S2464 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE2TIN0 RU1LDINC-ELECTRICAL p PERMIl'NO.
BEILDINC DIVISION APPLICATION/PERMIT PING PROJECIFx:DENTNC 7 S 2464
BUILDING 1'RflJli(YF ID4:N'1'Ix'ICATION
BUILDING ADDRESS: SAN',RY NO PLICATION SUBM ITTAL DATE
19675 LA NAA- Dr9;1 , e-y i PIa GA `-9 � 7
OWNERS NAME. IIIONF.: CONIRACIUk NAMIi: ID �� CLIC NO I B
✓ X/-^D- NIC CONTROL)
ARCHITECT/ENGINEER; LIC NO: ADDRESS: A ❑
10 q�' ,riz'1
CONTACT: 1'IIONE: I BUILDING PERMIT INFO
Aln J 1 e 4 oB _,r�� E3 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB -
LAt
CH
y5
LICENSED CONTRACI'OR:S DECLARATION /Y QTY ELECTRIC PERMIT FEE .Lr✓Jy ;?- CJJ/
I hereby affirm the,I am litroseal under provisions of Chapter 9(commencing JOB DESCRIPTION
CZZ with Section llX.11of Division 3of,he Bminessand Professions Colli my licensers - RESIDENTIAL:
6100 1'IiHMIT ISSUANCE s
SIy� in toll Gswand effect. Bp �$FDWI, [I KITCHEN REMODEL
QUU License Class _ LieN AI'I'LIeWCF_S-KESIDEN'I'IAI, }�9Fm1'UON ❑PLUMBING RE-PIPE,
hQa Dam TSDContrE L f�-'avrt ❑MUhTI-UYIT ❑STRUCTURAL
ARCHITECTS DECLARATION 1
ZOanZ Iand...:end my plansshall Incensed as public records I'ANEIS MODIFICATION
L,^ DI"(0200AMPS
OZ"� LJ INTERIOR 0 CHIMNEY REPAIR
x-�t:at [,iccnmd professional 201-I000AMPS IMPROVEh1EN'IC]SWIMMING POOLS
y•1E OWNER-BUILDER DECLARATION OVER IBOBAMPS [3BATH REMODEDREPAIR [I DEMOLITION
oC Q 1 hereby affirm that I am exempt from the Contractor's Licaesc law for the
XO'1 U following rrnseo.(S7031-5,aclina7031-5,Business and Prnfcesione Crde:Any,'dy or evenly SIGNS ELECTRICAL El OTHER
m whim require,a parinii to construct,hirer.lmprev,,demolish.nr repro,any Inundate
pQ prior to its issuance.also requires the applicant for such pem,it to file a signed statement SPECIAL CIRCU TF/MISC.
F�}' that he isliccmed pursuant tnthc ptovisionxofthe Contractor's License law(Clmprer9
W L�E lemormeaing with Section 90X0)of Division 3 eftbe Businessand Poresivn Code)or TAMP METER(IR POLE INST. COMMERCIAL
E. C that be is rxwnpl Therefrom l I the basis ba,the allegrd excmpGon.Any violulent of ❑NEW BLDG/ADDITION ❑DEMOLITION
K�6' Section 90Jl5 ny any applicant Toro Pmmit mbjear lhcuppbcam to ac iv 11 penalty of POWER DEVICESTENANI
not one than five hundred dollars(5500). ❑IMPROV ❑FOOD SIiRVICIi
=C ❑ I.as owner of the propony,or my employees with wages as their sole compensation. SWIM MING IN H)L ELECTRIC Inll'R(VF:n1ENT
p... will do the k dt %fracture:not mended B df Tsai (Sac9044,Bmine,s
IWi1'Jm and 1 :. :Cate Th Contractor's I d t apply(I water OUI'1E'I'S-SWI TCHES FIX'I ORES
0'3'� pmpnrly M1 b Id: p :In J A d :: 'M1 k h If through
his oxo mnplo)ecs,provided tom such mpnnements arc net hall, or offered for NEW RESIDENTIAL EI CCTR SQ FT
sales If.however.the building or improvement is sold within one year of completionthe Q.1-7.FLOOR AREA 5/SQ.FT
eshadcC,w.It have Ne madcn of pro ing,hal he did Tun build m IniPns c for par
p "n f. ). v
❑1 f the p pen) on exclusively contracting with licensed commerce,In
conestroma theproject(S2044B :- and P f Comb I IlcrHaImeasl.
s d , pplyt ,p psnY n builds p Therm end QTY PLUMBING PERMIT FF.E
who c)nns,x 1. sett p,Jests vilbu cinoaclons)licensed ptt lacCormutors tit
Cracow,Law. PHRM1I'ISSUANCE
El Iamexerramder5ee .B&PCIormoreaom
ALTER-DRAIN&VENT-WATER OA) VALUATION
0,net Data l 3
WORKER ad,,SCall,of S., bUECI,ARA'HON HACK PLOW'I'ItOTECI'.UIiVICF. f\
Ihereby labor tl R Iy of pcj ry f,h•foll � gJ P fma. ICJ
❑ Ih d 11 int Cri&a¢n(C uv If-ins f N k .Compcm DRAINS FLOOR.ROOF.AREA.COND. STS '1'1'PECONS u ION
sation, provided f by Section 31(X)of the Latur Code f am perhournambe of the
walk far h M1d , e L FIX"1'ORF,S-PER TRAV
I J fliburnme Worker,C ,I (
Inaloularic a,mmumdbyS ,
3_700 ❑M1 taurCeall forthe pemeoc fesptrmiis 'J,.
