S2812 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERNIIT I.1.lAlBIN(:-pu]c11nNICAI. Q n O
BUIh X PROJECT IDEN'1'1t'I(:1'IIUN 1J L o
12
BUILDINGADDRESS: SANHARYNO. APPLICAIJONSUBMl'ITALDA I'll
ZI oik
OWNERSNAME: PHONE: CORACTORS NAME: LI'll O:
G NI NIC CONTROLN
+ odl�Iti Cot, 4943 43
I1;'1'ECT/IiNG1.UEER: LIC NO: AUUR135: �^ ❑
Eco D 2. <Ad
SCONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MITCH
(ice Lo 3 20 �' F7' go—
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am Ilcenmd under ptovislons of Chronic,9(mnttmeminF JOB DESCRIPTION
WOZO with Section 9088 of Division 3 of the fornnasand Pmfe.sions Code,and city license is PE ISSUANCE RESIDENTIAL'
1-,y_ in fall fore`and eBeel, 49.4 43 ❑SFDWL ❑KITCHEN REMODEL
Q,UU License Class APPLIANCES-RESIDENTIAL ❑AUDITION C1 PLUMBING Rh i'IPIi
f,_4C Data Camra
❑H ARCHITECPS DECLARATION ❑MUIJI- IC3 STRUCTURAL
ZOz land erxwnd mypbe mad aspuhlcreores PANELS MODIFICATION
OZyn
UP 10 2001 AMPS ❑IN'['I7RIOR El CHIMNEY REPAIR
F�'tM Licensed Prole,nnal 201-1000AMPS IN1 VEMI:NT C]SWIMMING POOLS
reg OWN1.R-BUILUIiR DIiCLARAI ON OVER IfIX1AMP5 I A11REMOIJEUREPAIR El DEMOLITION
C x Q I hereby affirm that 1 an exempt from the Contractor's License Law for the
ul 3 u U following masn 1.(Seaion 7031.5.Business and 1'mfession,Cade:Any airy or county SIGNS ELF.CTRICAI, El OTHER
y laid,r,q.i...a Error to e atom L alter.impnrvu,denu.11xh, a repair any Ftmeturc
t"'�'O5 prono its issuance,also requires the applicant for such permit to file a signed statement SPECIAL Cl RCUHUM PSC
�j�, that he is hoscisfJ pursuantm the provisions of the Contmaor's License Law(Chapter9
X00 (0o.intracingw hh Scow.71O)oi Div kir 3nfthc Rusinuszand l'rafcsnio is Coddor 'FEM R ML I'ER OR POLL INST. COMMERCIAL:
a a c;Y that he is exempt therefrom and the basis for are alleged exemption.Any violation of ❑NEW BLDG/ADDITION DEMOLITION
m4 Section]1131.5 by any applicant for apermin subjects theapplicanno a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
to
nm nitre than live hundred dollar,(S5(Ap. IMPROVEMENT
r TSD E]Las ox nor of the Imitator,tit my employees%fla wages astheir sole compensation. SWIMMING POOL Ii [I OTHER
L., will do the work.and the structure is not intended moffir d for sale(Sec.90,14,Bazin,, A
Wand l I e:tidll Contractor,L 1' 1 t apply t cr of OUII CTS SWIN2111 ORBS
la. propcny h h'IJs nr' p e:th d 'h J h k1u : If through
his own employee.,provided that such Imp overfa is are not intended or offcreJ for NEW RESIDE Ah CIR SQ FT.
sale.IL hourver,in,tomfiingorlmprovemfnti—old within one yceno(c�mpleti�n.the SQ.FT FLOOR AREA b/SQ.FT,
ertmPlder will hove the burden of pm ing that he did not build no improve for par
poeofsaler
❑ I,nx owner ill the property,am exnlnxivcly contracting with licensed coutmnors
mmimct the pre jeet(See.7044.]business and Profor,imas Coah,)'me Contractor.Li- -
seLawdtwsnotapplytoatownerofpmpenywbobuildsorimproves themon.and QTY, PI"UMBING PERMT' FEE
whoa, tract,lnrsudtp,fns with a connaaor(s)limned pursuant to t he C'nntrmmiorn
License Law. PLRMIT ISSUANCE Y..!
❑I am exempt under sec. .B k P c forthis rail
Al:1'17R-IIRAIN&VONT-\VATGIt l I'A) VALUATION
Uilf
W'ORKER'S COMPENSATION 01arp,or DECLARATION BACK FLOW PROTECT DEVICE Q
ill
IM1crewill amnmder pendryof,xrjiamem nfnlf-irlare taldeeluraiun R ?Co .�/
_
m
lhave and willf on,Se�io ificatcnfCe Lsoh Crods,feehrWoamusCeof the DRAINS-FLUOR.ROOEAHFA COND. STOR 'S TYPIi C(lN5'IRUC'1'ION
rin,m provided hi for mi Semina d]IXI al the Lubar CWe,for uhf per(omwncc of the ^
work fm which this penult is dxucd. PIX'TURES-PERT'RAP f...!
