S 2757 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPIERTINO RUILIBNG-ELECTRICAL PERMIRN Y
BUILDING DIVISION APPLICATION/PERMIT PLUM] G-MECHANICAL 5 1C 7 C 7
BUILDING PROJECTIDEoN1'IFICA'1'10Y .•J 1
BUILDING ADDRESS: SANITARY NO. Ali'LIC 'I'll SGBMl' 'AI.DAJE
223 ,5 � HULA ASA &L biz o c t1�( J,�'
OWNERS N,kMV a PHO E: ��f� C ,TRACTOR'S NAMF(� ` LIC NO
1lvv dd "0q.5L NIC C NMOL
A CHI'ECDENGINHER: LIC O: ADDRESS ❑
11 c- Gil- . 21 IGS 12362 cl/ - rl0
CONTACI:y b . PHONE: 13OILDING PERMI'I•INI )
❑ Consultant Fces Paid by Applicant(Initial) HLD :Lli PLUMB MSCI
IU�PC�I
LICENSED CONTRACT ORS DEC`LYARA'I'IONI \I L (1TY. ELECfKIC PERMIT FEE
1 hereby ammo th d I am lime wd nntkr pnwi.innx m'Club".9 tomos emmg _ JOB bESCRIPTION
0KZ wise se,finn]ggpd Division3ntthe Business and rn,lcssinns Crile.and my license is -� RESIDENTIAL
H O O PERMIT ISSUANCE
FIy or ❑xce:uW ellen. ❑SIOWL. ❑KHCHFNREMODEL
,W [I
Licece Clan LieN APPLIANCES-RESIDENI'IN. []ADDITION ❑PLUMBING kI3,111PE
ti 6 a Drop' Convenor
ARCIIITIiC'I'S UIiCLARA'I'ION ❑MI11dhUNIT ❑STRUCI'UkAI.
PANELS
IunAemand lay plum sha111n wed ns public mcoMs MODIIICATION
UP TO xIp AMPS ❑INTERIOR ❑CHLMNEYREPAIR
Lmcnscd Pmtassicnal 261-100I)AMPS IM OVF.MEST ❑SWIMMING POOLS
•.1 OWNER-BUILDER DECLARATION
a Q 1 hereby affirm Ism 1 um esmnpt from the Cnmmct"Ix License Law Inr the OVER UBOAMPS ❑ TH RI?MODFI R'❑ Fah [.11 10
1�dO y U following mean...(Semina 7031.5,Ipomea and ProlvKxionx Cole:Any city ur cuuntY SIGNS GLEC'TRICAI. (y HH
W 3 LL y which optio s,a Permit In congma,our,Inlpmv",demolish,nr spun any amnure
O pri"no its issuance.alsomquirex the applicant f"rsuch Nippon to file a signed statement SPF.CIALCIRCUIT/MISC.
thou he is licossed Pus.a.,to the pmvinmw of the Counselor's Liceme Low(Chapter9
114 0 @"nnn,n,ing with Section 71X30 of Division 3of the Rusin...and Pr..l'csxionx CoE)nr 'I'HM It METER OR POLE INS,
a Dat c q that he is exempt therefrom and the basis for the alleged exemption.Any Ontario.of J L/ ❑NEW BI.DG/ADDITION ❑DEMOLITION
•„w Scel'Ian 7031 t by any applicant for n permit subjects the applicum m n civil Pcnnlly nl POWER DRVICF.S ❑TI?NANT ❑1700D SERVICE
:t more than five hundred J"Ilars ISS(XB.
F Z> IMPROVEMENT
Sp ❑Loshe work,the thenny.mmynintoyees with wages ax theirs",compensation, SWIMM1IING POOL F.I.
F willAntfi work,and the heonscome Coinamonimm�Aed oral one,nrenl uFF,to ad o,ix ❑0'I'HHR
3 m anti property
who
M%or imp Cnonsereo License Laws such
not apply In lf r throe of DO]'LIiTS-SWITCHES q
4' property who bolds m improves thereon,and who ntws such work himself Or through
his own empinyaes,provided thv ouch improvement,ore nun imandcJ or offered for NEW RCSIDENTIAI.IILEC I'k P
sale.If.Mfwcser.the building or improvement is sold within one Year ofcnmplction.tire SQ, � . S/SQ.FE
er-builder will have the andim of proving that he the oat build or improve for pur-
cf,
r of Ibe
property,am exclusively contracting with licensed comments to TOIA
m,vuct the pmjcel(Sec.7M.I Euxinss and Profeceions CmIcJ The Contracmkc Li ���
whaw Anes not upPlym nn owner nfpntpmy who milds nr improves thereon,unA QTY. PL UNG PI_?RMIT ?E
who contracts for such projects with a contraeun(n)licenced pursuant m the C"mscto/s
4AE1
License Ia.. PERMIT ISSUANCE?
