S 0708 �APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO Bm1.DBV0.ELECTRICAL PIFSIIT NO. 0708
BUILDING DIVISION APPLICATIONIPERMIT PLUM PROJECT' CAL
J
BUILDING 1'ROJ F:CI'IDEM'IF'ICAq'1UN
IIUILUINC ADDRESS: SANITARY NO. AI'I'LICATION SUIIMI"I'I'AI.DAPI
O 'NERSNAh1F,: I'll NE: CO TRAGTORM1 NA��M+E: LIC NO: NIC CON'fROLA
'CHI'U T/Ii GINEIiR: LIC NO: A DRESS: nT ❑
W 81
/• CONTnCI': PHONE: BUILDING PERMITINFO
❑ CUnsaltant Fees Paid by Applicant(Initial) HI.UCIiLF,CI'- PLUMB MEECCIH
IbV a LS3' L7
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT 1''
I hereby of an that 1 am licensed under parmsinm of chapter 9 mmtm,endng JOB DESCRIPTION
"Z with
thSctio and effect.
Dlvlsiun 3ol'if,Business and PrnfiI Coda and my license is PIiRMIT ISSUANCE RESIDENTIAL'
LLWp in �Lic. c77i/Z'L ❑SFDWL ❑KITCHEN REMODEL
Fa-ZlUi1 Darn: CPa Contraanr T APPLIANCPS-RESIUPNTIAI. ❑ADDITION El PLUMBING RE-PIPE
y Q 6 ❑MULTLUNIT ❑STRUCTURAL
AHCHITbe ma DECLARATION
F,Dr� PANELS MODIFICATION
w 1 underslann my Alam shall M used as puhllc records
H UP T021XIA STA
O
El INTERIOR EICHIMNEYRE IR
O {y Licenwd Ymfessinnal 2UI-11XX1 'S IMPROV F.MIiNT ❑SWIMMING POOLS
<•1 F,J
OWNER-BUILDER DEC1.ARAl'ION oVIiH N ❑BATH RF,MODEIJREPAIR ❑DEMOLl VION
C z Q I hereby affirm that I an exempt from the CommOus License Law for the ❑OTHER 1B A A A
X il:C.OLL F following mns0n.(Section 7031.5.Business and Profession,Craft:Any city at caunly SIGNS 'LECfRIC.
y which"arm,a permit m construct,alcor,approve Jemnlixh,nr repair any ummnrc
FLL0I prana,n,ismeace.ahsrectures lheapplicam for such Permit to file a signed statement SPECIAL TIMISC.
9991y } that he is license)pursuanunthe pruvixinm of the Commclnrs License l.aw lChaplcr9
p(Q� (commencing wa�Scchan]IXNIIafDivixinn 9nf the Beli our and Pmfnssion,Cyte)or TEMP.ME :R/R LH ST I
a a mC Ilia he is c,mnpt IM1crefrom unA the basis far the ullegcJ csentptinn.Any violation of ❑ 61,DG/ADDITION D:MOLITION
..m Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of WER UEVICIP3 O ��Z :qp O SERVICE
F.Z>
not more than foe hundred dollars lS51NB. IMPROVF.AYL9TVUYCi1��V
❑has owner of the Propcny.or mY cmplOYee,wilM1 wage,a,thrir,ole complan,aunn. 'WIMMING POOL ELECTRIC
a, will do the work,anJthererearre isnot ilnendedorntiered for stile 70,14,Honors, ❑OTHER
L 3 and Prom"anes Cosa:'I'he Comenclor'a License Law)nes not aPply nr nn owner n OVILh-I'S-SWITC116S-IIXTURP_ti
Jq
property who builds or improve,Ihemm,and who docs such work himself or through
his own employees,provided that such improvements arc net intended of u0imel 11n NEW RESIDEN'rIN.ELECER SQ FI', or
sale.If.however,the building orimprovemcal is sold w chin one year efcompletion.the
$��T SISQIFT.
cr-builder will have the burden officiating that he did not build or improve for par-
poseofsale.). (. _
❑amownerofthe Seemy,am cxsi andal,aodessiins Cae:)neeW imon, i- 2-
who
r�t
m1. ,,the project(See any..ilill,BusinessIda and Profusions uh licensed
d come eau to UY J
,claw Jars ntnapply w an owner of property who builds or improves iieram,and QTY PI UMBI ERMIT FEE
who contracts for such projects with a umnracmr(x)licensed pursuant to the Comracmrs
License Law. PERMIT IS.
❑I am exempt under Sec. .B A P C for this reason
ALTER-DRAIN& T-WATER(EA) VALUATION
Owner Data
Wm under penalty
D€CIARlowing ACK PLOW PR ,E �•}l.
