S 1945 (2) —APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECIRICAL rnRpllT No
Bu11.U1NG DIVISRkN APPLICATION/PF, rLurvinwc-Mr:cnnrvu:nl, l' Q ^ C
14UILUING I'HfIJEL"I IDI 4 5 NTIFICATION V V
HUILDINGADURESS: SAN]1ARY NO. APPLICATIONSUIMITIALDATE
0o r Pr Cu E� itie �10�
-7 --3 9'$
I
IWNER'SNAME: I�� C'ONTROI,p PHONE CONNRAG FOR'SNAME: LIC NO:
N/C
ARCHITECUFN HNEER: LIC NO I ADDRESS:
CONTACT: PHONC: BUILDING PERMIT INFO
c6fit-/fit ���0`. /J�/ 7/' ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
11 O SD ` 7T ❑ �� ❑ ❑
LICEM1MDCONIRACTORS DECLARATION QPY EI.ECPR[C PERMIT FLIT,"
II nynrmmtl r a 1 p Ictrll �( .e ens ' JOB DNSCRIPTION
Wap n'fullfl 7eMl�r'D n3orthv Eus andl mlLas on.-Cde linylSensus RESIDENTIAL
PERMI'1 ISSUANCE.
W,V I,cense C s Lie,p ❑SFDWL ❑KUCIIEN REMODEL
vZWet, hale Contmcicr APPLIANCES-RESIDI?N'I'IAL ❑AD1dflON ❑PLUMIIING RF.P[PE
I,,,O1 ARCH1'1'I7L 'S DI?C1.ARA1'ION PANIeIS .-� q ❑A1ULT1-UNIT ❑STRUC'IURAI.
ZO Z^Z I understand my plans shall be used as public records / L.� STRUM
MOD1CA AL
UP IO 200 AMVS
G X Loaned Pmlcssumvl 201-❑XXIAMRN ❑INTERIOR ❑CUPONHYREPAIR
Y� OWNER-BUILDER DECLARATION Ih1PROVEMIiNT
$W IMA1ING POLLS
Cd I herehy vBrm that 1 vm axanpl faun the CO r.,r is License L:w ba tho OVER I(XX)AMPS ❑NATII RCMOI rL/REPAIR 9 DIiM01.IT10N
O a U Tollowing mason.Section 7031s,lumina"and Plates....... Anyon,or cot Iy ❑0111HR
wCode:A '
y131y,F SIGNS ELEM RICAL --
F+LL Orn which mgrcz.permit ur cnnswcl,almq impnrv'e.Aemolish,or repair unY swaurc
Pon'an Is'Wool,also rits,im,Il, appilcam for,achl I 11 -g d Inincomen SPECIAL CIRCUIT/MISC.
>. mall he II :m II 0 1 III C t s : L ((I p4r1) - �� r
SSS"' d (ern t g Wi Stclion 7000)ofllSsmt]oltne Husimssend Pt fessuns Coda or
kw3 q�O O TEMH MITER OR POl.li(NST. COMMFRCIAI'
X m LL that M is exempt Iherefnnn and Inc M1nxis for the alleged eeemptinn.Any vinlaion of
section 90315 by any upplicmn for u t h cc the upplicunl lo.civil ❑NEW BLDG/AUUITIGN ❑DEMOLITION
ly..rn permi su j"Is penalty of PO\VI?It DEVICES [I TODD SIiRVICI?
^y y nm more(nun five hundred Jollvrs($SIMI) ❑TENANT
=01]Las nwnendthe propene,or my employees wilM1 wages as thcirsole m'" minion. SWIMMING POOL ELECTRIC INIPROVEMEN'f
WH will do he work:nal the unmmm Nant intend,,]or offered nrrnale(Se,7(94,Hminess ❑DTI IHR
and Pml'e"iana Calle'The Cnnvador'x License Law does en apply In an owner oI OU'I'ILE PS-SWTfC{{IiS-PIX'I'llltl?$
.- property who builds or improves thereon,and who Joel such work himself or Ihmugh
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELEC]R SQ FT
sale It,howeve,the huiddingurinlpl-anent is sold within nncyean ofwmpletlon.lnc SQ.FI'.I1.00R ARE A• $/SQ. -T
erhuilder will have the buNen of prwing Into he did all build ur imp....c for,).r-
,a aofsNc,).
❑ I,as owner'd tire property,nm exclusively evnmvming ,in Iiccmed lontmaoq to OTAU
Bram the pmjcat(Sea 9011,Business and Prnfe,in is Cori the Corim,lor's Li-
naUse,does nolally"Ianawncr'if Post who build,or unrmves lherevn,and QTY, "PLUMBING PERMIT.. FEF.
who convects for such projects witbn contractor(s)licensed pursuant to the Contra s _
bice m Law.
❑Ivmcs,thim ndar Sec. ,I&PChn Nisremon PHRMI'I'ISSI]ANCE
OwnerALTER-DRAIN&VENT'-WA'I'Elt(EA) VALUATION
-
W'ORKER'S COMPENSATION O[CLARDeloAI'ION BACK FLOW PROSECT DEVICE
I herehy alRrm under penalty of perjury one of the following dedurmions.
