B 0622 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATIONfPFRMIT PLUMBING-MECHAN1CAI.
RUB,DING DIVISIOn BUILDING PROJECT'IDENT F'ICATION 50001
BUILDINGADDRESS: ,� I .��`/ qOo/4 SANITARY N(1. AI'I'LICAI'ION SUIIMI'1'I)\I,DAIIi
OWNER'SAMI!: I'fIONE: C C(1NTRAC'IORS NAME LIC NU:
^` _ O�C / WC CONTROL#
A RCI 111 ECT/ENGINEER: LIC O�NO: ADDRES T (KBO ❑
A1011-
CONTACT' PHONE BUILDING PERMIT'INFO
S, «• V�tcscv� a 8 - a3yr
S�� SQ' � ❑ Consultant Fees Paid by Appli7AE3
BLDG ELECT PLUMP A1ECH
��-SGO w S � ❑ ❑ ❑
LICENSED CONI RAC OR S UECLARA'I'ION QTY. ELECTRIC PERMI
I hereby a1Erm that 1 tan licensed under basmors of Chapter 9(mmmencing JOB DESCRIPTION
won vimseclion]nll»nfDividon 3onbc Buxlnexxand PmfmsioviCodeaudmyheerea i. SIDENTIAL:
WOO PIiRMIT ISSUANCIi
W in full tomeand cllkcr (aC YDl41. ❑KI'fC11EN ItBMOUI?I.
QVU Lirema Clan.W-Y-u- —Lic,M API'LIANCGS-REti1DEYf1A1. []ADDITION [I PLUMBING RIi-I'll'F
11 hZw Dale Conmerm
iziARCH[IIiCI'S DECLARATION ULThUNII' ❑5'1'RUCI'ORAL
Z~O y Z L undersized my plans shall he used as public record, PANELS MODIFICATION
pZn?Q UP'1'02WAMP5 NTERIOR r�C'IiIMNEY REPAIR
1 F4,f.W Liesmed lauhrsonal 201-INX)AMPS IMPROVEMENT' 0SWIMMINGPOOLS
�s1E" OWNER-BUH.DERDECLARATION OVI!RIIXMIAMPS ❑HATHkFlfOUEI/REPAIR DEN UNION
ti Q I hereby alarm#hat 1 am cscmpt from the Cnmramar's Liccntt Law for rhe C3 OTHER IQ li". w-AA,O%
'a(36 fallowing rtamn.(Section]031..5,Business and Professions Code:Any city or county SIGNS ELECTRICAI, -hit
W W
y¢ which relit.,u Mori t to consvtmt,shoo,nnpoo,,dnnoli,n or repair any mobtare
prior to itsissuance,also requires the applicant for such permit to file a signed statement SPECLALCIRCULTIMISC.
EV1}„• tba M1e is licensed purauanun me provisions ofthe Camr¢e-ondi' Law(Chapmr9
1+' COMMERCIAL
Iw a C O [ns,he is exempt
therefrom rand the basis lot ofthc the exam J on.Any vii Ction of '1'IiMP.METI!R OR IYII NS'f
a W M e- that io i. 31n5 b therefrom aryl the basis los the ctsthe exemption.Any violation of ❑NfiW'HLDG/ADDITION ❑DEMOLITION
��N Seelion]OJIS M1y any aPPlicam fnrupermit subl¢ts the applicant mu Buil penahy of IYIWER DI!VICES
not more than rive hundred dollars(55(10), ❑TENANT El FOOD SERVICE
El an owner of the propcnp or m ❑OTHER
y employers with wages as their sole compensation. SWIMMING 01.ELECTRIC IMPRlVEA1EN'T
1... vidl dod,work,.cd lheswcwre is nm iaimandmlBcml for talc(Sea 7(a,Business THE
and potassium,Code:The Cnntncmr's License Law Jces nm apply m an owner of OUTLET -SWITCHES-FIXT OR
ei'3.. p,,, ,ny who builds or improves thcrtan,and who Joe,such work himacll or through
his own employees.provided that such improvemcmx am not intended or offered for NE E DENHUAL ELECTR 5
Sale.If.however,the building.,impmvemrnln,ohl wthin
enc year o(unnpininn,the SO UP.Fl.DGR AREA ESQ.PI'.
cr-bailder will has.the burden of pmving that he did iter huild.r Impmvc I'.r pur-
pmc of sale),
I,as mener of the property,am eulunively contracting with licensed connuann m TOTAL:
nenuel IM1c pnicm(Sar,7(1 ,liesro
nd Pfess ms"ore.,".a"'we,-oi s Lt-
crnsl-awd.es not apply al an owner of Property who huddor improve,themon,but Q'FY. PI,UMRING PERMIT FEE
who contracts for such projects with a contra cons)licensed puraanun the Contmcmrs
License Law. PERMIT ISSUANCE
❑ I am exempt under Sec. .If A P C lin his moron
ALTER-DRAIN h VENT-WATER(EA VALUAT10N
Owner Dam 11 g6 s- OU
pp
. WORKER'S COMI'ENSAI'ION IJI?CLAR6L'ION HACK FWWPR(ll'T:CT.DIiVICE
1 hemby ton-under penalty of perjury ane of the following decherauonx.
