S 0948 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE.RTINO BUILDING-ELECTRICAL PESdITNO
BUILDING DIVISIDN APPLICATION/PERMIT PING PROJECTNG [CDANIFIC 0948
I31111.U1NG PROJECT IDI:NI'If'ICATIUN
SANffARY No API'LICA']'[ON SU13MI'I'1'Ah UArp.
HUILUINC ADDRESS:
1%X7,-h"K ueLAe_- I0_CD —9
OWNER'SNAME: pre I'HONI; CONTRA R'S NAMES LICNO: _S� N/C CONTROL If
.ARCHITIiCI'/IiNGINEER: LIC ADDNESS, G((�� ❑
CON' T:
PHONE;:
BUIL-DING PERMIT'INFO
S � ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MSCI
ENSED CONTRACTOR'S DECLARAI ION QTY. ELECTRIC PERMIT PEEIt
JOB DESCRIPTION
I hereby affirm that 1 ten licensed under provisions of Chapter 9(commencing
WOZ wim section 7"OfDivision 7 onbe Business,and Professions Code,and my license is AL;
Y1iRNIIT ISSUANCE
1- in full foretold Onee'. ❑KITCHGN REMODEL
U hren.c Llok APPLIANCES-RESIDENTIAL ❑1'I,UMBING BIT PIPH
pZLLU] Dule �i T'SD CLARCIII'I'IiCr'S IlHC1.AkAT ON T' ❑STRUCTURAL.oAZ I understand my plans shall be used as public recordsIANI.LS MODIFICATION
021-'- UPT02(XIAMPS ❑CHIMNEY REPAIR
W Licensed Professional 2(11-HXX)AMPS IENT C:]SWIMMING 14)OIS
` E, OWNI;R-BUILDER DECLARATION
J OVER IafIOAM1f I'S ❑BATH RIiMODIi1JREPAIR ❑D1iMDLITIGN
W6 1 hereby affirm that I um exempt from the Contractor Limn,c Law for me ❑(Of HER
LY�S�ImU fellowingreaxon.(St'ie..7031.5,assaults,and Pink,...,.Code:Any city......story SIGNS EIAIC'I'RICAL
t+)31Ly whim require..a Permit m cun%rset,ahc[improve.demolish.m repair any structureFu'OG 'norm its issuance,who"nims the applicant for such permiuofite asigned statement SPECIAL CIRCUIT/M ISC.
fly that be is licensedpumuenuothe prnvisnns ofthc Cnntrecme,License LanyChapter9 COMMERCIAL'
�C�0 (commencing with Section7000)Of Division 3ofine Businessland Professions Code)m TEMY.METER OR POLE INST.
2 L e that he I.exempt therefrom and the basis for the alleged exnnption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
:2 to Section 71UL5 by any applicunl for npermn nuhjna,the upplicunl leu civil penally of POWER DEVICES ❑117NANT FOOD SERVICH
not more than live handled dollar.($500). IMPROV EMF:N'1'
=C1]Lax owner of the property.or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC
❑OTHER
F will do the work.and Imaractule isnot intended inrnered for sale(See70cl Basil,
W m and Prnfcssions Cede:The Contractors License Law does not apply to an owner of OUTLETS-SWITCH S-FIXTURES
L 3 pn,,ny who builds ar improve,thereon,and who does wch wnrk himself nr through
his own cmployet,providaen
l lion such intpnwncmx arc not intended or offered for NEW RGSIUENTIAI.ELECTS SQ PT.
sale.IL however,the buildingor improvement is sold within one ycurofcompletion,the SQ.ET.I FLOOR AREA SISQ.Pf.