❑ IhuvounawillnminlainnCetliEuatcol ConscnuoelFintutu fry Wurkcl's Cninpeu- DRAINS-FLOOR,Rf1DF,AREA,GOND.
,dool.w provided for by Scolio 37(X)of the labor Cub.for dic nab rniume of the STORIES 'I'VPF.C(1NSTRIIGI'ION
x-okwhich this permit isiswcd _ FIXTURES-PER TRAP
hove and will inaiolno Werkcr's Compeasa ion Imurance,as regmrel by Section
3700 of the lalso Code,for performanceof the work lie whirl,this arrant is ismed. GAS-IiA.SYS'I'I?M-I INC.4OU'ITIiTS UCC GRGIP APN
Aty Workers 6p�p 4117 line envier and Policyzi�f ?��Q��
Carrier:_ ✓ J` r (L Policy No.:7(p GAS-IiA.SYST1iMAVIiR1(.AI
CIFICIFICATH OP EM7 MON FROM WORKIiRS'
COMPENSATION INSURANCE GREASIVINDUS'I'RL WASTE INIli ItCEPT OR
Clhis lecrian lead no be eampleed if the permit is notice handled dollars p$11Xh BUILDING DIVISION MFS
ur 1ps] GREASE TRAP
I certifythat in the PLANCIII!C -
> any runner sit Nc work for whichtto the Wisie.s'Crimpr- SEWER-SANITARY-SfURM EA.2WIT.
nm employ any person in any manner so as m become subject m the WnrAcrs'Comlrcn- F.NG PEE
zZration Laws of Cul 1Grmia.D:uc WATERIJEATIiRW/VEN'IMELEC'I'R
0 APPlirant t GRADINGF�Ej,
h NCTICIi'10 APPLICAW IC after making this Cevificme of Exemption,you should WATER SYSTE daR:ATI NG '
F toccomr,subject ur the Workers Compensation provisions of the Latour Coale,you must
- SOfLS ITIi
w I'onhw'un comply wllh such pl'nvlsfonsnthis Imrmit el,:Jl bo deemed revolved. WATER SERVICE
4 Q
z CONSTRUCTION LENDING AGENCY NEN'RESIDENTIpI.PLMH. SQ.FT. ('AID
V Q for
orcbyuBrm l per
e thurc:.sued( et,30 laming u6cnylirr the perlinmmnce nr Dnlc Receipt
e4 F
he wtrrkr rwla.dt this permit i,lssaal(Set,3097,Ch.c.)
Lenders Name
TOTAL:
Lcndu2Address 'TOTAL:
E'l'y y I c gree (nut 1 have road thirty and coup and diva ces Ilio vnove i,,,reatinn to _ BUIIAING FEE
Uti correct,l agree rium, ad with Lurch, dry and county ordinances d dad state rows rclmins m QTY MECHANICAL PERMIT I FEE
huilc nerns..ell ,and Inin tai 0zereprc.entutivesuf rhiscity toe air, nothe SHISMIC Fit?
ubnvemve)agrepropane foremnify an keeph.. . ..
(We)agree In save,indemnify and keep harmless the City of judgments, Cu Winn a t PI?RMI'('ISSUANCE
inhiliries, mans,costs and ex a Gains ELELTI2IC FEE
6 pens,.which may in any way aeons,against said City 3 1;Z 7
into-r,enc of the grtmtln of thinterm;'. ALTER OR ADI(TO MECII.
h PLUMBING PoiIi
APPLICAN' 'NDERSTANDS AND WILT,COMPLV WITH AL1.NON-POINT AIR HANDLING UNIT('ID I0.0M1 CFM)
SOURCE RI.3 .ATIONS. MECHANICAL ITE
es � 7-1 -.�� AIR HANDLINGUNI'I'(f1VER 111,11(X(CI'M) CONS'I'RUCTION'I'AX
Sigvamre n(A ,tor Dale .(((/// EXHAUST HOOD(W/DUCr)
IIALARDOU. ATERIALS DISCLOSURE HOUSING MITIGATION ITC
Will Inc vppliaant or t'omic bu'JJing cccnpam srorc orhmally hazardaLL'nal II?A'I'ING UNI'('('TO HX),0k)BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Salify
Code,Section 25532(.)? HEATING ON[[(OVER 1!10,000 It'ITD
❑Yes 0 N
VEN'IE,ATION FAN SINGLE RESID) PAID
Will the applicant m Insure building occupant use equipment or devices which Date Receipt If
omit huachats air eemanintal,1 ledned by the Bay Arco Air Quality Mmw6cmem HOILF.R-COMP OR Uh,thO B'IU)
i. District? DI
❑Yes [3 No BOILER-COMP(OVER lWTxx)BTLU
Leve real the haznnlnus mvvriuls requirmnentx under Chupwr fi.95 nl dna Cali- AIR CONDITIONER
lomin Hemdt&Salcty Cede,Scams 25505,25533 and M5341 a idenrand ma If tnc ISSUANCE DATE
hmldingdtks vo[nunenlly have al nord,]hal it is my reerymsihidily mmnfly the tecuplt NEW RES[[)I"IN M ECH. SQ.IT.
of the mtlairemen.which must he rao,rior to iannamaol a Cenlfemenf Occnpuncy.
Owner crate novzed ahem Uam TOTAL: ISSUED HV:
OFFICE