S 0335 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDINGELECTRICAL PERMU Ili
BUILDING DIVISION APPLICNHONIPERMIT PING PROJECT
IDENNIFIC S 0335
ItUII,DINf.1'ROJ I:C'T IDENTIFICATION
SANITARY NO, APPLICATION SUUMII Al.PATI
BUILDING ADDRESS:
'ZoC=ol •a
OWNERS NAME: PHONI!: CON TRACT OR'S NAME: LIC NO..
NIC CON'IA(11.M
Imo. L
RCIIITECT/I!NGIN[ER: LIC NO'. ADDRESS: ❑
vt 2
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLOC I'L� PLUMB MECH
LLCENMiU CONT OR'S DECLARATI N QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby uffirm Thal 1 am license under provisions of Chapter 9(commencing
OQZ with Sccunn]INXq nfDiviaionJafice Business snit l'mfssinnx Cole.snit my tleensc is RESIDENTIAL
Won in full force snit effect. PI!RMI'I'ISSUANCIi 111uuu❑nnn'SFDWI, ❑KHCHENREMODEL
QUU License Class Lie.# APPLIANCES-RESIDENTIAL pasUUITION ❑PLUMIING Rh1'll'E
in4W Daly Conlracmr ❑MUI.T1-UNIT El STRUCTURAL
ARCHITECT'S DECLARATION PANELS MODIFICATION
Z FO a`Z I understand my plans shall he used as puhllc records
Oil 10 200 AMPS ❑IN'1'PRIOR ❑CHIMNIiY REPAIR
{=.r/_+1!'u) Licensed Prffeaimal 201-1000AMRS IMI'ROVEmEls it 0SWISEMINGPOOIS
Qw�-) OWNER-BUILDER DECLARATION OVER IIXIO AMPS
E]BATH RF.MODEUREPAIR ❑DI:AIOLITION
C C� I hereby affirm that I;all.,snoop(front lL,Contractor's 1-I11nse Law tDr the
XO W U following remote.(Section 7131.5.Business and Profession.,Code:Any city or county SIGNS ELECTRICAL. ❑Ol'HER
lul 31,H which mquims a Pemba m c m anect,duet,improve.dery ish,or repair any.uncture
F�O.Q.I print to its issuance,also requires the applicant for such pcmoino file a signed.,mmmem SPECIAL CIRCUITYMISC.
} (hotheislicenaedpursuannrmhpnwisions oflhe Contractor's License Low(Chapmf9 R I I,
1WY 9 (cnmmeneingwilh SCNian]IlOgot DivieinnJ ol'Ihc❑usine,"and Prnlrssin 1,Code)" TEM IIMETERORPOLE INS'P.
a a c C that he is exempt therefrom..it the basis far the alleged hxemptirn.Any violdia.of NIiW BhDGIADDI'1'ION ❑DIiM01,1'I'ION
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES ❑T17NAW FOOD SERVICE
n more Ihun five hundred dollars(851X)).E2� SWIMMING LMMING I'001.ELECTRIC IMPROVEMENT h us owner of the prapcny,or my employees with wages m their,ade contlenxatton' ❑OTHER
p- will do the work,and the structure i.,not intended or offered for sale(Sec.]04i,Business
Wm and Profession.Code:The Contractors License Ivw does not apply to an nwner of ON'LE:TS-SWITCHES-FIXTURES
It. prnpeny win build.,ar improves thereon,and who docs such work himself or through
his wt empinyeas,provided that such Impmm
vecias am not intended or uffemd for NEW RESIDENTIAL ELECT R SQ
o
hale If.however.mhebuilding.r imprnventcm is sold wilhi ors,yeum
rnfcnple.lnn.the gQ.FI'.FLOOR AREA $/$Q.FT
el belittler will have the burden of proving that he did IN build or improv,for Pur-
:I`of sale.). O L:
r of the property.am exclusively contracting with licensed contractors to
tnsttuct the project(See 7044.Bitau e,and 11 fe,sionn Cate'.)The Cnmbn a'x Li- /s �T
w Law does not apply to an owner offauti who builds or improvesre
theon.and QTY. PLUMBING PERMIT li b V
who contmns for such projects with a conuacmrtO licensed pursuant o the CNnrzemA
License Law. PERMIT ISSUANCE
(] Lam even Iunder S ,B&P C iia thisrcasan
ALTER-GRAIN&VENT'-WATER(EA VALUATION
Owvn Date
WORKER'SCOMI'I!NSATION DECLARATION BACK FLOW PROTECT,DEVICE
Ih by affirm under penalty of p,rjnO one of liefollomingdeclamtlnnr.
