECLARA ON MODIFICATION
z0aZO Z h Z ]understood pry plana shall teased as mhlie records
Up
AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F 14t:w Licensed Pace ssinOut MPS IMPROV EMI,N'f ❑SWIMM ING POOLS
(OWNER-ROILDER DECLARATION th ML'S El BATH REMODELOREPNR ❑DRINIOLITION
Q I hereby uRmh Thal I am exempt from the Contractor's License Law for the ❑OTHER
!axOLU following reason.(Section]031.5,Business and Professions Cmk:Any city or county ECTRICAL
W 3 LL1 which mycat v pemat m am ata,altee improve,denu.l'nh,ar"'O'an'smimmx
I-E: prior to its Instance,also require%the applicant for such permit m rile a signed smtemem SPECIAL CIRCU IT/M ISC.
E2�.' that he is Eenoed pursaammme pO,iomr,of he Cmnanors License Law(Chapter 9 COMMERCIAL:
W-00= 2 (commencing with Section ttXN))of Division 3 of the Business and Professions Calc)nr "I IiMR METER OR MOLE INS'I'.
LL d o that be is exempt therefrom:mJ the naris for the alleged exemption.Any violaion of ❑NEN'BLDG/ADDITION ❑DIiAfOLI'1ION
NSection 711115 by any applicant for a pennil mMatn We upPlkum m v civil pen:dty nl IY)WER DEVICES ❑TIiNANT ❑FOOD SERVICE
t more than rive hundred dollars($5110). IMPROVEMF,N'F
_=Op l.aanwner Of lnepmpery,ormy cmployte,with wagesa theirsnle eampcn.wtim" SWIMMING POOL ELECTRIC
F. will do the work.and the samsaure is not intended oroRered for sale(See 1(144,Hmircvs ❑OTHER
13 m and Professions Cade:The Comractor's Liceme law does not apply pt an aware of OUTLETS-SWITCHES-FIXTURES
property who builds or Impmvcs thereon,and who Jou such work himself ar thruugh
his own employees,provided that such impmvntems arc nut intended or offered for NEW RESIDENTIAL ELEGIR SQ PI'.
vine.if.howevvq the building,impmvcmenl is sold within one year of completion.the
SQ.1'.FLOOR AREA SISQ.IT.
ncrbuildr,will have the burden of proving that he did at,,huild of impmvu for pur-
Iu na of sale), 'I OPAL:
1,as owner of the proleny,am ceclu.dvcly enmrceing with licensed c ntrannn m
construct One project(Sec.7B41.Business and Professions Code.)The Canavcmr's Li-
hw law does totapply bum ownerof pmpcny who buddsor impnrvcs meson,vnd Q'rY. PLUMBING PERMIT FEE
who contacts farsuch pmJects with u contmctar(s)licensed pursuanuo the Conitucmr's
l.wen.w Law. PERMIT ISSUANCE
0 l am exempt under Sec. ,It V 1'C lin this rcmh
ALTER-DRAIN B VEND-WATER(GA) VALUA'1'IIIN
Owner Dane 4
WORKERS COMPENSATION,im,on DECLARATION RACK FLOW I'ROTF:CT.UIiVICF, / OO
I hercM1y ufrinn under pen:Jly of penury one of the folhwing dcdamtinns:
I have cad will1contma a Ceniricmenf Cowm msclGimurc far Wnrkc,Compn:- DRAINS-FLOOR.ROOF.AREA,GOND. SFORIli5 TYPE CONSTRUCTIO
tion,us provided for by Sstion 31W of the LaWr C:Ne,for the performance of the
I a which Nis permit is issued. PI%TURIiS-PER TRAP
1 have and will maintain Workers Cnmpensmum Insurance,as mquimd by Section GAS-EA.SYSTEM-]INC.4 OUTLETS OCC GROUP All,w700 of the laborCndc,fnnheterlinmcace of the work for which this PPermiths issued.
