S 1389 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICA'1'IONIPERMIT TING PROJENG CT
T IDENTIpic' 1389
BUILDING 1'RO.I PICT IDP:NTIPICA'fION
BUILDING ADDRESS: SANITARY NO. AI'I'LICA'I'ION SUBMI'1'I'AL FIAI'F"
3 K I /FS
U�X'Na5eRSV.:NrAAME: PIIONs CONTRACTORS NAME: LIC NO:
MI.
�rte++,l rvl % ry/!//�I/N SQLOKyN J Z9l•l NIC CONTROL i1CARSit=1'/F.NGINEEH: LIC NO: 'T ADDRESS: ❑
�SraGNt�• �PaVL1LII>�
CONTACT PHONE: 13UILDING PERMIT INFO
CqkW6 U1,/) 1117.DaM 01-
0
^ ❑ Consultant Fees Paid by Applicant(Initial) 111;DK ELECT* P I
LICENSED CONTRACTOR S DECLARATION Q'lY, eLECTRIC PERMIT FEIi
1 nereny vrfir mm I am ban.cd ander pn,.i.hma or chapmr 9 gannnenni-9 1013 DESCRIPTION
°�'z with SmIior7W laf D.1iciva I It he Ita.incssamI Professlans Coda ain't tat license is RESIDENTIAL'
MW°° PERMIT ISSUANCIi
NIy Licaaa,Class
effect, ❑ShDWI. ❑KITCIIIN REMOUIJ.
e—yu License Clea Lica APPLIANCES—HEMPEN'I'IAL []ADDITION [I PLUMBING RF:-PII'E
yZW Dam Cnmmmar
ARCHI'IECi-S DECLARATION ❑MUTATUNIT ❑STRUC'FURN,
z c an z I undimaAnd any plans shall M used as public records PANELS MODIFICATION
O z-° UP TO 200 AMPS ❑INTPRIOR EJ CHIMNEY REPAIR
r_N.Ir R1 Liccnsal Ismessinnal 201-1000AMPS IMPROVEMENT []SWIMMINGPOOIS
OWNER-BUILDER UI[CLARA'I'ION OVER I0011AMPS ❑BXIHRFMODEL/REPAIR 0DEMOLITION
1 hereby affirm that 1 am eeempt from We Canvacmr's Lirense Law far the
S°6 U following.....I.(Section"1031.5,Business and Pro ..ime,Calc:Any city'air county SIGNS ELIiCTRICAL El OTHER
3(L N which re9aires a pernnt m enn.auel,III,,in.Pmve,.c nolkn air repnhany.anoame
=°a pdortoils issuance,also requires the applicant for such permitit)file a signed>Iatirmt SPECIAL CIRCUfDMISC.
C G.4 That he sncemed Finatim 1.thepnakirm,or,bc Cnmracmra lacunae Law(Cnapter9
COMMpsilt
WAC° (cmnmencing with Secrr OODA of Division 3 of the business end Professions Cde)m' TEMF ME 1'IR OR POIJ S .
L ax p oC that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW Id UG/ADDITION ❑DEMOLITION
W^h Section 7031.5 hY un)'uppllcan,hrtxperndt euhlcd.Ihc uppliccnt to acivil pcnahY nl POWER DEVICESF I" [I FOOD SERVICE
Eve
P.,z} not more Than hundred dollars($5aff. 1R r�1N u
qy 6 � 19 as owner of the property,or my employees with wages as Their solecompensation, SWIMMING L POOELECTRIC I"
C � will do The work,and the structure is all sanded oroffered forsude(Sm.9M4,Buain
rofessies. ❑OTHER
3 m and Pons Cale:The Erroneou's License Law docs not apply to owner o' OU'TLE'TS—SWI'I'GHES—FIXTURES r (✓UI—Ck s nLi�
pro perry who builds or improves thereon,and who does such work himself or lhmugh
his awn cm,I.ym,,provided That such impmvemenls me nm ioended or nllcred Int NEW REST PEND IAL P.LEC"R SQ ITP
sale.IL however,the building mr improvcmem is old within one yearsfcomplction.The SQ.17.Fl.fN)R AIt1iA 8/SQ.Fl.
