99120120 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYIts
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUII.U(NG DIVISION APPLICATION/PERMIT PLU PROD CTinbANIFIC
It1ALDINl:1'RDJECT IDENL'IFICATION
SANT"IARV NO. API'LICAI'ION SUIiNI'I'IAh DATE
till AUDRF,SS:
(alai 191
OWNER"N,\ 1F' PHONE: CO RAC(OR'S NAMC: LIC NII: NIC CONIK
l 1:5 let
CHITCC'I'TINGINECR: hIC NO', ADDRESS' ❑
r'1 Q,o A�JcSa
CONTACI': PHONH. BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB NIECE]
El ❑
LICENSED CONTRACT'OR:S DECLARATION QTY. ELI-,CTRIC PERMIT 17EE JOB DESCRIPTION
1 hereby anArm that 1 am licensed under provisions of Chapter 9(romntencing
CWZ with Seninn]10a17 of Divisionlof the BuxitrczlanJ Rofeazions Code.and my license is RESIDENTIAL,
PERMIT ISSUANCIi ❑SFDW'L 4KITCHEN RIiMOUEL
Nom in full farce and a f
Ox ~ Licenxc Clas Lica APPLIANCES—RIi51UliNTIAL [I ADDITION UMBING RF.111'E
Pzw Done C Conlmnna5 :L
CC A CHITECI"S DIiCLARATION Dan i'ANlilti ❑MULThUNI'I RO=RAI,
F' Iundenlund my Plamslmll be mood as public records MOUIFICA'1'I(ON
OZ— UPT0200AMPS ❑INTERIOR ❑CIIIMN17Y REPAIR
1=.41::y) Licensed Professional 201-1000AMPS IMPROVaIINI C]SWIMMING TOOLS
OWNER-BUILDER DECLARATION OVER11")AMPS ❑BATHREMODF,IIRF,PAIR ❑DEMOLITION
CL{yah Q I nereby affirm that I mon excmp Iran,the Colnmetar's License Law fart the ❑G1 HER
'a� 6 U fallowing rain n,(Suction 71131 5•Holmes,and Pmfevocal,Code:Any city nr camaY SIGNS ELECTRICAL.
1+13 0 vFi which requires a Permit to cnnsnuct,aller,improve,demolish,nr repair any stmeturc
Iii: prior...its s,mnce.also rtquirex theapplicant far such Permiu,,file a signed statement SPIiCLAL CIRCUIT'IMISC.
Into he is licensed pursuant)the provisions of the Contractor's License Law(Chopter9
4�i°I rep�O (commencing with Section](Mp)ofDivision Jofthe Business and Rsdessions Code)or TEMV METERO 'ION ❑DEMOLITION
O.A.o C thnl he is cxcn,pl therefron,and the basis for the alleged exemption.Any violation of
W r�N Section 70,31.5 by any applicant for o peold,subjects the appllcanf to a cold penally nl POWIiR DEVICI3. ❑FOOD Sh;RVICh
bat more Nan fisc hundred dollen(3510). 1,
L=Q L.as owner of the progeny.or mY employees with wages as Ncir ode compensmiom, SWIMMING IK)f)LfLp RIC TH R
�h. willdolhe wvrk.and Ne slrucmreisnel mtemdedoroReredfmsale(Sec.]BW.Rosiness 0MLErS—S WTI CITE R%T
13 and professions Code:The Com oreares License Law does nal apply to an owner of
pgeny who hi ilds nr improves(hereon,and who does such work himself or through
ro
his own mnployces,provided(hut such improvenmms am bol intended or offered for NEW KI-SIDENTIAL E., F
,all.If howavcrnhe building,,,improvcmant ,old within oncycurofcamPlenon,the LOOR ANDA F./S(1.1.1.
owncrlwilder will have the burden of proving that he did not build or improve for par- D
pose of sale.).
❑L a.s the of the See.704,am exclmivelynd contraProfescting Coad y licensed contractor,1IU
uroe Latheproject(Sec.]114,Business,,,, Professions Cedep The Commemr'n nd
ase Law Jneanot r,.Oh plytann with
aafmopuny whoJursuant to the docConracand QTY. PI,UMBINO PERMIT FEE
who mnlnwu 1'or such pmjmu who a nmmucun(s)licensed Pursuant m the Cenaumor's
License Luw. PHRMIT ISSUANCH
[am exempt under Sec. .B&P C fur Nis reason
ALTER—DRAIN&VEM'—WATBR H!A) VALUATION
Owner Due
WORK17R'S COMPENSA'I'I ON DECLARATION BACK FLOW PROI'CCT.DEVICL
1 hcrchy union under pcadly d Perjury enc ot'the fallowing declamti..nn:
have and will maintain a Cerificae of Concent tU self-imam for Worker's Con,cn- DRAINS—FLOOK,BOOP,ARF,A.CON D. S'I'fIRIIiS I YPIR CONSI'RIIC'FION
as provided far by Section 37W of the Labs Code,for the performmtce of the
aork for which this pcmtit is issued. FIX TURIS—PER TRAP
❑I have and will maintain Workers Co aNnesmion Insurance.as required by Section 40V1'LITS
}pglodada
lofthe e.Cfnnhe pc,bomnnGAS—EA.SYSTEM-]INC.
