99090074 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q
[""'LDINGADDRIlSS:-
TY OF CUPERTINO BUII,DINC-ELECTRICAL PE IT
HIJILDING DIVISION APPIACATION/PERMIT TING PROJECIADENTirI I.
IIVIhDIrvf.1'ROJIiGI'IUF.NrIhTCAT1UN
I SANITARYNO. APPLICATION SUBMITTAL DATE
'!ACT:
:SNAME; 1'IONH' CO 'I' ACI OR5 NAME LIC NO:Q /fo, 'DHGG / N/CcoN'rlxaL a
ECT/ENGINF,ER: LIC NO: OxSJ1 /r4rce� yj - n � (',_H &4.-N PHONE: dG'J- Cl C��R/rvR� a,Y17 IrVTV t BUILDING PERMIT INFO
to_(Z)- ❑ Consultant Fea Paid by Applicant(Initial) BLDG ELECT PLUM MECH
ek-is bus/an% )q o- 8 9 1:10 ❑
LICENSED CONFRACIOIt;S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provision,.of Chap...9(commencing JOB DESCRIPTION
Z im,CW,and in,licence is RESIDENTIAL
W O
F-O PERMIT ISSUANCE Lovell force and cRc 3' �y ❑SFDWL ❑KITCHCN REMODEL
Q,U V Licensee ns Lle.a APPLIANCES-RESIDENT IAF. ❑ADDH ON ❑PLUMBING RE.PIPH
F.zW Dam Contractor
N Q a ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLAR TION
I.
H Z 1 undcon�po� ypI. s II M(sed as n,vaod'// UPPA 10 S MODIFICATION
OZ-C ( '� L ` .CI i'R.K UP 10 200 AMPS ❑INTERIOR C1 CHIMNEY REPAIR
�i I.-W Lmanhat I'mellnuel 201-101DAMPS IMPROVEMENT (]SWIMMING POOLS
; OWNER-BUILDER DECLARATION AVER Ig1U AMPS LlBATH REMODFUREPAIR (]DEMOLITION
C C¢ 1 hereby affirm that 1 um exempt form the Contractor'.,License Low for the
dU following reawn.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHf;R 1 �{p�
LL13 fraye which requires' p I t c t t alter, p demolish, p' y stmcmre p ( iki !;y
/a
/
FSO.] pari t '1. 9 N aIpf a tl hptmu 11 t. J,amc nen SPECIAL CIRCIII I' FSC. YYY
5n" bar he is licensed pa,, n the p s f he Contractor,1' 1-t (Chapter9
1900 (c°mmcncmgxnh Scctmn]gMUof Drvsnn 3nf the Busnnas andN fc: sCodgm TEMP.METE RPOLF.INST. COMMERCIAL:
6 deC that he a exempt Ihcncfrom and the basis for the alleged exemption.Any violaian of ❑NEW BLDG/ADDITION ❑DEMOLITION
X m LL Section 9031,5 by tiny applicant fine o permit subjects the applicant to a civil penalty of POWER 'VICES
iLLl..y mm mon,than Ova hundred dollars($500y []TENANT ❑FOODSERVICE
FZQ La.cownernfthe n,nrm lu ices with wa cs es Neirsolecom anon, SW MINGPOOLELECTRIC ITHERVEMEN'1'
❑ the% r temp Y offered acts'
p., will do Newark.andc:ne minis pots License Lawdufarot apply to Business THBR
Lam aril property
whiol Gale:The eves Contractors License Law dims not apply m an r through of UThITS-SWITCHES-FI%TURFS
his o ny who baddh or improves h,eachn,and who macs such wad M1ed or of Norugh
his awn employecx,pmvidul Na such impmvememts ac not intended ler offered for NIiW RIiSIUFN'rIAl,ELIiC'1'R SQ FII
sale.If.however.the building or improvement in sold within one year ofcompleuon.the W1 SQ.1?FLOOR AREA USQ.FT.
