S 3039 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-RLECrRICAL Vitt I NO
BUILDING DIVISION APPLICATION/PERMIT I'I•DnmwG-MECIL\N]CAL 3039
BUILDING 1. O.P?CIIDENTIFICATION'
BUILDING ADDRESS: SANITARY NO. APPLICAl[ON SUHNII I Lon.DATE
o oRL}Fi me`- ,,a- /6 -zG 4
OWNER'S N n >. O� (0, Il-E I 1 C)NI'RACf(Ilj'y NA li: _e alae NIC CONTRIIhx
is SLAC VFx r ❑
• ARCHI1'ECTIVNGIN3ER: I LIC NO: ADD ' S:
CONTACT: PHONE: d BUILDING PERMIT INFO
BO) �ON( �� Elt Feces ConsultanPaid Ay Applicant(Initial) BUX ELVCI PLUMB MGCH
b �`N ❑ ❑ ❑
LICENSED GONI'RACfOR'S DECLARATION QTY IiLECI'RIC PIiRA11'I' FEE JOB DF:SCKIIaT10N
1 hereby action that
1 am licensed under provision.of Chapter 9(commencing
01YZ with Section7a)(hof Division 3olthe Hourre„mad Professlnns Code.and my license is RESIDENTIAL:
W O I'IiHA111'IgSUANCIi
E-2in full inerrant a. ❑M'DWI, CKITCHIiN RF-_MODIiI.
aVV : •CI , Lica I API'I.IANCfS-RESIDIENI'IAL 0AUDI'I1ON ❑PLUMBING RE-PIPE
Nab )ate Camrvclor ❑MUL'TI-UNIT ❑S'I'RUCTURAI.
y ARCHURCrS DIiChAHATION PANELS MODIFICATION
Z O,, 1 m,Jurntmul my plum mall he used us public ncurJs UI"I'(121X1AMl'S
❑IN'T'ERIOR ❑CIIIMNEYREPAIR
OZ ,
1-.,�tgw Licensed Protnn.ian:J 2ab10S)AMPS IMI'ROVFMIiN'I' CSWIMMING P0019
OWNER-I{I11I.DER DECLARATION OVER IINXIAMPS C I{Aq'H REMODBI./REPAIR C UEM(ll,l'I'ION
4 LL' ¢ I hereby ullinn mut u , x mpl loon the Contractors License Law Ibr the
x I>,U following rcmnn.(Suction 9f1.11 S.oIWeincs wed 11 Rossi Cod,Any city m manly SIGNS HLBCI'I11CA]. ❑OTHER
G1 a tY v which reyn'Ires a pormit m cnnaruct.ager,arpOwe.delnnfixn.or repmr any swcmre
p.�ONJ preirto itss alko otfile ppocz I for,ohn"Fill'Ifile '4 axwtcmem SPECIAL CIRCIII'I IMISC.
y
that he is Incersod personal I fic pluIllion,Idth Comestone,License L (Chaptcr9 M FR 1
Wa00 (sommans ,gwith Section 7000)of Iivir'nn Solfhe lia,mr,end Pr f:. .Code)nr I EMR ME.II'k OR POLE INST.
G e.e C mat be is cecmpl Ibcml'rom count basis far The alleged exemption.Any violaninn of C NEW BLDG/ADIII'rION ❑DEMOLI'1']ON
x!;NSection II31.5 by any applicant l'or a permit whjarts the applicant to a civil penalty of POWER DEVICES ❑TENANT Fool)SERVICE
not more than tivc hundred Dollar,S500). IMPROVEMENT
C]1.as owner of the propery.car my employees with wage%as their wk compeoution. SWIMMING P(l(ll.l?LIiCfRIC OTHER
P. will do the work.and the%fracture is not Intended or offered for sale(Sec.7044.Business
a5:=
3 w and Professions Code:'Me Confmctnr'%Licenw,Crew does not apply to an owner of OUTI.EI:S-SWITCHP_ti-Il%TURP_S
property who builds or improves fhemon,and who docs such units himself or through
his own employees.provided Nor such improvements am not intended or offered far NEW RE.SIDENI'[Al.ECFCfR SQ PT.
sale.If.however,the building or improvement I%sold within one year of c' c'
SQ.FE.FLOOR ARBA SISQ.IT.
