S 2067 (2) -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECBRACAL IT IT NO.
DUILDING.DIVISION APPLICATION/PERMIT PLUMBING-MECIANICAL 2067
,.."..DING.PROIECp IDENTIFICATION
11
II-D' GADDRESS: SAN["I'ARY NO, APPLICATION SUBMITTAL DATE
NERS NAM1tE:
i' , L: CONT CTOR'3 NAMJ: LIC or, - NTR
10 1 /AQIJcz�hN/C CONTR .%
Cl 1!Cf 1 ANEli : 11CNO: ) RI, D ❑
N�S/gC r�,���) /fit, 'Ql-�tal ONE. S ':T),r@ ps� �y/' .ILIILDINGP MITINFO
I-�•✓W� _Rt-- vrWAJA) //�V15 Consull/tanWt Pces at y pplica[nt(Inl[i�/ R nL G/ ELE PLUMB M11E❑('.H
LICENSEDCONTRACTOR'S Dli .A 14NI'ION QTY ELECTRIC PERMIT FEE �L'J( 1)ESCRI PTION
I herehy affirm that 1 am licensed order....imfns of Chapter 9(commencing
"Z with Section of Division 3 al"the Business and Professions Code.wed my license's 1
�00 xi i'IiRMIT ISSUANCE
F n all fall and cR I'� ❑SFDWL ❑KITCI IEN R OD) I
aVyV License Cla Lic.p (fes-- API'LIANCFS-RPSIDIiNTIAL ❑ADD"' N ❑PLUMHING Iip�CF:
hdS Data Contractor ❑M 'I-UNIT QST 'TIT
ARCHITECUS DECLAR O
F.,pN EANELS 1 'fl N
CZ^Z I n an ry ,lamilbeuseduspublwnsards
UP10200AMPS TERIOR 11.iNEY REPAIR
W Lic Jb9lir',.-it
201-IINNIAMPS [MPROVEME S IMMING POROUS
z<sl f,jj OWNER-If UI1.DER DECLARATION OVER IINMAMPS BATH REM ) FAR ❑DEv OLI I ION
{py6'{a{yy Q 1 t that I am exnnpt from the Contractor's License Law for the �y�[/�
pq p,C1 followingrelic.]031 5,Bov ar-w and Profess.......Code:Any city ail county SIGNS ELECTRICAL o O tt, `
W3WE' wh h ttconstruct. hr ' p demolish. pa y.racmrc A
H�0 pr t 'I - rte 1' 1 'the Cpl"l tI 'hpe a II 'g doom neat SPECIALCIRCUI'['/MISC.
} Ik I M1 I' p nu Ih p t n. f tb C t toil I c e 1 "Chapter')
y.« fmmmcrving with Section 7000)ofDvieon 3 ofthe Business and profusions Code)or I'EMI'.MIO. VRORPOLF.INST. , COMMERCIAL'
11 y o awn he Ic exempt IhereOom and the hnsLv for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
++�� I•
Section 7031.5 by any applicant for It permit subjects[he applicant n a civil penahy of POWER DEVICES
y nal more than Evc hmadresl dollen($510), ❑'TENANT C]IvOOD SERVICE
IMPROVEMENT=?OD [,as owner(if the prapeny,or my cmphlises with wages as their Note compensation, SWIMMING POOL ELECTRIC
{d{�� will do the work,and the structure is not intended or oilmen for sale Sec.7044,Business ❑OTHER
{y m and Pnnassions Code,The Convenors License Law does not apply If an owner,of OUILETS-SWITCHES-FIXTURES
prarely whit builds or improve..discover.and is he does such wok himself ur through
his own mmployces,provided that such imprnvemems are not intended or offered for NEW RESIDENTIAL RLECTR Q Ff.
sale.It,hawcer,the haildingm
frlmproveem is sold vihinnce yearofcomp[tion,the SQ.Fr.Ph00R AREA $/SQ.FI'.
owrmrvhuilder will have the harden of"paving the he distant build or in.pmrve fnr for-
'nar of ode.).
u l [D1,as owner of the property,am exclusively convening with licensed cfnfmmrs it)
TO I'AL:
consumer th.pajcet(Sec.7144,Bnsine,v and Professions Cods)The Camramar's Li-
close
i- -
censeLove does not apply to an owner of property xbo builds or improves thereon,and QPY. PLUMBINGP MIT FEE
who wowete for swell projects wain a contenor(s)licensul pmsmuu m the Cfntmarars
License Law. PERMIT ISSUANCE
I ten exempt under Sea. .B&P C no this enarm
art ALE.R-DRAIN& WATER(EA) VALUATION
UIO
W(1R ad.,is COMPENSATION rjorywe
BACK FLOW P ECT.DEVICE
1 hereby million under Certify of perjury one of the following ocdara'Co
have
and will nor by a ectioCertificate7W of Colthe La uo Isleet I.lot the
Worker's Q of mpan
-aQRA1NS..P OR;ROOK AR iA,G.ND,
ntion,its provided lin by SectinnJ700nf the Lader Csalc.iia th.perfnmaance mf the _ _ ', STORIES 'fYl'8 CONSTRUCTION
fill for which this permit is issued. -M-FUR -I'F.N TRAP
I have and will maintain Worker's Compensation Insurance,as required by Sections ..I_.. _• .• .--
3JIN)of the LaMm Gde.fnr the performance of the work for which this permit isi...eJ. j;,,,GAS ,'vA._SYS'I'I?M-I INC,4OUThBTS U:: �, ..c'�n OCC.GROUP APN
My Wor 'r Crnl]]�(' c I 1FF1��11(,v�� d Policy mother arc sr„ ' S IA'SYSTEMOVI Ii4(hX)!, s. .. ri ei.