'neo-builder will have the burden of passing that he did not build or improve for pur- 7��"�
pose ofsule.). TOTAL: (�L'/CEIV D
h a owner of the po,,.,am esdu.isely contracting with licensed carnations,m
m.wet the Eroject(Sec.7(W.Business and Professions Code:)The Contractor's Li-
ens.Lawdoes nmap,], ouIt owner ofpmpertywhobuilds orimproves merenn,and QTY. PLUMBING PERMIT FEE NOV ° 199
who contracts far such projen,with,a masons)licensed puts....tea lee Contntmrk
License law. PERMIT ISSUANCE
I am exempt made,Sec. .B&P C moors morel
ALTER-DRAIN&VENT'-WATER(LA) BV. VpLUA'fION
Owner Done 1.71
WORKI!R'S COMPENSAI'ION oi?CLARATION BACK FLOW PRUTC CVICE
1 hereby affirm under penelty of perjury one of the following declarations:
I havemd will samomm a Cenificatcof Comnnnn,elf-Insure lin Workc-Colopmt- DRAINS-FL ROOL AREA.COND. STORIES 'TYPE CONS'IRUCI'IfID
source,as provided for by Section 37M of the Ca1nn Costo,for the performance of the
work far which lis permit is issued. FIXTURES
1 have and will maintain Workers Compensation Insurance,as required by Seltion O LI?�ti
370ofthe Lown Code.fnnbe Performance ofine work forwhich thispconit i,issued CAS-IiA.SYSTtiM l IN OCC,GROUP APN
MyWorkcr'x Co pensauon h'u+c dPulic,nu� n __ _�-2 GAS-EASYS'riJM. VL 4(EA
Carziec cl'nlicy No.r �JmCI
C RTIFICATF,UP EXEMPTION FROM WORKLRS' GREASF/INDUSTRI A) EiREPTOk
COMPI?NSATION INSURANCE BUILDING DIVISION I+EES
(Tntsection need not be completed if the Norat is for ane hundred dollars E$100) GREASETRAP
or lea.) I'LANCHECK 197l7
Icmmymdnone pe,tirrmanccof the wnrk lbs which this pmamir is i...ad.I.mll SHOV HR-SANIT )F.ARY-STORM 171,1 ENERGY 19717
not Outplay any prolamin any manner",.a b.bcunm.subject m the WorkersCom,11-
Z cation Laws of California.Done WAl'I7R HEATER WIVENT/ELECTR GRADING M.z.
Z O Applicant
NOTICE TO APPLICANT:If,enter making this Ccnificam of EacmPtioni,you should W'ATTiR SYSTEM/TREATING SOILS FEE
F "N"' naomt,object to the Worker,Compensation provisions of the IaMn Code,yon most
fall comply with such Pnw l.inn.nr this permit shall he dasmolm,ekcd. WAD7R SERVICE
171 0
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL 1'hMB. SQ.Pr. PAID
U z Dole R,¢ I p
U Q Ihereby hichthi that there isue.construction,0lending7, agency lar the performance of
� the work for whim this Permit is issued(See.Jly)7,Co.Civ.OCT - TAI,;
O Lender..Name TOTAL:
{UA Lcndcr's Address BUILDING FEE.
G I,enlfy that I have rend this appllewllnn and state tine the above infnall 4 1 is
or,,,I..gree m comply wim all cay and conmy nnAtelnecs and.,am laws relating n+ QTY. MECHANICAL PERM I't' FEE SEISMIC FEE
U z building ennsescnon.and hereby authorize represenrutivesofthis city astnter upon the
above-mentioned poi for inspection purposes. PERMIT ISSUANCE ELECTRIC FLEE ±(WO agree to save,indemnify and keep lec nlese the Co.,of Cupertino against a
liabililics,judgmenls,cn,bondcxPcnzc.which lnuy in any way aecmc againeLsaiJCity ALTER OR At)])1`0 MECIL orIIMBING ITIi
msrymcoce of rbc grunting nI'This petted.
APPLICANT'CINDERS'I'ANUS AND WILL COMPLY WTI'H ALL NON-POI N'1' A1µHANDLING UN I'I'(TO IE,(E 0CFM) M 17CI IANICAI,FEE
SOU RCE REGULATION'
^ � 77- AIR HANDLING UNIT(OVER I Woo)CFM) CONSTRUCTION TAX
Signers p actor Dale EX13AUST HOOD(W/DUCT) IIOUSI NG M11 GATION&12
HAZARDOUS MATERIALS DISCLOSURE
Will tile applicam",lots"Codefineed by the
Cupertino
upep no Municipal lCode.Chapter 9.12 r and the Health and Safety HEing ouctiolsoll store ATING UNIT((D IINI.OW B'TIl1
fING UNI'I'(t
as
HLA (OVER IW,IXIO B'1 U)
Yes Obla VENT]CATION PAN(SINGLE RESI D) PAID
Uac Rcaipt /
s Will the oppou,no no more building n,euponl a,c cgm neem'oto do,,wca which HOII,ER-COMP(Jia'OR 100,000 HI'U)
mit nova dou,ter cmmmnitatim n de0ncd toy arc Hay Ara Air Quality Managclnan
Dimucl? BOILER-COME(OVER IIpjinst E'r(j)
El Ycs No
I have lad the hamNsm,mattrials mquitemxmu under Chapter 6.95 of the C.R. AIR CONDITIONER IS ANCIi JjATC
folia Ilculth&Safety Code,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL.MITCH. SQ.FL (lam
building coconut rm�ormhu�llKy have a tenenl.lout it i.in,responsibility w..miry thaeump:nt
cftit mmocusw on t he mu prior On is..anceofo Cendial of OaoPmeY.
�l-G-9'r /nom C7
Owncrorauthoriudamis Uam 1�70AL ISSUED BY:
OFFICE