S 2880 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOHER I.DINI:-HLECI'RICA I. PERMH NO,
BUILDING DIVISION APPLICKI'IONA'ERMI'P -LUMB Nf-MECUANICAI,
I{II I LDING PROJECT IHEN'I'I FICAI'ION
BUITI)INGADDR- S. SANI'T'ARY N(I. APPLICAI'IONSUBMIII'ALDAI :
I
OWN NAME I'linaso 17v^4 -3Q I' IRA Mfi:-1 �� LIC NO:
tle_ Y IATFVAQ!" /�l'IL.0Jkyj
NIC CONI ROLA
I- ARCIII'IiCUENGINEER: LICNl1'. ADDRESS: ❑
CONTACT: [,][UNT: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLUG ELECTPLUMB MECH
❑ ❑� P--- ❑
LICENSED CON'TRACTOR'S DECLARA'T'IONQTY ELECFRIC PERMIT FEE
I heresy affirm 1 license order pro.i.mns of chapter 9 antme
nming JOB DL'SCRII'TION
m mam
M=7. with Section 700(nof Division Sot Ile Basi ne%s and Profession%Code.and my license it /' RESIDENTIAL:
F _ I al l floe mW effect. PERMO'ISSUANCE OgI DWI, ❑KITCHEN REMODIiI.
xUF m
aUU Ltac°.c Clwn Llu.fl AI`t-1.IANCL}-R13S I DENT IAL ❑ADDITION ❑1'LUMI3ING RE PIPE
�QWI Rate Coal'; ❑MULTI-UNIT ❑SIRUCI ORA[.
F.ON ARC)III LCI'B DIiO.ARATION 1'ANIi1.5 MODIFICATION
O 7=7 I understand my plans stand be used as public recorJ.s
Up 10 210 AMPS 2- 2pi
❑INU?RIOR ❑CI{IMNEY REPAIR
I-mindd Professional gal-IIxX1AMP5 IMPROVEMENT E)SWISMINGPOOIS
,s 7
OWNER-BUILDER DECLARATION OVHLR IIxXPAh1PS ❑BATH REMODEUIIEPAIR ❑HEMOLITIGN
CCG I hereby affirm mal 1 tart strap,from
m the Conlracr's License Law for the
X O 1 m U following n,(Section 7031.S.Businca`and Profen m Cmlc:Any city or county SIGNS ELECTRIC �('T�E�
Y:3 4.y which require,a permit to ennamct,aecr,improve.demolish,or reran any structure
0< part f,s, I. thef suchpr It tlsignedstatement SPECIAL CIRCUIT'/MI$C.
date d paroanarb.,im1oinoofthe C t t UllialeIn.,tCl pt - COMMERCIAL(c osng with Sector ltxll)al Poison 3rfthe lion' us dPr Iv ,Cr.'),, '1'I:MI ME I HR OR POLI;INS'1',
L y o Ilan lie Is v e a,l memimru and the husis lot the allege cxanpuon.Any vinlalio.if ❑NIiW I{LDGIADDITION ❑UEMOLI'1'ION
x..m Soli 111131.5 by any:,,hilum fill a permit subjects the amhern(hr a civil)coaly of IN)WIiR UPiV ICPiS 01ENANI' ❑IsQDD SIiRVICIi
Ill.,mom man f vc hundred dollars 1351X). IMPROVEMENT
Sp ❑ Las nwncreOhe Pmpeny.or my cntplayec.with wages ns their sole compcn.wtion, SWIMMING POOL ELECTRIC
F• will Jo the work.and the.aractureI%not intendcdnraReed far tale(See s 11114.Imoincxs E3 OTHER
W 3 m and Pmfo.ions Cale:The Contmcmrs Liccnd Ww does nal apply man owner of OUTI.Ii I:S-SWITGf{ES-FI%TURP_S
property who builds or improves lheram,and who Jots such work himself or @rough
hisr rc employees,provided that such improvements anot intended or oOcred fR for NEW RESIDENTIAL ELECSQ IT.
sola If,however,the builJmSnr ntpra con is%old within nuc Year of anaptelion.'hc SQ.Fl.FLOOR AREA $ISQ.ITF.
