S 1897 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUR DINr.-ELECTRICAL Pat]LNO
BUILDING DIVISION APPIACATION/PF,RA11T PI.U)IRIN; MECHANICAL 1897
BUILDING PRGLIC(:1IDEM Flh'ICATION
BUILDING ADDRESS: SANR ARYNO. APPLICAI'IONSUBMIFI'ALDAIF
a� 3 G/ Q�
OWNGR'S NAME: PHONE: CO "HAGf 'SN LIC N(1: NIC CONTROL#
ARCHITEC117ENGINFER: LIC NO: AD ❑
CONI'A( PHONE: BUILDING PERMIT INFO
❑ Conlin anl Fees Paid by Applicant(Initial) RL❑UC ELECC'I' I'1,11❑M1iB MECCH
,ICENSED CONTRACI ORIS DI:CLARAl ION QTY ELECTRIC PERMIT FEE
I wrathy affirm that 1 am licensed under provi%inn%of Chapter 9 ran...nencing JOB DESCRIPTION
O52 win Smion]a )nf Di%i,ionJnf me Business Pn%fessions
CA it % license is RESIDENTIAL:
,C,C) to PERMIT ISSUANCE
mad ul- full race. e �9 ❑SFDN'L C3 KITCHEN REMODEL
QUV I.jccnse Clas Lic.p APPLANCES-RIESIDEN'UAL ❑ADDITION ❑PLUMBINGRE-1111117.
yQC U..ic Cunhactor
RC TECrS 1317 YJ ❑h1UhTl-UNIT ❑STRUCTURAL.
FmL n nibl'v� PANELS h UIIICA'I'ION
OZ— a ��JJJ UP 10200 AMPS ❑IN'I PRIOR CHIMNHY REPAIR
F.�.�1+1 Liee dPmfe st �// 201-10N)AMPS IMPROVEMENT E]SWIMMING POOLS
(
NER-BUII.DIiRDiiChARAI'10 7 OVER I1N1I1nhiPS ❑HAIL REMODEURBPAIR El DEMOLITION
C56 1 herehy alfinu mal I ton exempt from the Contractors License Law for the
�a O6U fallowing reason.IS«tion]0315.Business and Pmfecrions Cale:Any city or county SIGNS ELECFRICAL ❑O'I'HLR
1+13"h which re9uhn a pvnuir.o vemarre.cher,imps se,dermolid,or repair arty nmchmv
F40a pr on t :. I' 1 :thapplicantt suchpermit' fl signedstatement SPECIAL CIRCUI'List ISC.
y doth I Ip tt h p " n 1t1 C I 1 .L I (Chapter 9
xa�OIn au,umbwlhSwln]l)kb dD.....13o la,lit%i Ess and In G.,.v%t:Cde)m Fmli ME'1ER OR POLE INS, COMMFRCIAL'
that he is exempt decal ru I and the favi,for the a lard exemption Any viola.....o! ❑NEW NhUCIADDI'IION ❑DCNOLI'f10N
xm Section 7031S by any applicant for a permit subject%the applicant to a civil penally of POWER DEVICES ❑'I ENANT ❑1%OOD SERVICE
nm marc man f vc hundred dollars(8500). IMPROVEMENT
ESD ❑Lar ownerof the pmpcny.nr myempinyees with wagc%avheirsnlc nompcnmiom, SWIMMING POO 'CIRIC
H will do the work,and thestmnure is not intended orortcred for sale(Sec.](HJ,Business []OTHER
L 3 m and Professions Cede:The Contractor's License law does not apply u)an owner of OI/ThETS-SWT oS-II%'TURFS
propcny who bolds or inpmnves thereon,and win does such work hi ri nr tinmgh
hi,own employecx,provided that such improvement%sere nm Intended m ndece far NIC#RI?SIDENTIAt.P "k $Q FF.
,ale,11,hu r,.hu hujbling nr imprn cot —old within enc yasi-0cvmplau ithe SQ.IT.FLOOR ARBA S/SQ.hF.
