S 0598 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING.ELECT RICAL PI§II I No, 0598 598
BUILDING DIVISION APIa1,ICATION/PERMIT EXIABNG.MECHANICAL S
IIHICI11NG PROJECT IDEN'I'IF'ICNOON
SANITARY NO. APPLICATION SUIIMI'1'I'N.DAPI
BUILDING
"" Aii Qj ck
O ISR'SNAMI: ���� PI -u—,�� )N_I'IjCOMSNAMI?. LIC NO: NIC C(I�OLN
ARC/fll—TF{•CT/E GIN--�� �LICPH NO, 90HISI �'S /� ❑
CONTAC
PHONE: BUILDING HERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) 1iLliCT Phuaut Ml:cu
LICENSED CONTRACTORS DECLARATION QTy, ELECTRIC PERMIT' I'LL JOB DESCRIFTION
I hereby affirm that 1 am licensed under provisions of Chapter 9 mo:racer ng
ZU with Section 7")nl Di 3nfthe Business and Professions Codc,a ylicense6 RESIDENTIAL:
°� I'IiRMI"1'ISSUANCE
F�UF ncen force and effect, ❑SFDWh ❑KI'fCfIF.N REMODEL.
UE- License Cl - Llc.k� APPLIANCES-RESIDENDAL ❑ADDITION ❑PLUMBING RE-PIPIT
p.Zm1 Dec Conhrennr ❑MUI.TI.UNI'f El Sr
ARCHITECT'S DECLARATION
PANELS MODIFICATION
Fv=tZ I undershoot my plans shall be used ospublic records
OZ4- UP TO 21X1 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
(.4 F'111 Liccnsud Pmfeaional 2111-DNNIAMPS IMPROVE ENT DSWIMMINGPOOIS
OWNER-BUILDER DECLARATION OVER IfNNIAMPS ATH RI?MODE/REPAI ❑UEMOLITION
!� 6 I hereby affirm that 1 am exempt from the Contractor's License Law for the
KO a U following reason.(Section]031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL «\�
W 3 LL y which requires a Permit to consumer.altar.improve,demolish or repair any summurc
Q prion to'its issuance.also madras the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
Out he is licensed pursuant to the pro of the Contractor's License law(Chapter COMMERCIAL:
�ya�0 (commencing with Section 7")of Division 3 ofthe Basins T E
and Professions Cade)or THMI1.MER OR POLE INST.
a d e C that be is exempt aerefrom and the basis for the alleged exemption.Any violation of NEW HLUGIADDITION ❑DF.M01.1'f10N
X�y Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of ('OWE 7V1 S ❑TENANT ❑FOOD SERVICE
W not more than five hundred delta.(3NiM. Ih1PkOVFiAIEN'f
�S� (]Las owner of NC Pmpeny.or mYemplaYces with xmgea az nc�ir sole compensation. SWIMMIN 'ACT'RIC (]QTHER
F., will do the work.and OciJmeturt is not intended Or offered for sale(Sec.](IW.Business
W�w mod Professions Cade:The Cameroon's License Law does nm apply bs an owner of OUTLET' -SWIT I -p% LS
a 3 property who builds or impmves thereon,and who does such work himself or through NEW RESIDF,NHAL ELEC SQ IT.
his own employees,pros'ided that such improvemems arc not intended or Offered for SQ.IT.FLOOR AREA 5/SQ.FT.
sale.If.however.the building or improvement is%old within one yem of completion.the
"builder will have the burden mf proving that he did not build or improve for put-
Tom
ut- �/�,
posse of sale.). TOTAL: RT h// p
❑I.a%Owner of the progeny,am excluximly contracting with licensed contractors to \I I`l_
consumer(M1e project(Sec.]DW,Business and profession,Chea The Contmcror s Li
c w law does not apply to an owner of property who builds or ba,mums thereon.and QTY. PLUMBING PERMIT FEE \ �\
who contracts for such projects with a carnations)licensed pursuant u,the Commcto,s I
Liccnm law. PERMIT ISSUANCE rA!'�
slam cxemphumler sec. .H3 PCfor tM1i.x maven ALI 17R-DRAIN A,VENT-WATER IIA) ',/Y
C ^c VA.DATION
Owner Date en sof- �l0/V
WORKERS COMPENSATION DECLARATION HACK PLOW'PROI'IiCf.DEVICIi
• cc..d gal normodder PenahYncof(anyone ofhhefnllxeb"WoluaiCor
❑(have aodwiealfor by Section3M ofthe Labor
Code.