1 hereby affirm under penalty of perjury one o the following declarations:
a'�on,as poswill rfor by eC3700 of Cnmem to Coda,for(tier Workchce or the DRAINS-1'LOGR,RUO". 'OH[. $TORIliS TYI'F.CONSTHUCI'IOt
hon,as hick his
for mi Section,issu3]ql of the Labor Coda,!oohs Performance al the `
• work for which this permit is iaruaJ, FI%TURES-i'IiR TRAP
❑1 have and will maintain Workers Compensation Insumace.so.required by Section
3700ofthe I.W,Code home performance ufilm work for which this permit is Usncn, GAS-EA.SYSTEM-I INC.q OUTLETS OCC.GRUUI' AI'N
My Workcrg.l,.}uRcJu y�ryl^cc to ranA Policy numbcram: ,
CamknR1LPnIlI No.: GAS-Eh SYSTEM-OVER CERTIFICATEOP COMPENSATION
INSURANCE
WORKERS GREASEaNDUS'I BE WASTE INTERCEPT
COMPIiNSAT10N INSURANCE 1301 N 'DI N FEES
flhinsection need not xcnmpled ifire pemtit i,farnne hundred it.]].,IS100) GREASETRAP
or ks.) I'hANCHIiCK FET:
I canny that in the perform;aiceofthe work for which this permit i.issued,I%hall SEWER-SANITARY-STORM FA.210 FE
nil employ any Prison in any manner so as to become suhjret to the Workers'Compcn- ENERGY Wilt
z cation LII.,of C.ffi mia.Data WATER IIIiA'I'ER WNIINI'IELECTR GRADING FEF,
zZ Applicant
h NOTICE TO APPLICANT:IL after making Nin Ccnificatc of i!semption,you should WATER SYSTENIO BEATING SOII S PER
a ? become subject to the Worker's Com,fortlon provisions el'the labor Code,yo trust
forthwith
S O comply with suchfr...Niumnr This plammshAl be claimed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. PAID crap
a z I hereby affirm that there is a constioclion bindingfor the rformance of Date
U O at.) Ie
4ks f' the work for which this Permit is issued(Sec.3007.Civ.CJ
Lenders Name 'TUTAL:
LU Ls:nda'a Andres., ` ItUI1.D1 J E
I certify That I have read thin application and,tale that the mMwe infnmmlinn is
F Vat) Our Ia,.I.comply with all city and sourly ordinances and slam law,ellangto QTY, MECHANICAL PERMIT FEE SEISM
C.) Z building conomclian,and hereby amhnriie representatives ofthis city memerulam the
alawe"mentioned property for inspection purposes. PERMIT ISSUANCE IiLE 1 if
(We)agree to.ave,indecently and keep harmless the City of Cupertino agalmt
Judiiities.judgntcnls.casts and as,spoc%which may in any may seems,against said City TCR OR AUDIO MECIL P h R3
'n con.equcnce of the granting of thin Nmit.
APPLICANT UNDERSTANDS AND LL MPLY WITH AL1,NON-POINT AIR HANDLING UNIT IT 0 lq(XX)CPM) ME(. 'IC I, TE
SOU S.
2a 9� IR HANDLING UNIT(DVI?R 111,0(X1 CPM) CONS" U(,TI NTA%
Signature of Appl' o 7, u` Uae EXHAUST HOW IWIDUCI'1 HOUSING IGAI'[ON PEE
HAZARDOUS MATER LS DISCLOSURE
WilDheapplicmnr l'ume,buildin cmpan ,oneor handle hroml...I mmeriai HEATING UNIT(TO 1!0,000 BTU)
as Jd1nN by the Cupertino Municipal c Chapter 9.12,and the Health and Safety HEATING 11NIT LOVER I WJXO BTU)
Cade,Section 25532(0)]
C]Yes ❑No VF,NTHATION FAN(Si NGLE RES I UI PAID
Data Rett'ipl p
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,00 BTU)
hvuJous air...taminanl..as claimed by the Bay Arca Air Quality Maoagmncnt I'f 1
tet l BOILER-COMP(OVER 100.000 B'rU
5i, ❑Nn �r
I have real the hatondoes materials requirements miner Chapter 6.95 of,he Cali-
AIR CONDITIONER / ,'UANCE DATI7
fomiu Hexith&Sxfety Code,Sections 255115.25513 and 25514.1 understand thm if the NIiW RESIUGN'TIAL MIiCH. SQ.I'1'. I•fjL a..,
hadding)res nut curtcndy have a tenanl.that itis my te,M'^sibilhy In notify the'vetrpant t y fY J
of the r•-p intn are,which mull Water poor In issuance of a Cenifewe of Occuperay.
D�
Owner or amhoriecd agent Data ISSUED By:
OFFICE