GAS EA BYb FM-I INC.JOUTLETS O GR q/I'
N
My do � ,�
Can 'y N GAS EA SYSTEM-OVER J(EA)� m
IT 1'ptEXEMPT
ION FROM WORKERS GIt EASUINDl1S'I'kL WAS'fII1N'fF,RCIIPIDIt
COMPENSATION INSURANCII Bt111.UING DIVISION FEES
1'nus section need nor be completed ifshe)mortis torose hundred dollars f$100) GREASETRAI'
or IiPLANCIIECK FGIi
Ioy.eyrhm int he performunwn(rhe woofer wuhj,,I,o,hc .,,kl,Co ,eno SI?WP.R-SANITARY-S'FORM EA.200 IT.
un anpiny nny Iw,v nny n,roar sn es Its txl�un,c xnbjcct In rbc WorkrrK Cnn,pni ENERGY PEE 5-.3 ,
I :nn in rI ... .J
,Z .mien Lawwo(Califnmia.Dom RATER HEATER WNEN'I'/III,ECTH
z 2 Applicant GRADING PEE
(n NUI Up TO APPLICANT:If,ahcr making this Ceo ficme of Exemption,you should WATER SYSTEMNIZEATING
� � be.emns.bj.,a„heWork,rw Bompenction pmvlsions oft he Labor Cale.you root SOILS PIiIi
fenb,virhcomply teal,such pn.....mso,lhlsfermi,.ball he decnmdrevoked. WR'I'ER SERVICE
a
CONSTRUCTION LENDING G AGENCY NIIW REI NTIAL YL -Q. PAID
V O IMreby altirm than there is uconrvaion srnn lleending ugcnay for the per4,m,anaa of Data ReceiprM
F. the work for which me,permit ix ivord(Sev.31R9I,Civ,C.)
0 Lenders Name 'DYEAL:
} ULenders Address "101'Ah
G 1 certify that I have read this application and Stam that rhe annve information is BUIL)I G G
F res comet.I agree Io comply with all city and county ordinances and state laws relating m QTY. 1FCHANICAf. ERMI FEE
U Z building cnnaumian,and hemby noamriec milmsen,ari<cs of this city to enter open tile
SEISMIC T.F.
aMwc-mentioned properly forrop„don Purlv,ses- PERMIT S'LANCE
(We)ag.a save,indemnify and keep[nameless Ne City of Colman again, FLED' tIC FEE f
liabilities.judgments,costs andeg,eneswbich may inanyway merge againtsaid City ALTER
PLU ICING IFF,
in consequence of the....ring of III,,Penni,.
AI'I'I,ICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT' AIR HANDLING UNIT(10 I0.001CFM)
MF A ICAC FEE
SOURCE RECULA'TIONS.
1a71NF/II AIH HANDLING UNIT IOVBHIQIXNICFM) CONSTRUCTION TAN
n � j/
Signature of pp icanVCon,oal J Dole FXHAUST HOOD(W/DUCT) HOUSING MI'I'IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will rhe applicant or future building occupant suite of handle hamrdvas material H HXI'ING UNII'(TO UNION)BT U)
as defined by the Cupertino Municipal Coca,Chapter 9.12,and the II,aIIb and Safety
Code.Section 25532(0)^. IIIIACING UNIT(OVER 100.000 BTU)
❑Yesa�1 No PAID
1K VI;NFILAI'IONIAN(SINGI.IIRESID) Dntc Receipt If
t
Wilma applicant or future building mblipan,use equipment nr devices whirl,
emit hmurdoms air contaminants as defined by the Bay Arca Air Quality Management BOILER CHP OR I(NLWO BTUI
Discoid? 'UTAL:
�Y BOILER-C(lMl'IOVIiR I,XI,INNI BTI) f
I have read the hanardoes mmcrials requirements under Chapter 695 of the Cali" AIR CONUIIIONER ISSUANCE,DATE
forma Health&Safety Cade.Sections 25505.25533 and 25.5.11.1 understand that if the NI2W RESIDENTIAL MECH. SQ.FF. n C�
M1uilJing dm.nr cuemndy M1uventOnunr,Coal irdlny rcerymsib{li,y to notify the occemun, L �{ T r
ofliv6re,marm nan,wpir;M1 xt M1c at��r�lo inxaance nfa Cerlifiram����a y. .�
Ownermarthorinedagcr Z Uam TG ISSUEDBY:
OFFICE