for Worker's Compeer- ORNNS-Iq.00R.R(B)I',ARFA,CONU. 'bMHUILDING
smioO.a% hick.1 forma Section 3]W of the labsr Cale.for(M1e peRnrmnnce of thework for which this permit is iszuW. 19%TUkES-PCR'IRN'❑ l lave and will maintain Workers Compensation Insurance.a%requited by SectionGAS-P.A.tiY$'I'Ehf-I INC.JOUTL[I:S3]00ofNe La�ode.for the perforreave ofthc work for which this pemnih i%ia%ued. OCMy N'orGAS-E•A.SYSTIiM"OVER4H A)CaricaERTIFlCATIi OF EXEMPTION IItOM WORKF,RS' GRFAsI%INDUSI'RI.WASTIi INTIlHCEITORCOMPENSA'T'ION INSURANCIi ON FEES
('Do,ochadaved,m Mear,laWifthc pemit isfmonehundrtddolbrs(SINE GREASE;'TRAP
PIANCHECK I13E
Or less.)
Toy any lhmim he any mannceof as to
subject
bjetto Permitisers'CoIshan q;Wlik-SANI'fAHY-SFORM ITA.21111 PT' IiN1iHG1'I:1]3
not employ any person in any mannerso as ho become subjttt On the Workers'Compcn-
z scion laws Of California.Done WATER HEATER WNINTNI.ECTR GRADING FIT.:
C)
Q Applicant
NOTICE TO APPLICANT:If,of er making this Cerificme of Exemption.you should WAl'IiR SYS'1'13M/TRLATING SOILS FEE
F' 5: beconm.subject o the Worker'sCompersmian pmvi.xions of the Leb r Code.You must
as - forthwith comply with such provisions err this Permit shall he decreed mocked. WATER SERVICE
a Q
p"
CONSTRUCTION LENDING AGENCY NEW kILSIDIiNI'IA1,PLM1111. SV.Er PAID Dom Hccnpn p
UQ work
both
tm(hmn¢tisised(Sec.i30 lend;,,agencyfon the Perinmlancc nl
the work Por whicM1 phis permit is issued(Sec.1(5].Civ.C.I 'IY)TN.:
Q f" Lender's Name 'TOTAL:
Lender's Address BUILDING ItiE
1 certify that I have read this application and nam'hot live above inhumation is
.F. 0 c meet.l agree m comply with all city and county ordinances and sale laws mining, QTY. MECHANICAL PERMIT FEE SHISMICFEE
U Z, building construction,and hereby uohnrizc rcprmenmivc.of this city comm,c,,O'he
r above-memimed property for inspection pupwsc% PERMIT ISSUANCE ELECTRIC FEE
1 Wa)agree m oust,indemnity mW kecp harmless the CihY a!CUPenino against
Iiabilitics.luJgmenh,%.unhh anJexpentts which may in any way aa<me a,ains said City ALTIik OR ADD'IY)MECIT. PLUMBING Igili �
on lupionce mf the granting Of this parboil.
APPLIC NT UNDERSTANDS ND WILL COMPLY WITH AL1,NQNP LINT Al.HANDLING UNII'1'1'O IIIJNNI L'IM) MECHANICAL FEE
S N 'tEGULATI0 S.
IIA )LING 1JNl'I'(OVER IdkX)CFMI CONSTRUCTION TAX
Signature Of Applicanl/Conn c r Da 1? I 1S'I'IIOOD(W/DUC'E) IGGSINGMI'fIGATIONIPE
HAZA US MATERIALS DISCLOSURE
Will the applicant or folate building mampanl sore or handle oar.MOus nnnleriol HEXI'ING UNITOO 100..011111111
as Jefinod by(M1e Cupcnino Municipal CWc.Cbip¢r q.12,acts the Healthand Sol'cty
Code.Section 25532(m! HEAPING UNIT IOVIik Igl,gNl❑TUI
(]Yes 0 N VENJCA'I I ON PANS I NGI.13 It FSID) INID
Ualc kocciplp
Will the applicant err future huilding occupu,t use equipment on device%wool, BOILIHR-COMP OHP OR HA NN111'1'UI
in
hmurdaux air contommu is us defined by the Bny Arca Air Quality Mana,enum 'I(yl'N;
)islric,7 BORXIE-COMP(OVER 111110/0 H'I'LEE
❑Yes 0 N
AIR CONDITIONER ISSUANCE
I hods S the h ode,Section,
55 5,25533 of under 5534 1, i ,,la mf me CUh. F``/✓//1
Ibmiug does not
cum Coda.e a out,thod,25533 oil 25534 I nndcawnd lout it the I ryliW It1iSIDI1N'1'IAh MECIL GQ.FI'.
bathe drewnmcurrently bust ntenant,dun it is,ryccola Cldl mnmil ytbmecupnnl
of the rcquirmncros which ams be met prior m isvuunec olio CesOOu¢nfoccupmny. ,
Owner or authnritW.agonal 1)am 'I'O'IAI.: ISS,ld)I3Y: y
OFFICE