r-h,.IaA so III havo rbc M1unlcn of proving,h:n he All not huild or improve for Our-
ryne o sown). r�1/11
❑I,a owner of the propenyl nm exclusively contrvcling with. ...licensed cnntmdnII m TOTAL: l/l/
construct the esnnot (Sec.oan owner
and pI'mfsaran.,ds ori Tho Cnnmuomn.Li- - -
nseLaw
lmer,fomtapply man awn en'somehnywhosedprsimpro theComon.and QTY. PLUMBING PERMIT FEE
who wnwe¢liar mch pnsjects With a nmwemr(s7liccnsed pursuant to the Commmors
License law. PERMIT ISSUANCE
Tom csmu Vale Sea 7y B&1'C for,his.,,in
AI:NR—DRAIN&VENT—WA'fGR(IiAI Inv VALUATION
Owner ' Date
WORKER'S COMPIiNSAT10N DECLARATION BACK FLOW PHOTECI'.DEVICE O�
1 hereby affirm undo penally of perjury ane lot he fnllawing Jedvmtinns:
Ihavcandwillmvinmina Cmaficme ufConscnunself-insure for Workers Camper- DRAINS—BOOR,ROOF,AREA,COND. S'T'ORIES 9'YPH CONSTRUCTION
scion,.........load for by Semloo 37(1(I of The Labor Code,for the pcdorunw ,, he
work for which this peril is issued. FIXTURES—PEIt'I'RAP
❑I have and will meiando Wnrk"s Cnmpemvtion Imar once,we required by Section Ai
3](0nf:1he Lahnr CuIa.or lheperConmonacul he wnu Is for which This penuit is issued. GAS—EA.SYSTEM-1 INCA OUTLETS OCC.GROUP APN
My Workers Compensation Insurance comer unit Policy number arc:
Comer: Policy Na.: GAS—EA.SYSTEM-OVER 4(IIA)
CERTIFICATE:OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPr0R
BUILDING DTVI ION FI'+S
(1m,W Tln t ncminm be complcod if,bc permit is future hundred dollars IS 00) GIEASb't'RAP
or less,) PLANCHI3CK FI313
I cenifythatin the pcarminative ofthe work furwhich thispenmirs issued,Ixhall SEWER—SANITARY—STORM EA.2(X1 FT.
nal employ any..eman In any manner so as m becalm subject To The W akerd Camp<•n. ENERGY PER27
0 z saloon laws of Califomia.DamWATER 1113ATEI1 WNIiNT/ELIiCfR
'J Applicant GRADING FEE
G N191CII TO APPLICANT':IL after nmkirg Flom CenlBenle of Exemption,you should WAFER SYSTBM/TREAIING
NfN—' become subject m the Workers Compensation previsions of the Latin Code,you must SOILS FF.Ii
!-p limhwith unnply with such pnrysome,..r this permit shall be deemed revoked. WATER 511RVICIi
Q
U O CDNSTRUCTTON L lion la GAGENCY
agency NEW RESIDEMIIAL I'LA1B. SQ.IT. PAID Dale
I hcrehY arnrnu thus lhoc is o cunxwctiun lending agcney fnr,hc pertbnnOnce of
11� The work for which This peril is issued(Sec.3092.Civ.C.)
I.ender's Name 'TOTAL:
1 landm.,Addrens TOTAL:
F BUT[. N P'G
certify that 1 have read This vpplicmion and state lhm the aMrve infonnatinn is -
�., lin ca m'.I agree to comply will,an'i"and enunry ordinances and Nu,c lows rdaung n' QTY. MECHANICAL P13RMIT FEE
U z building construction,and hereby a flasp.e represenmdvesmmis city m enlerurym Jos SEIS M IC to'1-54
alswe-mmrationed pmpcny for inspection purry.as' 1'13RMD'ISSUANCE.
(We)agree m save,indan uil'y unit kcal,homlcss The City Cape Tina against ELIiCIRI PEE
Iiabilities,judgments.costs and expenses which may in any way Occurs,against sold City ACITR OR ADD TO MECH.
nugnenceorthe granting mf this permit. PLUMRIN P
in ca "
10
APPLICANT UND17KSTANDS AND WILL COMITY WITH AL1.NON-POINT ABR HANDLING INTI(TO I0,(k10CFM) 1
SOURCE RF.r ULA fflxls I
MECHANI A(
AIH HANDLINGUNI'1'(OVER ".000CFM)
/1 CONSTRU N'TAX
Signature ofA plicanU'ommc,or 1) EXHAUST HOOD(W/DUCT) HOUSING MI 'A[ION FEE
HAZARDOUS MATE WAILS DISCLOSURE.
Will theapplicantor fuwre building occupant scoreer handle lmzsalous material BEATING UNIT(9'O 100,000 BIG)
as defined by the Cotonou Municipal Calc,Chapter 9.12,and the Health and Safety
Cade.Smium 25532(x):' ][HATING UNIT'(OVER 101100 OFF)
Yes
VENTILATION PAN(SINGLE HESIID PAID
Date Receipt p
W01 The air contaminants
or future melding wane[l ace equipment or devices which
it hawNnm air cmnmminams vs Jebned by the Flay Amu Air Quality Management ]TOILER—EOMI'(3HP OR I01,000 R'I'U) AI
UistricYl
Yes BOILER—COMP(OVER 100900111U)
L7Na
I have read lhchvsJoua ma¢rials¢yuirenants unJar Chvpmr fi.95 of the Culi- AIR CONDITIONER ISSUANCE DATE
famia Health&Safety Code.Sections 25505,25533 and 3534.1 understand That if the NEW RMIDF,N HAL MECH, SQ.IT.
building does not currently havcn,cnan4 that itis my respon.i bil try to noti ry The occupant x (f
of the fa CenifDfNcye( � puy
Owner or inheritedagent . TOTAL: -ISSUED IY:
O
OFFICE