net ofilder will have the No Men of proving that he did not"I2, or improve for pule
,duce of sale.). TOTAL:
L as owner of the propery,am exclusively contracting with licensed coovactom to
con%acct the project(Sec.](IU.Business and Professions i-ol.a,Corroommr%Li-
veoxLaw does nmapply it)an owner of pm,ery who builds on improves thetenn.and QTY. PLUMBING PERMIT FEE
who uommcts fmt wch projects with a cnntremmgO licensed pursuant m the Contrmon's
License Law. PERMIT ISSUANCE
❑ I am exempt under See. .B&P C for this mason
Alai?k-DRAIN&VENT'-WATER(BA) VALUA'HON
Owner Dam
. WORKER'S COMI'HNSA'I'ION DECLARATION BACK PLOW I'R(11'IiCT.DEVICE
-3
1 hereby intoe..under,.,ally of paint,one of the allowing deelumnion% �'-/
I �Ibuvcandwill inuinminuCarfllianco[Conxcnnnmlf-inwrefar WorkdsCompcn- DRAINS-FLOOR.ROOF,AREA.GOND' S'OWIiS 'I'VPHCo S'I RUC ION
xalinn,as provided for by Sell an 370NI of the Labor Code,to, performance of the
work for which thin,emit c,,o d Ir1X'1'l1KV_S-I'lik'I HAI'
11 'll a I' her ma s l e t r : 4 mil Section
3ID0 f tl I lb Code,f II i vel work for who'll cal':p l:c ection MS I:A SYS'T'EM-I INCA UII'111i 1'S UCC(ill(it)P APN
My Workers Cu nPso:em lst , r nal Policy number aro.
Carrier r Policy Nn.: GAS-IiA.SYS'T: -OVHR4DEA)
CI?k'1'IPICA11701PEXBMPI'IONIzROMWORKERSS GREASEANDUS'I'RI.WAS]'Ii IN'IERCITTOk
COMI'HNSA'I'ION INSURANCE BUILDING DIVISION FEES
(This,mctinnnced nal N:con,plcicJ It pcm,il'df root hundred Joliet%151IX)) GREASE'TRAP
PLANCH[CK PCE
,it less)
I eerily lila in the perinrn,ann cal the work[Or whim this Permit is issued.ishall SEWER-SAN['D\kV-S'1URN EA.2W IT. ENERGY FEE
not employ any Noun in any nen npg�'yI Thcly),N')enmtheworkers'Cnmpen-
Z : 6n 1aw�Calj hou a.l)�Ic W Al Y E W
ATER '' WVNT/IiLECI'R GRADING I'19i
board
Z
O` NOTICE'I' ANTVI\h ufler�ing this Certificate of Exemption,you should Sy. '1'1 SOILS FEF,
? become subject m the Worker',ConiNionam provisions of the Libor Gale,you most
0. forthwith comply finisher pmvi%ionsnrthin,cosh shall h dccmcd revoked.
PAID
CONST'RUCI'[ON LENDING AGENCY as Receipt a
V p l hereby affirm that is a coorfmaion lading agency for the performance of
the work for which this permit is issued(Sec.3(191.Civ.C.)
r( cal.:
C) F' Lendce%Name
Addm TOTAL:
r {U I<nJcrs Address
0. 1 certify mm 1 have reactor,application and some that the above infommtion aBUILDING 4'F
rN on.,.1 agree m comply with all city and county ordinances and state laws relating to QTY. FEE SIHSMIC RAi
7 Z bei Icing comtmchon.and hereby uumorim repre%enlativesof this city bisect upon file
uMws-ntentionad prolwrty lin inspccdinn pumowl PERMIT ISSUANCE ELECTRIC il3
(We)agree fn save.indemnily:rod keep M1ariale,the City of Cupcninn against
Iiabilllics.judgmcol%,eod.vandexpcnscs which may in any waylmcmeagainst slid City APER OR ADDTO MECIL 1'LUMBINGF '
in naquenca ni fin,.mooing of Ibis perand.
APPLICANT UNDERS'LANDS AND WILL COMPLY WITH ALL NO -POINT AIR HANDLING UNIT('I'O 10.INXICFM) MECHANICAL IL;i
SOU 13 " ')IS. ����
.tY'�IJ GVA\ AIR IIANULING 11Nl'1'(OVER I11,I11NI CIM) CONS'I'HUCI'ION'IAX
Si�rcofApplict l/ nmmnyot Doc BXIIAUS'I'FOOD(WIUUCI') HOUSING SIRIGA'I'ION FEE
HAZARDOUS MAI ERIAI ti DISCLOSURE.
WIIl the applicant car lulnm building nacupunt store or handle ha,conuammttial HEATING UNI'I'('10 1000g)ROD
as Defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety
Code Seeman 25532(a)'I DEATING UNI T(OVER IIXI.(XXI[11 j)
[:1 Y., -1 No VENTILATION I AN(SINGLE RESID) PAID [-)'are kcceiptx
Will the applicant or future building occupant use equipment or devices which HOLLER-COMP(3111'OR 100.000 BTU)
c man --
mit boardnus air coantlno as Defraud by the Bay Arca Air Qualify Management L:
1l61rity BOILER-COMP(OVER I0I.00113TU)
p Yes 0 N
I have read The hafmdous meant regaimpen¢under Chapter 6.95 of the Cali- AIR CONUInoNEk ISSUANCE LIM1i
fmom Dealth&Safe,y Calc,Sections 25585.25533 and 25531.1 aademand that if the NEW RESIDENTIAL.MECIL SQ.IT / xr
holding does not currently have a)enm.that it May re,,doilany no notify due occuprom ( (� {�
of the"trimments which must w mit prior to issuance of a Condiment,of Occupancy.
Owner or mobs i oagent Dane TOTAL: ISSUE[)BY.
OFFICE