S 0226 (2) A.r?PLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL - PERMFFNO.
RDILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S - O Z Z{/��V
_;I '. ',IIUILUIN(:'1'ROJL:CTIDEN'i'LFIUATION•', 'r'•
BUILD( GADDRESS. qq ,f SANITARY NO. API'LICnT10N SUBMITTnL IIA'1'L
CON'1'RACTO N
NIC CONTROLa
CIIITHCT/ENGIN ' LIC NO: - AU R S' ❑
CONTACT: /a//L i Pu—a/Tq4'/``/� r r^.Bl11hDING PERMIT INFO '
! ZG-7 ❑ Consultant Fees Paid by Applicant(Initial) t-BLDG E PLUma MEC
^
LICENSED D CONTRACTOR S DI CI ORATION QTY {1 I ECTRIC PHRMIT'ber +' �'I I'LL
I hereby amnnm tl I' acdue p fcnapmr9(commencing ). .� r+ JOB DESCRIPTION
OIYsZ with Saban 9(MMI of Di is nn 9nfthe B."reuandLmfic"ousC,alc and I license is F T
1 Y -RPIID.N IAL:
WOO PERMIT ISSUANCE O 'C EN REh10Ulil.
FU., in full fnssx anAc c, ❑SFDWL ❑KII CH
EN
tF) License Clashic.a APPLIANCES-RESIDENTIAL F1 ADDITION 0 PLUMBING RISPIPF
FF Z W Dam Connacmr
bs60.. �26 ❑MUL'fl-UNIT ❑STRUCTURAI.
y ANCHI'1'EC'I"S DI!CLAItATI N PANELS
F MODIFICATION
Z O y,Z„ I undersand my plana shell he toed ax public records
UP'f02(MIAMPS ❑IN'1'IiRIOR ❑CHIMNIiY REPAIR
Licensed professional 201-1M0IAMPS IMPROVEMENT E)SWIMMING POOLS
�Y'f',.•,11 OWNER-BUII.DIiR UECLARAI'[ON OVERIo00AMP5 El BATH REMODF,IJREPAIR [ID17MOLITION
Cas, 1 hereby affirm that I am exempt from the Contmemrs License Law far the
eO F U following mason.(Section 7031.5.Business and Professions Coate Any city or county SIGNS ELECTRICAL Ll OTHER
u+a U F which requires is permit to canslrun,duce improve.demolish.or repair any swemrc
prior,.it......ame,alknoopiresthe.pplicam for ouch Exannamfile.signed sournson SPECIALCIRCUTI'/MISC.
a� that he is licensedpursuanitotheprevisionsoftheContractorsLicenseLaw(Chapta9
Icnmmamingwitn Semion]PXAII of Divixioa7nfthe tlusiness and Pmfessinns CWs)or TEMP.METER OR PULL INST COMMERCIAL'
C.y o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADod rJON ❑DEMOLI'PON
Section 70315 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES [I TENANT ❑FOOD SERVICE
y nm frow,haa five hundred dollan(5500).
E-Z6 I,as owner of thepacifism,onn to ccs wish avelip,as iheirxole I u inion. SWIMMING POOL ELECTRIC IMPROVEMIiNT
^k.�0 ❑ YemP Y li pens [I OTHER
y will do the work,and the structure is not inlemkof or offered lot sale(Sec.7044,Business
LLl and Professions Code The Contractor's License Law does not apply to an owner of OUTLIffS-SWITCHES-FIXTUR '
property who hullds or improves thereon,and who does such work himself m Ihmugh
his awn employees,provided that such improvement,am not intended or olicred for NEW RESIDENTIAL ELECTR SQ PI�
sale If,however.the Wilding or lmprovemenl ixsnld wilhin one year of templet) .the SQ.IT..FLOOR AREA S/SQ.FT.