ceof the work far which this pemal is isaucd. ��^���••• OCC GROUP APN
My Worker's Compensation Insurance tar rand Policy ,�' '1.,In Q _'3,�0
CeolaF� a 11_ Tic Pnlicy No�C_9F i 'xd 4�wC11-o� GAS—I3A.SYS1'I?Md>VL'RG(EN
CERTIIgCATIi 01'F,%IiMITION MOM WORKERS' GREASFANDUSTRLWASTEIMTRC1iMOR
COMPENSATION INSURANCE BUILDING DIVISION('LES
(Thissectianneed n..lhecompdered iflhepermitisfurunehundrtddollurs(5100) GRBASETRAP PLANCHECK Igiii
or lms.)
I coal dythat name
in po monorails,
Oil hekfmwhbjec,Or,Permit..ker,Comperll SIiWIiR—SANII'ARV—STORM EA.211(11'(, IiM71OGY ITH
nal mnploY any Item°n in any manna so ns in hcc,,nu subja'f r,the Worked Cnnq,cm
Z salimm laws of Califnmia.Dmc WATER HF,ATRR W1VFN'GF,LEC'FR GRADLNG RA
Z Applicant \
Z NOTICE TO APPLICANT:If,after making his Craimine of Exetmption,you shears WATER SYSTF.WI'REA'I'ING SOILS FEC
F " become subjc[t tonic Wbrkeh ComPensminn Provisians of the lama Code,you must
Lli fool"ohc..mply with such poAkina,or his pramilahall Is,diamond re—lord. WATER SERVICIi
W Q
0.
CONSTRUCTION LENDING AGI2NCY NEWRESIDE 'IIALPI,MB,NSO PT. I'AIU
7 Z Data uceery,t x
V O l hereby oRmuhat then isaamslmninn lending agency fnnhe performance of
W f•` the work for which this Rental is issued(Sec.1097.Civ.C.)
Q.0 Lender's Name TOTAL: �I
W) Lender's Address Iltlill, INGR
I scall,that I have rend this up,hralian and ante taw the ubovc man nmol....Is I�
Q.
crcor.IIt,.in comply win all city andcountyordimncexand state laws rdatlng In QTY. MECHANICAL PERMIT' PEE SIDS I Ppi
U Z building corwonetion.rend herebyauthoatecteptasmmroses of this city to enter upon the
aMrve-mcntirmed pmpr-Y for inspection Pnrpsses. PERMIT ISSUANCE I LECfRICFE 99
(We)agree to save,indemnify and keep harmless the City of Cuperino against
liabilitics,judgments,costs and expenses which may in any way accrue against said City ATTER OR ADD'1'0 MECH. PLUMBING FIiC
in ncquel e,of ds.....ling of his prna
APYLICA '1 UNDIiRS'I'AN UD S AN WI LL COM PLY W I'I'II ALL NON-
11'1)1NT AIR HANDLING LJN I'1'(1101O,(NNI CFM) ME= ALlgiL
S()l'ICF IILATIO S.
a&4? AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTIONTAX
Signature of ApplicansCornmdnr Date E%HAUST HOOD(WIDUCT) HOUSING MITIGATION FI.I7
HAZARDOUS MAI'F:RIA LS DISCLOSURE
Will the appl icant or f con,building ucntprm state or It dc hozaNnaxmaterial I]PA]INC UNI'('1'IO InI1,lNNl III L)
as defined by the Cupcnimo Municipal Gaic,Chapter 9.12,and the Health and Safety HCATING UNIT HOVER 1 W.W)BTU)
Codc.Section 25532N)'! ` PAID
a
❑Yea �} VHWILATION FAN(SINGLE RESID)
[—)am Rtteipl a
Will the applicant or(mare,building occupant use equipment or devices which BOIL ER COM('QHPOR 100.(0N)I3"1M
it In,enlnus air cnamook ants as defined by tnc Be,Area Air Quality Management
iinricY: ROILER—COMPIUVCR IW,WnBTU)
❑Yes No CJ�B+��'
AIR CONDITIONRR ISSUAN\ E
I h' J Ili k rl er ul tcyuiren u J Chapter 6.95 of Ili if the
n it ih&Solely C Ic S i :255(15 25531 d 25534.1 J .t'mA that Y the N1.W RI:SIDIiN'TIAI.M5CH. SQ.!T.
b'I l' 6contractionalYto t .fl t O: Y .p bltyl 'fy the ' Pum
.I he mcne.wbahm clf,Cn'I t fOcc y.
U nc g nl u D tc f! TOT'AI" ISSUED FIV
OFFICE