IM1uve and will maimuln hCcnilic:nc of Cnnsem mxll-innum for Warkcis C.olpen- DRAINS-FLOOR,ROOF,AREA COND.
-tion,as profL
provided(or by Section 3710 of Labor Code,[or the perhlrmarca of'he SIONII;S TYPE CONS'1'N{JC'IION
work for which thix permit is issued. FIXTURES-PER TRAP U/N/
����a1 have and will maintain Worker's Compcmatinn Insurance,as required by Section
.r1](M)at the Labor CWe,for the pr,onnonteol he work in,w Lich fin,sanlit is Issued GAS-FA,SYSTEM-I INC.4O(] ,IS'LS OCC.GROUP A�oAIPNN
My Worke Q �e do'll1�mmwr�aria and Polity nu are N Y
Cartiee IL'1',sa t Poliry Na.; _alel IyyF GAS-EA. OVER/A) 3
CI!R'[iisicArEOIxiixEmi,ii1NizKOMWOliK1iRS'l J' tdoG GRfiASF/INDUSTRhW .TIi INTERCIiP10R
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This mation need not becomplctW if the permit is fomite hundred dollars(SHM) I!ASF,TRAP
orlces.) CRn. P NCI#iCl(rrEE
I certify that in,he performance.]the work for which this arms is issued.lshall on SEWER-SAN .RY-STORM F.A.211 t
not employ any persin any manner so as m become imbjee ,)the Work,,-Co.,.- F,NERG
zZsilion Lawsto Calif.min.Data WA'117RIII! F.RW/VIiNI'/ELEC'IR
Applicant I IN P
N NOTICE TO APPLICANT:If,after making this Cenifea¢of Exemption,you should WATE YSTEM/TRHATINO
F - hearroc,annjeena the Workers eampen.atm 0 pmvisi.lis of Labor Costa rmi niml SOILS F 1:
IaLI Rmhwim comply with such pmvisiom or lb,permit nhull be decmW ne,okcd. W 1R SERVICE
Q
1 CUNSTRUCI'ION LENDING AGENCYI!W RESIDENTIAL PLMB. '—
U C) Ibe Bionmatthem i.a rmnvwcd.n lendin6a.rn, Oniba fmma,,or .m RccciptX
L.)Q i1 y n .) Y IST
0 Lewes too is his arnh is Leaw(s«.3(9].cis.c.)
Lender's Name TOTAL
Le '
Lcndar' Address TO'1'A L
1 :
} {>a 1 certify What 1 kava rest mix appllrtian wd simc that IM1c uMac informmion is BUILDING ITtli
F ra/l const,I agree to comply with all city and county ordinances and unite laws relating to QTY MECHANICAL PERMIT FEE
C..1 z huilding construction,and hereby nation-repremm
seaiven of this city emer sendc
SI!ISMIC FEE
aso c-ou ntioned m,by lin inspection p.,,,a,. PERMIT ISSUANCE!
(We)agree m harmless
save,indemnify and keep the, p,
City of Cu .inn against
ELECTRIC PEE
Iiabilitiea.judgmenL.cost,and expenses which may inany way acrucit,imtseid City AU[17R OR ADD TU MECIL
m.cyuence Orme grunting.#'#his aarm. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 101X10 CFM)
SOURCE REGI if S. / MECHANICAL FEE
2[ Alli 11 AN)LING UNI I'(OVER 1(1.0011 OF CONSTRUC ION TAX
Signature, Applicunl/Cnmmcmr Dam EXHAUS1'HOOD(W/DUCT) HOUSING MITIGATION FI!i!
HAZARDOUS MATERIALS f4. , OSIIRI!
Will the applicant or future building occupant stere or hnnJle hazardous mmcni.l HEATING UNIT TO ROLM)Ii )
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safay
Code,S,tdoo 25532Lu)] HINTING UNIT(OVER #NM)BTU)
Yes n
VENTILATION PAN NGLI$RFSID) PAID
KiDae Receipt#
ll the upplie or future building oecupunt use equipincnt or devices which
NOII_I3R-CO3 11 Is
•emit huu.dous air on anlinams ar de inrd by the[I.,,Arca Air Quality Ntio,cmem BOILER- MP(GVERIIIgI IM 911i'rlp Ol
District!
❑Yes ,�Nn U)
AIR C UI'I'IONER
Ibavr realthrhvnrdnusmzx,2555.2553cntx 2553 .1imiChapter bJS.fthe Cali- ISSUANCE DATE iM
fnmiz Ilullh k SafetyCWe.Sminm 25505.25533 and 2553J.I undcrmnJ Lha If Ibe NIN RLSLIl1!NTIAI.MF.CH. SQ.lel'. t- 'J
huilding Acer not cunenlly have u moron.mut it is tnY ro�nnrihility t.notify 0,ocamtmt 4
.1 the require ,which nest be tact novo,,armee of a Cenilir W t11 Occupmmy.
Owner nnwmmrr, ogcm I Dale MAAL_' ISSUED BY:
OFFICE