S 2541 J APPLICANT TO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE.RTINO BUILDING.Pi.KC'rRICAL PI?RMI'1'No).
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MI?uuANirnl. �+ 5
❑I111,I11Nf:I'ItOJlsd;r l Dt:N'rIfICATION J J
BUILDINGADDRESS., SANITARY No. APPLICATION SUBMITTAL DATI
ls�S d�kryieE y0
OWN[ 'SNAME: J / I'IfONI?: CON 'R CfOR:S NAME' N LIC
NO,
crla C �y6-/lS� co�E f 5Z u� > ;s� NIC CON"1'Rol.»
I�I ARCHITECDI?NGINHER: LIC NO: DDR[g5: LSH /h ❑
rZ
CONTACT: Pi BUILDING PIiItMI'1'INI°O
70 ❑ Consultant Fns Paid by Applicant(Initial) BLD ELECT PLUMB MECH /
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby often that I um licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
WOO with S1cdon7fXXho1 Dirsinn3oflhe Brsinessma Professions Code,ane my license is RESIDENTIAL:
WOO O p l PERMIT ISSUANCH
W-v- in full three and iLZ� C3Y D1rf ❑SFDWL ❑KITCHEN REMODEL
QUU License Class C 1.ic.p ) APPLIANCGS-RESIDI?NTIM. ❑ADDITION ❑PLUMBING RI:-PIPE
y<i n.ve e.mDHCL
ARCIII'1'IiCrS DECLARATION ❑MULTI-UNIT ❑SI MODIIFICATIO
N 7'/z PANELS MODIFICATION
Z O y Z. I undtt,InnJ my plans shall M;used us public rccnrJx
UI"1021NIAMI'S
OZ^� ❑INTERIOR ❑SWIMMING REPAIR
OOL
Licensed PmfaeinnW 201-IfN111AM1'fi IMPROVEMENT SWIMMING POOLS
OWNH
W< IiJlowing redbu an(Su,, ban l ni cs,hTI sI ml he Cl i er Co Liecnse Law mime
OVER IfNXI AMPS El BATH REMODI?IlkIiPAIR ❑DIiMGI,I'I'ION
J
0.0i4U Je:Any city or county SIGNS ELECI'RION, ❑r]THER
v- whi,h re,-' I I o....nin ree,'ll p J I'.n ,m y structure
.4 pro I t c,al...re'nine,bealp,licoulI hpemail file.vilendstatement SPE LI AL CIROIJI'I'/MISC
�oe"I 'hat licensed personalretire provikinanordic C I t r' Live.,L (Chvpter9
apo (cam n¢nclny wuM1 S«uon]INXBoI'Divaanm3 nflhe Busine..v and Pn[ ,Code)., TLMP.ME"GER LIR POLE IN9T. COMMERCIAL,d p,M a thin he is exempt dread oro and the hasix for the illegal exemption.Any violation of -W BLD /ADDITION ❑DEMOLITION
W^e" Section 7131.5 by any applicant lin a permit subjects the applicant v Civil penalty or POWER DEVICES ;NA ❑FOOD SERVICE.
not more than five hundred della,,(5500), EMIiNT
I.. hot
as owner of the property,or my employees with wages as their sole compensation. SWIMM NO Pool.ELECTRIC
_WF2 will dothe work,and Restructure isnot intended orolTered forale(Su.7ULL Business THE
L3 ce and PmIc%siuns Code:The Commerce's License Law does not apply to an owner of OUTLETS-SWTTCIBS-VD<TURHS
property who builds or improves theme,anti who does such work himself or through
his awn employees,provided that such improvements am not intended or offered for NEW RESIDENTIAI,ELECfR SQ FT.
ale.IL hansen the buildiager improvement is sold within one year o(completinnJM1e "� SQ.FT FLOORA USQ.ET.
owner-builder will have,the burden of proving that he did not build.,impnwe for par- '�
p.wxvfsale.). A� Q
❑L owner of the propy characters am exclusively contracting with licensed mracters to ",OTA L
us : ( 9
emseme,diep jest(Seco 7144.Business and Profession,Cale:,The Corm s.,s Li- \ O
verse Low do,,muapplyInunowe,,ofmoNce,who builds.,improvesmerlon,ane QTY. PLUMBING PERMIT F
who contracts for such projects with a cnimcmr(e)licensed paneam to the Contnch,s V a
License Law. PERMIT ISSUANCE
1 son exempt under Sec. ,B 5 P C for this reason
ALTER-DRAIN sae VENT'-WA'Tl?