I hamcmd will mainwlnn Cerid,am,(Cor,ara mlf-in...v for W.rker'x Content- DRAINS-FLOOR,ROOI(ARI!A,COND. pp STf1RIES 'TYPLi CONS]ROM 10f
smion,as provided for by Section 37(X1 of the Labor Code,lint the Perfunhance of the P /�1 ,
work for which this permit is issued. LIXIURES-PER TRAP A
ID
] I have and will maounin Worker'%Compensation Insurance,as required by Section GAS-EA.SYSTEM- INC. OUI'LITS
37X)oflhc Labor Code,for the perfiniance of the work for which this permit is i., cd. OCC./G�sR.OUP APN
My WorkersCompensation loommeecartierand Policy norma re: GAS-EA.SYSTEM-OVER 4(EA)
ice
Cis Policy NiNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS' OR GRI!ASPIINOUSTRL WAS'T'E IMLRCI!Yf
COMPENSATION INSURANCE ,'I BUILDING DOT ON FEES
(Thi.,scmion nueJ nor wc�mpleted if the lermit islN nnc bundmW.11urx(311X11 GRI:ASE'TRAP PLANCHEC
or less.)
Fcertify Mainthe pdamomtanc,oO unwoketeod,Imhall SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
�1
not employ zny person in ry mnerso too,fecnnm wM1jcd,,the Workers Comen.
QZ. Italian Lawsof California.Date WAIT TRI pAl Fit W/VFN'I'/ELEC'IR GRADING ITB
O Applicant
z NOTICE TO APPLICANT:1f,after making this Car ificam of Eaempti.n,you should WATER SYSTEM,TREATING SOILS FEF!
1"f become subject to the Worker s Compensation provi.,ions of the Labor Code.you must
�o > kathwlth comply win such Prosdsinn,or mil Pcnnil shall be Jccbed mvnked. WA117RSEIRyIGII
a �
CONSTRUCTION LENDING AGENCY NEW RESNENI'IAI.PLMB. SQ.19'. PAID
D z ate Receipt x
U O I herebyIn,
afh,gtwui,m isacrd(See 30 IenSmg agency for the perinrtmnce of
the work for which mit permit is issued(Sea 11149.Cv.CJ T(YfAI:
O L ndes Nanta TOTAL:} Isndch AJJrtss BUI 10:P li
1 certify that I have mad bis application and state that the drove infomtmi.n is
iF.l0.p rrecL ldgrec¢t,omny with all city and entry ordinances and nam lows mining in QTY. MECHANICAL PERMIT FEE SEP I !-
C) ,Z building construction,and hereby uwhmi,erepru"ohn"r,nl this citytu enter upnnihu
above-mentioned pmpcny for inspection pa,"Iles. PERMIT ISSUANCE 1!LL'TRIC 1!li
(We)agree m save,indemnify and keep handless the City of Cupertino against
liabilities.judgments.costs and expenses which may in my way accrue agoiml,aid City At ERORADITO MECH. PLUMB G Fin mequcnco of the gunfir,ol'this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('IU IONXICIM) MECHANICAL
UNIT
SOUR :RF.GULS.
AIR HANDLING (OVER 10.(Xp CPMI CGNS'1'RUCL'ION - X
n' reef ApplicanU .ntmemr Dm EXHAUST 1100 /DUCT) HOUSING MI'I'IGAT I NIl?E
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future wilding occupant store or handle hazardous material HEATING UNIT(TO I011.IXp BTU)
us dhkn,J by m,Catarina.Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10,0X1 BTIU
Code.Section 25532(a)?
I'AIU
❑Yea E]No VENTILATION FAN(SINGLE RESID) Dam Beer,4
Will the applicant oto future building occupant use equipment or devices which BOILER-COMP(3HP OR 1(G,OX)BTU)
IIIIIIIIIIIIIIIItit ha'ranlous air contaminates as defined by te hBay Area Air Quality Management II)L'A.:
;mnin'I
BOILER-COMP(OVER Ioo,(XX)BTU)
E]Y,, 0N
have mmtl Safety
h adv oSc funs 2 5 re.25533 an trader Chapter and 695 of tau it the
AI R CONDI'1'IONER ISSUANCE DATE
Inertia Health&Sofety Qde,�Scclinm 255(15,25533 mJ 25541.1 understand that it the NEW RISIUIJJI'IAL MliCll. SQ.Fir '
wilding arcs nor cumenBY have a tenant.that it iuny rezrytroibility m notify the oxeuryb
- of the rcyuiretmnts which music be tun pnnr et iaruance ofd Cmificnm of<kcupancy. ���
Owner nr amM1oriz<J ugem
])at, TOTAL: ISSUED BY:
OFFICE