er-huilder will hove the burden of proving that he did not build or improve for pur-
Ja se of a.leJ. -
❑h as snwner of the pmpeny,am excluiivdy commcting with licensed mmmcusrs m I"
n.t ct thepj tfS ]U44B 'I adP C I )TI C t t I 1 Lt ' "+ a' 'ER `
cense La d t hPai an fp pent' a Held p ,C en d QTY ISL, to. I'PIRMIT EE�:•'P
Who Contracts lin such pnpunsw'lheunnmuogMlsen:cd par,un no O�Comn enema ' 1".. `
License Law. rz PEIUH p ISSUANCE
I am exempt under Sec .B&I'C for this reason
ALTER-DRAIN&VENT-WATER(EA) AI N
Owner Data s`
WORKER'S COMPENSATION DECLARAI]ON HACK FLAW PROTECT..DEVICE
I hearty oflimm under penalty of parip,one of the folliwing deelamticum:
� Ihave and will lmnimaine Certificalcof Cnnunuoself-inwnne for WmIoasConn,n- DRAINS-FLOOR.ROOF,AREA,COND' STORIES 1YPEC0NS1'Rf1C'II0N
van,as providal fur by Sedinn 3](X)of the lalhnr Code,fnrthe Iarouramcc of the
for which this permit is issued. IIXI TIRES-PER I RAI'
wn 1 have and will mainmia Worker's Contionsation Insmmrcc,as myuired by Section
3]fM)nflhc Wlwr CrAq for the performance of the work for which lh' tis issued, GAS-IiA.SYSTEM-1 INCA GU'fi,G'I'S OCC GROUT' APN
My Wnr C cnsat c ricrand Pnli
Cauier'��PION GAS-BA.SYS'TIiM-OV-R4(EA)
CERTIFICATE COMPENSATION
INN('ROM WORKERS' GRF.ASFANDUS'FRL WASTE INTFRCEPFOR
COMPENSATION INSURANCP. BUILDING DIVISION PF.Bfi
(This section need mat bocampleted i f the permit orf ueanahundam dnllan RlBb) GREASETRAP
or lest)This
FEE
I edifythm In the performanceofthework for which this permit isissued.(shall SEWER-SANITARY-STORM EA.20X1 FT
nal employ any person in any mm�ner so ns to became xobject In No Workixn'Caru,u- ENERGY FEE
Q z satian Laws of Calif rria.Date WATER HEATER WNHNT/IiLECi H GRADING FEE
Q
s'TApplicant 'i r%1 NOTICE TO APPLICANT:IL auctioning this Certificate of Exemption,you should WATER SYSTEMO BEATING - Soil's LtiE
abecame object to llm Worker"Compensalinn provisions of the Labor Code,yon moat _
IJ-1 forthwith comply vvithsach provisions or this permit shill he deemed revoked. WATER SERVICE. '
0
p" CONS.i,C.c ONLENDINGAGF.NCY NEW RISIDENTIAI.1'LMB, SO FTI PAID
U p Iherchy nRnm that Otero iiacomm�uvinn lending agency punto rycrlornumm of Date R 2c mJl
H the work far which tris permit is issued(Sec.7091,Ci,C.)
Q U Lender's Name T01'AIa'
leaders Address T(YFAL.
,FUs 0z t ' I _
ILDINGFii
I l that l .ati t n,ppl t II l h t i IBU
TY. MMT F
corca I g ct c ,.ts,.,in ell city nJ c y 1 pe. oil soneretain, ; F
b�ldingcnslnun and herchy amnrzau representatives of this city or enter alp,in the
SIBSMIC PEE �V)
.hove-mentioned pmpeny far imisceion puryous. PERMIT ISSUANCE V(
(We)agree to save,indmnnify lard keep hnrmlexs the City of Cupeninn against / ELECTRIC Fl" KJF
Iiabilitics,judgmems costs and expenses which may in anyway accrue against said City ALTERORADD'FOMECII
muaquenw of the gnmGng.[this pennln PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TG IO,0d0 CFM)
SOURCE REGULATIONS. MliCiIANICAI.PI LI -O
AIR HANDLING UNIT(OVER 81,1100CFM) CONS IRUCIIO '1' -
Signature of Applicant/Conuactor Date EXI MUST,[1001) W/DUCT) •HOUSING MI'I'IGA ON FET!
HA9.ARDOUS MATERIALS DISCLOSURE
Will lhe.ppliewa or mare baBding atcapam"ere It,hnndlc humaloas mmcrml 14EAI'INC,LINT,f110 100,000 BTIII
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code Selby the .pert /,`-nicipal IIEA'FING UNIT(OVER IIXhIIf)(I I1T117 -
�Ve'x VENTILA'T'ION FAN(SINGLE RESID) PAID -
Da'e Receipt If
Will the applicant or future huilding oecup of use equipment or devices which BOILER-COMP(JIIF OR IIX1,B11f1 BTU)
mil haaanlaus air tonmminrox as defined by the Buy Arca Air Quality Munugemmn IUTAL: ��
District BOILER-COMP(OVER 100,000 BTU)
s' ❑Yea _ ,.
I have rand the ha.nrdoux annamals ragni mamas ander Chapter 0.95 al the Cali-. AIR CONDITIONER ISSUANCE DATE
fomite He h&Safety Code.Sections 8505.25533 and 25571.1 understand that if the NEW RESIDENTIAL.MECIF SQ.FT. q /D (? s J
building notcumall have a noon,lhut'n ismyraspm.ihility m ratify theaccupunt
n ire swhis mel be incl pdnrmissuarice nfn Cenifrte f(Xue y
Ow ¢
'I'O'TA h: I I"'EDBY:
OFFICE