er-builder will have the bonen of proving that he did not Wild or improve for put- �/
q,'a of rale.). "I OTAL:
I,ax ownaf of the Properly,i crclvsivcly contracting will,licensed eootranors to
instruct the project(See.9194,Business unit Professions Cmlo:)The Contractor's Li-
copse Law does not apply manowner ofproperty who milds or improves thereon,and QTY, PLUMBING PERMIT FEE
who emmmets for such projects with a onnuutnr(s)licensed pursuantlo the Caromnor's
Liwmc Luw. PERMIT ISSUANCE
Form�rcmpl under Sr, ,B&P Clbr Nistoasnn
c AL'I EN-DRAIN&VENT'-WATER DA) p VALUATION
net Dore Wf
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DI?VICE
I hereby al)i nn under realty of perjury one of the following declaration,:
I have and will ntainion a Certificate of Canwnno xeltlnsure lm Worker'a Compen- DRAINS-FLOUR,ROOF.AREA,COND. STORIES 'TYPE CONS'T'RUCTION
sution,as provided for by Section 37W of the labor Code,for the pentommvace of the
Zwad fn ich this permit is issued. FIXTURES-PER TRAP
ave and will maintain Wnrkcr's Compensation Inmrance,as required by Section GAS-EA.SVS'I IiM-I INCA O
p(got the Lnhur talc.I rthc Inmanc otthcwndllnvdich Nispurmitisissued. OCC.GROUP APN
Carrier:My nkc n 'an In l Poky No.�numlxt
Cl; (FICA F,OFEXEMMIONFRONW KER.' G N 'TRL S 1 )H ✓}`� Or'7
COMPENSATION INSURANCE BUILDING DIVISION FEES
fTriaseedan need nm hecnmplmedltlhclwtmil is for nuc hundred dollur,($1 GR 'IBA
or le,.) L14NCHIiCK FEE
I verily that in the performance ofthe work for which this permit is issued,l sh SF 'R N RY-ST( 2WP
not employ,any person in any manner so n w become subject m Ne Wnrloos Compo ENERGY FEE
Z ,anion laws of Culifomia.Daa 'ER H. I1R W/VENT/ELEC R
O Applicnnf G wDINQ,I(C> ,�-,� y_ '
NM ICE TO APPLICANT:IL mr,making this Cenificma of Exemption,you should WATIiR SYSTFMOKEATING
[- ? Wcume snbjcct ur the Workds Compcnsaina provisions of the Labor CWe,you..It 5 ILS EE /� 4 I .�.�
forthwith comply with such provisions or this prmin shall he deemed revoked. WATER SERVICE
f �� CONS I'RUCI'ION LENDING AGENCY NIiW RESIUIiN'l1AL I'LM 11, SQ.Pill I' I SDB }Re1' 4
U O 1 hereby affirm that Here is a construction lending agenic,for the performance of l
fA the work far which Nis permit fl,isued(Sac.J09].Civ.CJ Name TOTAL
O U Lend,/ Add T
W I,cndu4 Add T, TOTAL:
Ly,
CL.
I comity that I hove rend this application and orae that the above inNmtmion is Um TNG PL'E
L N central.l agree to comply with all city and county announces mdstae laws reining to QTY MECHANICAL PERMIT FEE SEISMI
U Z building construction,and hereby authorize representatives of this city to enter upon the
aWvc.nmmioned pmpcny for inspa9on purpow, PERMIT ISSUANCE ELECTRIC FEE
(We)on.to save,Indemn ly and keep harmlewv Nc City of Cupcnino against
liabilities,Judgments,costs and expcmeswhich mayin any way accrue against said City AUTER OR ADUTO MITCH. PIT MRINGFEE
in consequence of the graming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)) MECHANICAL HE
SO�U^RC•E�.REGULATIONS. / �
AIR HANDLING IINI'TIOVIiIt I11.Ug1 CF CONST'NUCf10N
XX
SiYYg....namrc of Applicata onwnor Dae I.XFIAUST HOOD(W/DUCr) HOUSING MITIGATION E
HA9ARDOUS MATERIALS DISCLOSURE
Will lheapplicant or ftuure building occupant store or handle hazardous mctcrial BOATING UN,(TO IW.( IU) If
as dclined by the Cupcnino Mums al Cnde,Chapter 9.12.and the Health and Solely
Caine.lection 25532mit HEATING UNIT'(OV I(gq)B BTU)
❑Ve, 'o PAID
VENTILATION N(SINGLE RESID) Date R"IF,#
Will the nPFlwo m lulme building o,capunt sac cqulpn Tal or dcviah which BOILER- _)MP(311P OR Ig1,UW B U)
rud hazardous our contaminants as definal by the Bay Area Air Quality Management 'Tor
L
n01 . -COMP(OVER IN)."BTU)
read the hamr�orickv,niinncnfs un dm Chapter 1,9.5 of the Cal i IH C0.1'flI'1'IIINER C ISSUANCE DA F.
&Safety Code.Sections 25505,L5533 and 25534.1 understand Na if the NEW RESIDEM'IAL MIiCH. SQ.FT. l //3 Qat
not currently have a ran Lthat it n my rtapm..thi ,to mrfythem(fyypam
cy.S wliEM1Cledy Aori'r.ed agent p ¢ TOTAL: ISSUED BY:
OFFICE