❑ 1 has,and will maintain Workeix Cnmpenxaier Imurance,as mqulrcd Na Section
3]OOofnhe LaburCmla for the performaneeofthe work forwhich this permit is issued GAS-EA.SYSTEM.]INC.4 OUTLETS OCC.GROUP �4
C�My Wrtk^rix. _IYy.xnlpnJ yt�pce came Policy Sri.:
...ac
MV GAS-Eh SYSTEM-OVER 4(EA)
CERTIFICATE OF EX17MM(ON FROM WORKERS' GRFASEINDUSTRL ASIDUEHCHlH 13kIRGVSION >f?LCOMPENSADONINSURANCE $
(This`fiction neat not MfomplfncJ if the penult ix l'or one hundreddnlhta f5l(p) GRIiASE TRAP
or lax.) .1 -P�.1�1'CI+EC t P 312 11
Icerdlythut rodurpaToonancoolthcwak forwheilthlvpnoaitislsxncd l dint SI WI?R-SANITARY-STUItM EA.21H1 Fr. V' ^ �
ma rmploy'any person in any manneruo xs m bccomc ad ject m the W'orkcn'Comlwn- l I!NEItOV Plili
O z stolon Lawz of California.Data WATER
HIiATLR W/VF,N-111 fR I API .GRAUING�PE. i
Z 2 Applicant
py NOTICE TO APPLICANT.It.after making this Carlinville of Exemption,you should WATER SYS'I'EMOREA1 ING , SOILS FEL
NF" !warm`adcal 10 the Worker's Cnmpfnxanon pmviomw of the lanes Cale,you must
LD
forthwith comply whh such provi..aa u,this permit sbnll be dcwnwd mmoked. WAI'13H SERVICE P..V
C
7 z CONSere s acONLENDING AGF.NCY NEW RL.SIUENTIAh PLM1IN. SQ.FT.
U QIhttcby nlirtm that them lsxainxrmainn lending agency lirt the perlbrmnnce of a eceiptN
the work fill aboch nix conat is issued(Sao.30)9.Cl,C.) 'TOTAL: .,
O U Lender's Name
TO3'A
,rIf
te Lcnl All :: x BUILDING 8313 �"
,r 6. I nay thin lh read thisapplication' J tot duh M i t t .
uo) correct.1 agree to comply with all city and countyordinances andstate 1 i yto QTY. MECHANICAL PERMIT FEE �O
UZ htyll g tomo ,and thereby aullnry pcentatve%(f fink city itnt
cerugnt the Z1SMICFEO
vnrvomenlioned property for incpmnion Pu alfa, PERMIT'ISSUANCE
(We)agree to save,indemnify and keep hamdess the City of Cnenino against 13LEC'1'H1
Iiabllines,juJWnem...rants and expemee whichmoymretry way acoue agni no said Cry ALT ER OR ADDTO MEC II.
in nsequcnce of the nanfa,ol this pcnnil. PLUMB 11. QO
APPLICANT UNDERSTANDS .L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB.tHl(i MECH, IC .FEE
SOURCE "IONS
I /2/�� AIH HANDLING UNIT 10,0N)CFM) CONS'IR "I ION TAX
gnatirent Appaant .omnmtur
.4 Oct
Care EXHAUS'P HOOD OV/DUCT) HOUSIN MITIGATION FEE
HAPAKDOUS MATERIA 9 DISCLOSURE
Will rhe applicant or future building occupant store or handle hazallous material IIHATING UNIT PTO 1af afford 89U)
ax dennfJ by the Cr,om na Municipal Con,Chapter Y.12,and the Health and Sale,
Coda.Section 2553^200' I IIiA'I'INO UNIT(OVER IOlo0 )11'1'U)
❑YU ^Z VENTILATION PAN(SINGLE RF_SIII) Zv PAID
Dee Receipt M
L Will IM1 applicant f n hnilding rwcupant see equ p rte n or day cez wb ch ❑OILER COMP('GP
UR orPdn BTU)
.At h b remnant cit: 'defined by BetBay Arca Air Qunlny Ma epcolvat TDIAh:
UIxV n. n BOILER-COMI'(OVER IrX1.(NI(111'IU)
❑Ye,
I hits a read the hazanlnux materials is under Cha¢r 6 o5nfthu Cali- AIR CONDITIONER ISSUANCE"
rc.2553s p
forma Health&Sul'ny Cala Sati acr ffira 25533 and 2-5534.I understand Iba Il rhe NEW RIiSIUfiNTIAL MLCII. 5Q.NC /Y
building da�- umndy have nano.dna smy nsry)nsibililymnmify the acupam
oath t ill. hie of ceofa Cenilienre fa pone •�/y1/.
Owner or authonuJ agent Dee '] TAI- ISSUED BY: ( `
OFFICE