crhaildcr,will have.tic barmen of"o Ing shat he did not build or improve lar pur-
pow ,I vld v TOTAL:
❑L as owner of the property,am exdmlvdy contracting with licensed contractors m
rmwn the project(Sec.](Ry Hmmr,,and I'mfessions CW.:)The Cron.vt n's Li-
cent,Law does not apply to an owner mpropeny who build%or improver thereon.and QTY PLUMBING PERMIT FEE
whn mntmas for such projects with a commatons)licensed pursuant to the Cmumcme,
I.hemc Law. 1117RMI'F ISSUANCE
❑ I ton exempt under Sce, ,B&1'C tonbi,reason
AGI IBt-DRAIN&V IiN'1'-WAI LR(EA) VALIIAI'ION
Owner Date /D
WORKER COh9PfpajorION DfThe following
IMCK FLOW PR(YIIiC'I'.DIiVICIi 11
1 hereby illfmai under penalty to perjury enc ro elf following dcdkiar`o Compact
�Ihvvc and will.for lav eCion 37 re ofComent Lame sdf-ifor for#comm ve of the
DRAINS-FLOOR.N(RIIa.ARLA.COND. S,O IES I'YI'E CONSIRUCI'ION
sntinn,as provided for by Section J]W of me IaMm Calc,for the pcdnrmuncc of the
t for which this permit is issued, FIXTURES-PER TRAP
I will maintain Worker',Compumation la,maree,as re,ir l by Section. IIhnl the labor Calej thcpurlirt. jtnc free wnrkkal thj seed/ J GAS-IiA.gVSTEM-I INC 40VI'LETS (ICC GROUT' APN
My Work yi r cel'��JnRurul , �o1ic ✓� J
C'arricr. No.. sec- MS-PA.,1'YSTEM.OVIik4(P.A)
CERTI1ICAl"E OF F,%EMI%1'ION FROM WORKERS' GREASIVINDUSTRL WAS 117 1N'I'ERCEPIOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Tbi.v uxtion naAnot becompleuJ ifthe lermir is foronc hundrcddollars(51 WI GREASETRAP
less) 'I. CHECKFEE
I cenify that in the performance oftbe work for which this permit is issued l shall S17WITR-SANITARY-NIO .2W
out employ any person in any mane,so ri in hectare oditat m the WurMrs'Contpen- IM,
Y PEE
OZ %ardor Laws of California.Out, WXJ ER HEATER WNFN'17FI \ G 1 'G 191E
Z Q Applicant
y NUI]CHTOAPPI..CANIF ILafterinakingthin Certificate of Excn%pdon.you should WA'FI?R AYSTEM/II3EA'I'INC Sofi%17 a
F Iwwmesuhiceunthe Workers Qrmpemation pmvieion%of the labor Code,you nest
a hmltwith comply with meM1 provisinm unhis pinto shall hdeemnl revoked N'ATI3R SERVICE
V] p
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.IT. i'AIU
U Z 1 local affirm that is.a micastionlending agency lin the performance of Uum Humipt#
W - .he work for which this Per mtit is issued(Sec.JIFF,Co.CJ '10'IAL
� LcndcrNi
s at
U 'll)TA L:
rW lendcr'%Addreu
d I cenily tbo.I base rcud this applica.ino and.tate mat the uhave inlimnauan is BUILDING PEE
F. N
correct..agree in"imply with all city and county ordinances and ,are law.%relining to QTY, MECHANICAL PERMIT FEE SEISMIC FEE 5_0
U Z buildingn%mtmctlon.und hereby uuthome npreacmatives of this city loenarrurym the
adne-mcmionW pmpenY for inspection puBxnu. PERMIT ISSUANCE IE,ECl RIC FEE
(Wo agree a)save,indemnify and Map hamdcv%are City of Cupertino against
Iiahilities,judgmenu.costs and expcmes which may in any way aecmc against said City AITER OR ADD TO MECH. PLUMBING FEE
mon
mec t ence of de grarlir,of this permit.
APPLICANT EUN OIiTONS' NDS AND WILL COMPLY WI'Cfl AEI.NON-POINTG B
AIR HANDLINUNIT II It11MH1 CFM) MECIIANICN,FE13
SOURCE REO111.A I'I(1NS.
AIR HANDLING UNI'i'OVER 10.00()CFM) CONS'i'NUCf10N LAX
Signature of A,,b1rm1Conmcur Done EXHAUST HOOD(WMUCD HOUSING MITIGATION ITE
I IALARDOUS MATERIALS DISCLOSURE
Will the applicant or future building exanpant store or handle homnim,mains. HEAIINC UNFr(To 100.000 It FU)
ars defined by the Cupertino Municipal Ctxle,Chapter 9.12,and the Health and Safety
Code.Scctinn 25512(a)1 11HA'I'ING UNIT(OVER 100.000 BTU)
i]Yv, VI7.N'IILATIONFAN{SING1,17RESID) PAID
Date Iteccip.#
Will mcapplicant or future budding necupam use equipment or devices which BOILER-COMP(JHPORIIXhIXXOUG)
mit firmolous an corontinan m defined by the day Area Air Grainy Management 'B 'AL
srict? IIOIhIiR-COMP OVER IfX1.W11 H'Nl
Yes
I cast the hair maurials tv under Cha ter 6.95 of the Cali- AIR CONDITIONER ISSIIANCF J)ATE 5
req iiremcn p O ^
�)i,,
babbrSafety le,'nuti 25581 and 25534.1un% ruandib Irthe NEW RESIDFN'I'IAl,MliCH, SQ IT. ( 5
In Jing&- n uncia filth . tryre"maei ' t ratify.
I c 'Ihm ton prior m l%oancc of r
[)am)won or sum vg t me
TOTAL: ISSUED BY:
OFFICE