My Wo trope wu nl 'mc r JPolicyn h rc. GAS-EA.SYSTEM.OVER4(EA) D
Cumcr E INSURANCE
;R' I�ICAIE O'L'%EMI'TION PR(l O Rti GNEASIJINDUSTRh WAS'rEINTI?RCE('fUH
COMPIiNSAT1pN INSURANCE ❑I1ILDIN(l DIVISION Ir1iIiS
(This stolon need not be completed ifthe permit is for one hundred dollars IS 100) CREASE'FRAP PLANCHECK FEIi
ort s.)
(certify that
coamin an,mmiu,loDbewmk for which this thePermitWisissuCom, R SEWER-SANITARY-STURh11iA.'_W I4. ENERGY PIiF
not employ any peraam in any manner sn us w her at nvbjcct to the Warkcav'Cnmpcn-
Z stoma Lawa of California.Date WATER HEATER WIVENI'IELECIA GRADING ITE
ZQ APpllcum f
red+ NOTICE TO APPLICANT:IL altar making this Certificate of Escancinn,you should WATER SYS'1'EM/fR17 UNG SOILS FEE
a , M1ccomcsubjeo a the Workers Compensation provisions of the LaMn m
Cade.You mt
W fnnhwithcmnply.,In such pracA,mosor this permit shall be deemed rcvnkeJ. WATER S17RVICE
QAID
7 Z CONSTRUC'110N],ENDING AGENCY NEW RESIDENTIAL I'Lh1H. SQ,I.T.ITDam Receipt e
U z I hereby affirm that is a commction lending agency for the perlimmance of —
{L the work lar which this permit In issued lSec.11191.Civ.CJ �� -TOTAL:
O U L:ndcra Name 'I(YfAI.:
U Lenders Address K Rll)ING F6Y � U �l
a I mnify that I hove read this up,blZuum and mae that the atone informni'm Is
F N eoneet.I agree m comply with all city and county ordinances and a am laws relatingm QTY MIECHANICAL PERMIT FEE SIISMIC PEE
U butdingemmtmefmq and hercbyaattmiec remesenativesonms city menteru,snthe I '
11
chane-na,mOmad pmlx'ny lin inspection Purpose,. I'ERMI'I'ISSUANCE I;CTRI,
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Frafilhtcs,Judgmcnlg...frond apcnscs which achy in any wary teems aquina sail City N,9TRORADD'I'OMECII. f MBING FEE
in hmequence of the granting of this permit.
APPLICANTUNDERS"PANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000CF14) NIiCH'.NICAL FEE —
SOURCEREG IhA'I'IONS.
AIR HANDLING UNI'P(OVER MOM CITs1) CONSTRUCTION FAX
I�
Signature of Applicmt/Camaanr Date EXHAUST HOUD(W/DUCI) HOUSING MI'I'IGAI'ION FEE
HAZARDOUS MATERIALS DIS LOSURE
Will the upplicanl or future building avcuptm store or handle ha'carJuus rrmlerial IIIiAI'ING UNIT LTO 100.000 11 Hit
as dctimal by the Cu,muu Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I(M,OW BTU)
Cndc,Sectio 25532(a)': PAIDD Yes � - VENI'ILA]'ION FAN(SINGLE RILSID) D:ne Reecipl4
Will the applicant or future building oa'uPanl use cquipn cat it,devices which NOILER-COh1P(3HP OR UM.i)Ol BTU)
.if hvmdnus air cantnminants as dt ined by the Bay Arca Air Quality Management 'FO'I'AL:
istricff ({OILER-COMP(OVER IW.(XIt)BTU)
❑Yes
1 have read he hvimperial,nNousimperial,requirements under Chnpn
mr n 95 l the Culi-
NR CONDTI'IONER ISSUANCE DATE
foram Health R Safety Cale,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL Isi SQ.hT. �
huilJinegggd n0 eurcntly huv tGmnl.lhat 11 ivory respndihility enhntifytheoeea'anl
of the rnu whim musts 'or to isuunce o��f a CcniftcvrCpf fkrN pyrr� �y-�—
i /tet �� I L IT7 TOTAL. ISSUED NN, I �'
Owner or achorred agent
Date
OFFICE