@mer (:j�lye�l Ry Nn: ,A - "':'
V�V``TTGGR--I FICAOMPELLLEECXIMNINION FROM AN WONKI:RS .:G_REASI'IINI>USTRI IWASIF INTI?I1CUPPIR ._1 . ��Jl
GOMPENSAION Irian NCE I3UILUING VISLNIEF.S
(This rection need not he mmCletedifthc permit icfonmc hundred dollars BltXOi,GREASITRApA s,;s -- — --
mless.) -- J I" '� PhANCHECK EEE
I certify that in the performance tithe work for which this permit is issaeJ,l. I SI?WER'15ANITARY:SI'ORM'GA.2(NI Fr.
mol employ any person In any mfnncr so n..w beenne.vnhjcn to the Wn.ke s'CoINERGY FEE
en- LOLL LOLL �...,.-. : LOLL..
,Z satioo Laws of Culifnmia.Date -WATER HEATER W/VENYRLP,LTR"""s''1(
O Applicant - - - GRADING FEE
No]'CC 1.APPLICANT:If,after making this Cenificara of I:.mptio m should WATER SYS /PHEAI'ING e
a ; become subject w the Workers Compenvatinn provisions of the labor c,you awl 'OILS FEE
W forthwith comply with such provisions nil this permit..hail hu destare wkcd. Fro -_F _sEH F—
Q' Q CONST RUCTION LHNDING AGENCY N17W RESIDES r, SIR SQ.FT. PAID
V z Ilarch,afirm thanhere is a cmn,mx;fn len ding ug:11 nrthe"fornanccof Daecc
.ciptp
ure
CLF. the work(oil which this permit is issue)(Sec.3119],Cie C.) Ig�'�
Lender's Nam. 'DOTAL
O W Lenders Address 11yTA L:
1 ecnify that I have rend this uppllemlun mad sun but the shave info..:aims is 11LDINO IEE
hcorrect. agreewnnnply with all cityvnaammy.aN' sand nme laws retains a Q' y, 'NANICAI.PER FEE
UZ hoddingroummnion.and hereby aulhnriec represenr vs ul this city to enter neon the SEISMIC FITE
ubovo-mmdiored propcny fnr inspenifn purposes a PERMIT ISSUANC17
(We)agree m save.iodenarify and keep h' less the City of Caperton nnrinnt ELECTRIC FEET
Iiabiliiies.judgments,emtvandexpenseswhiehn y in any way accmengaisishidCity AITERORADDTOMLCI.
in canuquence of the greening of this permit. PLUMBING F[E
APPLICANT UNDERSTANDS AND WII COMPLY N'ITII A. NO -POINT Alit HANDLING UNIT UTO IOT(y)CFM)
SOUl CiREGt INS. MECHANICAL Cup
AIR HANDLING UNIT(OVER 111.100 CFM) CONS'TRUC'TION TAX
S ignaturen ApplicanJContrunarDal EXHAU S'1'HOOD ted/DUCT) HOUSING MITIGATION PEI:
HAI.ARDOUS 'IF. PS DISCLOSURE
Willtheapplicam o,futurch slam,cecured store or handle hazardous'material III7ATI NG UNIT(TO 100.100 BT U)
as JeOneJ by the Cupertino Muni d Cede,Chap¢r 9.12.and the lievfh oW Solely
Cola Sution 25532(vl't HEATING UNIT'(OVER 1tX)pp BTU)
❑Yes /otl�urd
a VENTILATION FAN(SINGLE RESID) PAID
Data Receipt Y
Will the applicabuildingoccupant use equipment ail devices whichemit bummers ar con isddlnedbymc Bay A.dAirQmJty M....enenl .OILER-COMI'(JHPOR I(NI,IXNIBTU) a0 �
Ulnlria9
❑Yes BOILER-COM P(OVER 100.000 BTU)
I have lead the briarm materials requirements under Chapter 6.95 of the Cali- AIR CONUI'fIONF.R ISSUANCE DA'PE
ffmiti Health&Sudety Coda Seclifns 25505.25533 and 25534,1 understand shut if the NEW RESIDENTIAL MITCH. SQ.FI'.
hail - gAoes nm eu n0y favwa tenant.the it many responsibilhymnotify the nccupanr
nfte ircm da rhe mea pdfnnisxuwceffnCenilicne of(bnaponcy.
O lar,31horildiren, Date 'I OTA L: ISSUED BY: � �uV1n l
OFFICE