Owner Dam It(BA) VALUATION
WORKERS
mtendrPCaltyof Nrjury on DECLARATION BACK IO,UW 1'It(TILC'I'.UI?VICIi
I hereby affirm under penally el perjury one of the intim mg Wmkv,declarations:
❑ I have end providll o,Ift,S11 ee ifamcof ComedoCoal,f.. for W.rmancrof er.do, DRAINS-PLOUR,ROOKAIt?A,COND' S'fOklliS 'I'VI'ECONS'I'RUCfION
,ate,uv provided for u Bs s% 3]011 of Lha Luhnr Cala for he performanw of rho
sen
for which this pcnnil in s% 1. PIX'rllRiiS-Plill'I'ItAP
have and will ntnintnin Wm Ark Congwnsfe w Irk I whi ax his per by Section
9]17)of tire Lnbnr CnJc,for the perfnnnnncenl Lha work(Cir which this permit is lxaued. GAS-EA.SYS'I'IiMa INC4Ul1'I'LISIIS OCG GROUP AI'N
My Wnrkcl I Cyy pyytt�ass nnNA1 sosmm/car rtnll$',,he ymgersKl���3/
Cmrice�4YrYVa Y� !ff rte Policy No.Z! / f/ f0 GAS-PA.SYSIPiz! VI?Il4 BiA1
CHWOVICA'I'1i OF l?X1?MPI'[ON(BOM WORKERSGR EASHII NDUS'I'RL WASTE:IN I'ERCEPTOR
GDM PHNSA'I'ION INSURANCE. BUILDING DIVISION WETS
fl'hisseeihmed not becumplered iftne permitisfornnehundoxidollars(SLOB) GHF.ASI?TRAP
or less) PLANCHECK 107E
I sentry that in the perfornanceof the work howhich dropermit ia...nor ishall SEWER-SANITARY-STORM ITA.2001T.
.at employ any persan
on in any mner sn us or become subjectto me Workers'Compen- ENERGY PER.
z2 serine Laws.rciribuld,Dam WATER I HAI ER WNENDELECR
� Applicant GRADING TLE
.N.a NOl'ICE TO APPLICANT:If,after making this Cmihcme of Exemption,you should WATER SYS'IEMaREATINC, SOILS FEF:
beroe su
nbject m the Workds Compensation provisions of the Leon,Code,you must
{fa forthwith comply with such provisions or this pemmitxhall be deemed revoked. WATER SIFRVICE
aQ
CONSTRUCTION LENDING AGENCY NEN'RF_SIDEMTAt'PLMB. SQ.ter. PAID
L) O l hereby affirm than there isucmnsaumion lendiegagene,mathepm
erforanceof Da ReceiptN
L➢ F' the work for which this permit is issued(See31197,Co.CJ
Lenders Name TOTAL:
W Lembue,Address IDEAL
G p cri ify thin I have mad this appliemion and state that the above information is BUILDING .13
0 correct.hares to comply with all city and county oninances and some laws relodng to QTY. M13CIIANICALPF:RMIT EFF.
U 'Z builJin6cnnnmcinn,and hereby anthnrin reprcscntmives of thixitymenmr upon the SEISMICFEI3
'--I aMrve-Mentioned property for in,pcaleo purpnses. �//--��
(We)n bra say 1 It. Ike, hairless the Cit fCu ninny airst PERMIT ISSUANCE L/ ELECI'RICF '
gree a y era p y. pe g
i,,bile,ex.
jWAIT
eg h , xpmmsavwhicM1 may in anyway accuse against said CITY gLTlilt OR ADD 11)MI?CIL
c6ran flhixpermit. PIAMBINC il?
HRS' )S AND WILT.COMPLY WITH ALL NON-POINT ADR HANDLING UNI'f(To .,,,CFM)fI - MFCIIANICAI. 'lilt
AlIt I1ANUhLNG 11Nl'I'(OVEIt I(I,IIB(I CPM) CONS'I'RUCHON'p'AX
SignaterealApplicnnl/Cnarrelor `r/ EXHAUSTHOODIWIDUCT)
HAZARDOUS MAI'FRIALS DISCLOSURE HOUSING MI'T'IGATION Plili
Will the applicant or fmnre huildingucupunl store or handle hazardous mmerird I[?ATING UNI P('I'0100.0N)[ITU) _'L0
as defined by the Cupertino Municip:d Calc,Chvper 9.12,and the Health and Safety
Cale,Section 25532ryr, IIHA'I'ING I]NI'f(OVER EIt IINI,INIII❑'I'U)
❑Yes QFm VENTI LATION FAN ISL NG LH R17S IDI PAID Date HecciptM
Will the applicant or fmurc building hetalar use equipmeril of devices which
emit hazardous air commitments as defined by the Bay Area Air Quality Management BOILER-COM('(3HPOR IINI,f(N)BTU) T'OIAL:
Domicty BOILER-COMP(OVER 1001X10 BTU)
Dyes pd
AIR CONDITIONER
I have nM by ma nap us thnox"airtmenrs unser Chapter 6.95 of the Cali ISSUANCIi IJA li
f a &'Mord nQdeS imin dere.8533;rod SS34.1 understand drat if Ne, NEW RESIDENI'1ALMIiCH. SQ.IT.
b dm , t1Y cnan6thatili.steryrt.pmsibilirymedify the«c I
men m u.aana nraeertifcme Cir n�a y
y
outhorizcJ egcm Da TOT - ISSUED BY:
OFFICE