'
own
i 'IJ FI 1 h 1 tp 6thlM1 JJ tM1 II P f
0
11 le ,P I tY IY t I' 6 id' 1 t r m
nt t form"
t(} 1114411 l ProlesvinoCore:)]IC t"t - ^y
icaoc 1awv1,n,,ma.,,IyalmI laturalli prown)xht null. vvs mvrun Y. L'UNIBIN'' PP. .13
who routines for such projects with a contracwr(q Ii enved pursuant err Ole Cone I �j�\
Licens law. .RN S. MICE I Lr\
1 am exempt under ice. .B k P C for oris m r
�, ACI'ER-DRAIN&VENT-\V6ILR IIiN ! VALUATION
°w°° APR 12 1999
KE S C 1'I:N, lG. DECLARATION BACK PLOW PROTECT.DEVICE
I hereby u0om under penally rrf perjury one of the following declarations:
t nIM1uvc and will muinminuCcnilicumnfConeem nr sdt:'meum hn Worker',Contpcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'IYPECONS"1 UCI'ION
%elion,asI..),idedt bY} I 37000he Labor Code.bujur pefounian,rotthe
work lot whaJIthis .air I IX'I'11121.} 11I.ItTRAII By
I 'll l W A ( P f y ' I by Section ��/^� O
311X1 ttl I err Code l tl t 1 Ill wild,for 'h hdin,p it is'iw.i, GAS I:A.SYSTEM-]INC4Ol1'1'1.E9'S V OCC GROUP APN
My Worker s Compensation lreumuce earrer and Policy number ate. GAS-IiA.SYSTEM-OVER 4 HzA)
Cmacc Policy No.:
CERFIFEC\TE OI;HXL%IP`IION FROM WORKERS' GREASE/I NDUSTRL WAST Ii INIT:RCEPIOR
COMPENSATION INSURANCE: BUILDING DIVISION I:I7I-S
or Ics.1'[his section need not be completed imhe permit is forone hundred dollars(5100) GRK SE TRAP
1'LANCIIIiCK FEB
.l
Ioy!my that in the pry laranceol the work
lcl(la wbichlh..the at Woser,C.Ishan SEWIiR-SANITARY-STORM IiA.MXIIT.
enmloy uny person in uny numnenn al III hcconte smject nr the WnrAcrs'Campem ENERGY PED
nalnnlr Lawn of Culife.oiu.Uatc WATER HFXI'ER W/VEN'I'ARLECI R
not
�/z O A icunt GINUINO PIil3
q (j NOI UP 10 APPLICANT'It,n a,r nmAing this Ccnifiemc of Exanption.Ynu Should WATER SYS,11F (TREATING
f•` Mmn,e sobject m the Worker's Cont tion I(he Luhor Code est SOUS FEE
pcn.0 pmvit hall you @
a � Einbwithnnnply wi�hsuch ptovisinnnorthio permit sM1vll MJcen¢A rmrrkcd WATER SERVICE
t7 Q
CONST RUCTION L17NDING AGENCY NEW RESIDENTIAL PLMIC SR FE I'AN
c - Date Receipt x
z Ihcrchy affairs lbauhcm is construction[ending othe performance of
U O
P the work for which this Rcoal is issued 1Sce.3091.Co,C.) TUI'AI.:
O Tendd%Name '1' AL:
WLender's Address Nl11LDING FEEf"' a F cc fy mm I have read this app0cwmn;md stem shut the above inflation oa ie
h correct.l agreeto comply will ell a hynnd county ordmeneesnnd staa lows 111 it 9t 1 QTY. MECHANICAL PERMIT FEE SEISMIC TLE
U 'Z buildingamsauclion,and bcrehy 1 It...ec ,pownfairoval mi,ony,o eller opo the
ahnvcmsurioned property Re inspection ImPoses. 1'IiltMl'T ISSUANCE Id, 11RIC REE
(We)agree to save,inJenudty and keep haralass the City nl Ctmacoma agaiaa
Iiuhiliticx.juJBmrnn.rosf.find expends which mayinanywayocamexgam"Itaid C11Y AUTIR ORADUTO MECH. PLUMBING FEE P D
in onteyuntce of the ingoflha rmit.
APp1.IGAN UNDf ttil) VU WILL COSII`LY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL FEE
'U' 17ROULAT NS
_\ AIR HANDLING UNIT(OVER I(AE)CIM) CONSTRUCFION TAX
S res of ApplicaWCmmntcmr l Umc I EXHAUST HOOD(WMLJCI) HOUSINGMP GATION 113E
HAZARDOUS MAE FIRIALS DISCLOSURE
WIII the upplleann nr Waleauldingoccul'am a ore or bundle hw:udnus nate,in I I EA I NO U N if(TO I oo'boo IPDA
ere defined by the Cluenino Me licilnJ Cee.Chapter 9.12,and the IIca11h and Safety
Code,Section 25532001 L 11861'1 NO UNIT(OVER 100.000 It I U)
U YI, 14N. VflN'III.AHON FAN(SINGI.E RLSID) PAID
Date Reeeirl x
Will the aplilicem or furore building rccupanf use aluipmem or devices which BOILER-COMP(IUP OR 100.000 HE HE
�hnil humbudis air conuminann a.}IclincJ by the Buy Area Air Quality Management 'P' A
Di%tm0 / BOIjdFR-COMP(OVER 100.00011111
El yes ❑No
n AIR CONDH IONF.R ISSUANCE DATE
have read the harm o n:nerial rn 25533 m d 2!(534.1 Chaffer rtland the Cali-
Tornio IlcIt Safety Cod.Sc:iut 2 . Y55ly le,255)4. unJv(it tltot if the NEW RESIUIINI'IAh MIiCIL SQ.Irl'. 7-
in
gm snranreml� . Iv nryre%rymsibllltymnnlity @c nav non
of m
""almen a t t nd,r c I''C'cniGc:d rl^n-
0. fir nr vu omzJ vgem
Date TOTAL: ISSUED 117OFFICE