99110002 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY aq I ,oat
CITY OF CUPF,RTINO Ii1111.DING ELECTRICAL 1HRMI N .
BUILDING DIVISION APPLICATION(PERMIT PING IIINI:l T1DEANICAI,
IIUILI11Nf:1'HfIJ I?C'r II11:Y1'INICAI'ION
HUILDINGADDRESS: SANITARY No. APPI.II;A/1N)UBIll']'AL DAPI
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N AME e,5 1NE8,�as IIJ
Z �' � NIC CON'IR(R.p
ARCIIITECT/ NGINf:EA: LTC NO: E,))`6ifMEvE I /_mss._S Ia�IO��I� ❑
NTACT p / IONE: G�+ S%I �/<eIlKe V G S•/�` BUILDING PERMIT INFO
6- o h kt / �p 35-6114 ❑ CO.SWIanl Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION QTY F;LECI'RIC PERMIT FEE JOB DESCRIPTION
1 hereby atfiom Our I am licensed under preskicto of Chaptem
r 9 h,maencing
awz wim Section y(xgO of Divdsion3 of he Business and Prr Tessiore of J ylicensc is RESIDENTIAL:
61 p O PERMIT ISSUANCE
F full force and effect f can ❑SFDWL ❑KITCHEN REMODEL.
my
in full Gab Lia.« 3745
ba.Z� Dme Comracau r AI'PLIANCIS-AESIDINTIAI, El ADDITION E)PLUMBING RE-PIPE
trisect. ❑MULTI-UNIT ❑STRUCTURAL.
F D y ARCHITECTS DECLARATION PANEL S MOLLIFICATION
Z O h Z 1 understand my plans shall he used as public records UP TO 2(X1 AMPS
❑INI PRIOR ❑CHIMNEY REPAIR
�yLw Licensed Professional 201-1(0N)AMPS IMPROVEMENT C]SWIMMING POOLS
K C C� 1 hereby firm hWNEat I m-exempt front
he Contractors' License Law far the OVER HXX)AMPS ❑BATH REh10DIi-UJRF',PA_IR UEh101�.I�TIO�N
X 3 a U following reason.(Section I031.S.Business and Professions Code:Any city or county SIGNS ELECTRICAL XOrHF,R'1 dq�r'L
a: t on which requires a permit to construct.alter,improve,demolish.or repair any structure K 0219 C4 kl�e'Vf 1
FNO; prior to its issuance.also requires the applicant for such scrnitto file a signed natcmcnt SPIiCI AT.CIRCUITIMISC.
f71} hoe he is licensed pursuant to Provisions of the Contractor Licenm taw(Chapter9 COMMERCIAL:
1a1�00 (commencing with Section 7")of Division 3 ofhe Business and l'ndcssions Ccde)m TIib1P.MET'IiA OR POLE(NST.
d d c ce hhe
at he is exempt refmm arum the basis for the alleged exemption.Any violation of ❑NEW BLUGIAOOITION ❑DEMOLITION
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES []TENANT FOOD SERVICE
of more than five hundred dollars(SSW). IMPROVEMENT
Dl.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F. OTHER
will do the work.and heordame is not intended or offered mrmle(Sec.70,14.Business
W3 m and Pmfnslons Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIX TUBES
Property who builds or improves thereon,and who does such work himself or fl mugh
his oxo employees,provided that such improvements arc net:mends)or offemJ for NEW AESIOENTIAL I:L[CfR SQ Pli
sale.IL hox'ever.the building or impervedsm is sold within one year ofcomplction.the 'Q.19.FLOOR AREA LSQ.IT.
ner-builder will have he burden of proving hat he did not build or improve fur Pur-
Frne ofsale.). 'TOTAL:
n 1,as owner of he property,am exclusively contracting with licensed conuactors to
unshod the project(Sec.]OSA.Business and Professions Cade:)The Contructu x Li-
cense law does not apply to an owner of progeny who builds or improves therean,and QTY PLUMBING PERMIT F
who conarmax forsuch projects sols a contractors)licensed pursuant o the Conrracmts
License Law. PERMIT ISSUANCE
❑lam exempt under Sec. .B&P C for his aaxn
ALTER-DRAIN&VI:NT-WA'IIR(EA) ¢VALUATION
Owner —Date
Y SLIro ,�
WORKER'S COMPENSATION DECLARATION BACK FLOW IB(TItCT.DEVICE ( 7
❑Ih.!I heresy affirm under penalty of Perjury one of he following dedwatians:
inmu ,ITdrumminaCenificateofConsenuowlhiresumforWorkeesCamped- DRAINS-FLOOR.ROOF.AREA.CON0. STORIES TYPE CONSTRUCTION
tion,ar,provided for by Section 37(IU of the IaMc Code.far the at...o1 the
mk for which this perms is issued. FIXTURES-PGR(AAI'
I have and will maintain Workers Compensation Insurance,as required by Section
3I00ofhe laMu Code Triadicpcournme,coldre work fur which this permit is issued. GAS-G.SYSTEM-I INC.JOITI'LISI'S OCC.GROUT' AI'
GAS'-
My Workr(s yCa�Pf��tJ��Insuince cauicr and Policy nu r
CaniecT �l Policy No.: IiA,SYSTIiMOVER J11:A1
/
COMPENSATION
INN FROM ORKERS' GREASEANDUSTRL.WASTE:INTERCEPTOR COMPENSATION INSURANCE IU1LU1NC DIVISION IgiIS
(This sectionmss ra,accomred:Etre Permit is forms,hundred dollam(SI(XB GREASETRAY
PIANCIICCK ItiG
or less.)
