S 3349 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL re rr No
AL
BUILDING DIVISION APPLICATION/PERNIIT PING R OJELIEC11ANIFIC 3349
If1111.111NG i'ROJF.CI'IU&YI'IfICA'i'111N
BU1LDINGADDRESS: SANITARY NO. APPLICATION SUBMI I-IAL DATE
l&APPr,%No� 1 ' 9sd/'t /2- /'o •Qy
OW IIR'S NAME PHONE, O y CONTRACTOR'S N, tE: LIC NO,
Jo J1 �- ^� Ltoa N/C COMIROL#
ILIBI"ECUENGINEER: ""No
ADDRESS: ❑
St N F&STS-1 5l 3
CONTACT: PxONIi: BUILDING PERMIT INlil
.• ❑ Consultant Fees Paid by Applicant(Initial) Eft DO 1: ECT PLUMB Nil CH
got 6-� 9- 5-
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aBirm mat 1 arm licensed coder provision,of Chapter 9(commencing JOB DESCRIPTION
`,ine7. PoPHRMI1'ISSGANCIRESIDENTIAL
a cc, wanSnt"nryD
FW. nfulltorteand ❑SfDWI, ❑KITCHEN REMODEL
=-i- License Clasn hic.p
6 U API'LIANC,IiS-RIiSIDIiN'1'IAh UI'I'[ON ❑I'LI1MI{ING RIi-PIPE
H Z Ed Unm Cnnln:[mr
'nQL ARCIII'I'EC'I"S UIICI, 4 PION ❑MUhI'bl1Nll' ❑S"1$l1C'1'l1kAl.
F y 7 It my plans shall be uaN ns pun rcands PANELS MUDII'ICA'H(ON
OZ�� UP10201ANIPS ❑IN'1'11RIOR OCIHMNEYREPAIR
F-Nt•+w Liccnsnl Pnde_"'arm 201.1000AMPS IMER(OVEMENT SWIMMING POOLS
OWNER BUILDER DECLARATION Ov[k HXXfAMPS ❑BATII RI:M(ODFIAEPAIR ❑DIiMD1.T1'ION
Y K C Q I hereby affirm that 1 am exempt from the Commmor's License Law for the
3:0w<
:6 U following reason.(Section 7031.5.Business and Pndessions Code:Any city or county SIGNS ELECI RICAL ❑Ol'1{IiN
W 3 LL which requires a permit m construct,alter,improve,demolish.of repair any smuctum
prior to t also q s the applicant fsuch Permit ric a signedsrmcment SPLCLV.CIRCUIU SC.
�E, that he,,liaml,di parromadoflic plowman,ofol Contractors LLaw(Chaprer9
0 (unnnmmngwth SectionANMD afDj,j,jaa3 Gh B ." r x, d Pode,,in,Gsde)"r rCMP ME IER OR POLEI ' T M
COMMERCIAL
d W a rL That be is exempt IhwGnn,w,d the nasi,for the alter,',c.e nption.Any violation of ❑Nh:W RIAG/ADD19'ION ❑DI? OL1'fIUN
iEm Section70315by any upplicl,nl fora par:nil enhjecr,the vpplicnnt n,ncivil lnomhy alPUWICIt UI1VICIiS FNAN
Dol more than five hundred dollurx($5gh. ❑'IMIIRO I' Id)OU SERVICE
�^Z"Q I.its owner of d,nr m, Ince.with wages dwirsoleeint aliaa. SWIMMING POOL IiLECf IMI'1tOVI:MIINT
Fo ❑ pripc y ymmp r sax as pen ❑o'1'xrk
TI d"nc�work,and me he Contractor,
o t is nor,Lwin Lir Law
due,
s(Sm.,I an,wi n
63eoo and1nywhiob CWIn Thelancrnr'x Licence Lawdoes Dolapply a, nthrougf OU'rLlTS-SWITCHES-
his cov.y who buil,.or improves t .Inn,and who dies such wnrk dedohimself or rhnmgM1
his own employees,provided thin such in,pmvcmems arc nm intended or offered for NEW RISIUIiNT1At.ELEC!R SQ 1l1
sale.If.however.me building or improvement is sold within one year of colude ion.the
owner builder will have the burden of proving that he did not build or improve for put-
pose"Galt). 'I'(Y b
D 1,as owner of the pr pc ty I ly summering with ho,nscd onrract,ms ro
any ul project(Su 7(94 B 11 1 '.' .Cd ITM1 r- t cl ,I �d
whoco I norapplyou I q n b II: :0-con.:Lid QTY PIAN1BWG PERMIT' FEE 3
'en I us,norapp I'u.wn.ro lr Ely)who sedbriis nOrlhc(.,nr ora
Tetras law. 1'ERMI'I'ISSUANCE:
F1 I an exempt under Sec. .B h P C far this reason
ACfER-GRAIN kVENT-WATER[EA) VALUATION
Owner Date d
- WORKER'S GGM1-ENSAT10N DECLARATION BACK FLOW PRUIECr,DEVICE 0
1 herby✓inn under penalty of ne Jury Line of rhe 4dlowing devitio ns:
I havandwill maintain mCmificateof Conmm mself-inwrc for Worker's Cnal DRAINS-PLOOR•RODE AREA,COND. Sl(Ikll!S
e . O RUCTION
Y. salion,as provided for by Section 3700 of the lana Cote,for the performance of the
work far hchtha perm issuedL FIXIURFS-PER rRAi' v
❑ 1 have and will maintain Workers CM -i 1 .marl rey dby Section
37110be I-albar Code h d t fll -ark far h h this Ecomil6,l,us GAS 17A.S YSA Elm-I INC.4 OUI LF]S OCC.( pUpNC)�
my policy
pol .y.,uheram:
Camepolicy No, �� GAS-INAI'EM-OVER'441?A) /
�
TsOrliMIW t
11 ION
'G-
FROM WORKERS' ORPASI% DU."I'RLwASI'Ii INTEItCIiI'IYIk d2--�
C(ONIPENSAI'ION INSURANCE �� GILDING DIVISION FEES
(Thi,secri.rovennot becardra,d it thepnnir kfmonehundreddolla,s(SIIXB GREASETRAI IO�1 f D
"r lee.) - --- - I'LANC' lccnifyr Din rhe pedomanec"E the work forwhich misyrcrmir is izwcd,lshill SEWER 4SANITARYl SIDNM PA.2661-x. I O
noternployany Is n' Y u r bj the W..kan.'Compcn- ENT: ' Hili •-r Z-n
,7, nmion Laws , : f a s ccum9su WATER HINTER WNF.NT/ELF.CfR S
Z Applicantcnna. r ` 1 GI-TE.
NOTICE'0 PPLIG :il,soler muting this Ccnilicate of E,an,prinn,you should WATER SYSI EM?RP_A'[NG
I-: ben:sox ect m be W'r1at Con:pemodon pro ms of rbc I.abur Code,YLiu nms. -_�- SOI :ITE
W formwi tartly w'h In provisions or This permit shall be decimal revoked. WATER SI{NVICR
Q Wall
PAI /
CONS'IRUCI'ION j_E DING AGENCY LADD
'I'IALI'hMH. SQ,PI'. Dat Receipt a /Q
I hereby affirm that is a mnQuictian Tending agency fir the perRmnance of O�
LUL.O the work lir which this permit is issued(See.100.Civ.C.)
Q Eamt's Naom 'I(Y
} {U fscaleLx A,dm,, OUILDIN 'li
y 1 certify,that 1 have read oris application and sate That the abtwe infornaion i,
F.
N nmecr.l agmu wcomPly with all cilY and county ordinance,and sma law,mhtingm QTY. MECHANICAL PERMIT FSE SIi15 .F'. Oil
U Z building anstmetion.and hereby uuthodee,nprcsenmrives ofthis city m enter upon the
movennentuard prai for inspection pugnsex. ANCE EI-1,'I'RE Plili S'"
(WO qvI o,save,indcmnily and keep hamdex.the City of Cupertino against
liabilities,judgments,costs andexpemes which miry m any wary acemcagaina said City D TO MECB.r the grunting Lir Ilia pcnNl.
UNDE "IANDS ANU WIhI,COMPhV WI'TII Ah NON-POINT G IINI'I'(TO IIO,INMICITIIME( ANICAhI cli 3 '
SOUL f;G . NS. G 11NIT(OVER PEI
CPM) CONF'kUCI'ION FAX
nawrco canVCnmmctor Date E%HAUSI'IIOOD IWNUCI') HOUMN rA11'I'IGATIONIFI3
r HAZ RDOUS MATERIAE S DISCLOSURE
the applicam it fumm building txcupanl shoe or handl hvallous mascot HITTING ON]"f LTO IIX),1X10 BIL)
as de J by the Cupertino Municipal Code,Chapter 9.12,and the health and Safety H17Al'ING 11N1'r(OVER 100.0110 B'TU7
Ci, rction 25532m)?
E3 yes ❑NoPAID
V12N'1lLAT10N FAN(SINGLE RESIDE Dam Rce l#
W'Jltheapplic:nu"r linnet buildull-comd use equipment or devil,which 0(1111?R-C(OMI'(311POR IIHI,IIIXI B'Ill)
mil ha,mduuaaircLaa ono:n,us 1,11 1 by me Bay Arno Air Quality Ma c"cmcar 'I(Yml.:
Dian? BOILER-COMP HOVER 100,000 IIfUI
*1.
0 N
do"s matcnak requinenxms under Chapter h95 of the Cali- AIR C(ONIO1'I'IONf:R ISSUANC(PIJA'1'E[
.Section,255(15.25533 and 8534.1 undcnun l that if he NEW RESIDENTIAL MECH. SQ.14. -1 q
ave a tenant,that it is my responsibility a,notify the occupant
M met Inmrmi"manceofa Ceni&a offlea
❑ale ISSUCU If Y:I al
OFFICE