Loy any tpresnt in any annerof the becameak e
subjewhichct
the ml is WokersuCLl)tall SEWER-SANITARY-STORM EA.21X)IT.
urn employ any person in any manner as m become subj,cuo the Worked'Compcn- ENERGY 1'EE
Z ...ion laws of California.Date WATER HEATER WISTSIVELECIR GRADING FIE
O O Applicant 1
zy NOTICE TO APPLICANT 11,after making his Certificate of Exemption,you shun, WATER SYS'ILMaRCAI ING SOILS IIS
become subject TO he Workers Compensation Provisions of he Labor Code,you most
W fordriahmmply with tach provinons or this permit Shull be doonaloevoked. WATER SERVICE
p QPAID
CONSTRUCTION LENDING AGENCY NEW RP_SIDISTIAL PLMB. SQ.BT. Date Rcecipl«
C.1 0 I hereby.hunt tharshere isa conawerion lending agency Cotte performance of
LLthe work for which his pcomn is issued(See.3097.Co.C.) TOTAL:
O lender's Name TITI'A L:
r IU Lenders Address _ BUILDING IT:
a I sadify that 1 have rand this dpplicmimn and ,are um that tabeve information 0.
(^ h const.l agree to comply with all city and loom,oNindees and state laws relating 11) QTY. MECHANICAL PI7RMIT Flan SEISX11C Idili
V ,�Z, buildngcnnstmetion,and hereby sultana,mpmsentatives of his city to enter upon he
alnvememianed fail for inspection purpmea IY:RMIT ISSUANCE EI.i:Cf RIC PHE
(We)agree m suss,indemnify and keep hamdess the City of Cupcnino against
liahilities.judgments,costs and expenses which may in any way acme against said City AL'TIiR OR ADD TO MICR. PLUMBING IBi13
in mOequeare of the granting of this Permit.
APPLICANT ONE . STANDS AND WILL COMPLY WI'L'Y ALL NON.POINT' AIR HANDLING ONI'I'CR,)1(hIXXI CFM) MECHANICAL FEE
SOUurrr��tr,Uf T NS. �qs
(\ 1 AIR HANIILING UNI'1'(OVI:R IIL(NNt CPM( CUNSTItIJC'I'ION'1'A%
Signammmf Appliaant/Conmemr D. EXHAUST HOOD(WMUCT) HOUSING MI'1'ICATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant nom or hurdle hmwdousmaterial HEATING ON 1'1'II G (Ed.b( I[ITT'U)
as d,Ened by the Cupertino Municipal Coda.Chapter 9.12,sad an,Health and Safety HEATING UNIT(OVER I(X),IXXI BIG)
Cods,Section 25532(.)1
❑Yes L_]No VI:N'I'ELATION FAN(SINGLE RESID) ('AID
taw, Ra„ipa
Will the applicant or forum huilJing acupvm use cyuipnunl ar coerces which BOI IiA-COM('(911P OR 10O.SX)H'OH
emit hvurdous air cantantinanw m dalined by that Huy Area Air Qual'ny Management '10 1
,)is uictl BOILER-COMP(OVER 100.0)(h)Ill Or
❑Yus 0N
AIR CONDITIONER ISSUANCE DA117
I heva real the hvanlors m:derluls redone, sunder Chapter 6x95 ofhe Cali.
Ibmla Health&Sutcty Cole,Ssvtio is 255(15,25533 and 29534.1 undmewml fait if the NEW RBSIDIIN'1'[A],MITCH SQ.Irl'. / f_
r
bmilt ingdrc,enoteumeally have a tan that it la myr¢spnon"'ty In nal by the"crude /
of he mynhcm„nx which¢mat be noel Pour e.is,oneca of a Cra ir,we of IXaapancy.
],TIAL
owernnr umhorieW ascot Dale ' : ISSUED By:
OFFICE