❑ Imnexemplunder S.c. .B&PCfnrlhicremnn
lwncr ALTER-DRAIN&VENNI' . 'R Fri HATION-
WO KB 'SMPBNSA'I' N ICI. RATIO TACK FLAW I'ROTIiCf.DE U
• Ihereby affirm under penalty ofperjury one of the following declarmion.s.
LI Inive and will Taimltinu Cenhwae of Cnpo,mto elf-inmre on,Works',Com per. DRAINS-FLOOR,ROOC AIe IeA,CD STUMPS(IES 'TYPE CONSTRUCTION
woom as provided for by Section 370 "f the Labor Code,ra the pedonnanc,of the
work for which Ihi,peri,in issued. FIXTURES-PER I RAI'
❑ 1 hove and will Inaimain Workers Cop,,n..ion In.utmna,as squired by Seerion
37gOdlheL:aor Ctvle,fmlheperfermance ofthe work mi-whob lhi.c permit is issued. GAS-EA.SYSTEM-I INC.4 OUT UPIS OCC GROVE' AI'IN'
My Worker's Compensation Inmmncc carrier and Policy number are: j y��0�-00t,Carrico Policy No.. GAS- •�F.A.A.SYSTEM-OVER 3 O
CERTIFICATE Of:EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRHASFIINDUSTRL WASTE INTERCEPTOR
Glosscdin inced nal hecnmplatedd tire.mull is Torr c lurelmd della',($IIB)) _ BUILDING DIVISION CEI?S
or lupi.) GREASHIRAP PLANCHECK FEE
I,arify that in the perh:rmonce.flhewcok for whichkispemut is awed,],bill SEWER-SANITARY-STORM EA.2W IT.
not mnpiny any person in any mmner s"as to he,vre subjecnn the W..set,'Crampon- ENERGY Poli
z2 suit".laws of California.Dale WATER DRAPER WAIENT/ELECfR
Q Applicant GRADING PER
.N. NOI'ICI?'I'O Al-PLICAPHE If,afmr making this Cenifeateof L'xro,amr, ,it,should WA'I'HR SYS IEMnRHA'I'ING
abecome subject m the Workers Compemanun provisions offer Labor Code.you must 5011 S FEE
Gia balmithconnply with sucIt....sig is or this parput shall be decmcd revoked. WATER SERVICE
640.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SR FT. PA,
'U Z thereby al'Bnn that there in it construninn tripling agency for the late Ir Receiptp
41 -1 the work for which this Permit is issued(Sec.3097,Clv,C.)
F' Lander',Name T(l'1'AL:
O CULL Lepdor9 Address 'I'OTAI.:
I certify that I have rad Ibis application and nme fist the above information ix BUIhIIIN. 1?h
%1 curler l agree mcomply with all city and county oNinances and spite lows relatingto QTY. MECHANICAL PERMIT PL'E
ti
UZ huilAingnmstmillion.and hcrebyrill uriec mpr"semaivtisnfnbiscitymenmrupon the $HESMIG aF?
above mentioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree m,ave,indemnify and keep hotmlexs the City of Cuponinn against ELECTRIC IT.
Inabiliticx,judgmcnta,e"N,and x,,r wl idi may tunny way accmcngaiiunsaid City ALT ER OR ADD'IO MUCH.
in asequence of the graming of this pefful PLUMBING £E
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NDN-POINT AIR HANDLING UNIT(TO 10,(1011 CPM)
SUl1RCli REGULATIONS MECfIANICA I. £li
GLx IR HANDLING UNIT(OVER 10.000 CIM) CONSTRUCTION TAX
Signature"iApplica VflnnradnrIV I Jur, EXHAUST 1 IDOD(W/DUCT) HOI151NG MI"TICA'HON PL'f?
HA9ARDGUS M4 .RIALS .CLOSURE
Will the applicant r future hulldingoccupanl xtmeor handle lumaxormnmteriul HEATINGUNIT(TO B(I,g BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? / HHA'1'ING UNIT(OVER 100.00h)BTU)
El Yr, An PAIL]
VL'N'I'lIA'fIUN PAN SINGLEItP.$ID) Uae I<wciptp
Will the applicant or future building oweupant use equipment Grill which
roil hasrdoos nor sero nli'vors a defined by the pay An.,Air Quality Management ROILER-COMP DHP OR 100,1100 3T(1)
RML:
District, BOILER-COMP(OVER I W,(KKI BTU)
❑Ycs 9A. �
I have reallthc hmallous materials re,mocroenu under Chapter 6.95 offs,Call- A112 CONDI'I'IONI?k ISSLA C ,V
fordo Health&Safety Code,Sections 25505.25533 and 25534.1 understand tha if the NEW RESIDENTIAL MECIL SQ,FT.
hulldo,dws not a..mody bout o amdnt,phut it is my sspomiluddy m notify the oce.pant
ofof thzregairte dri wl'hmus mot pdonnissunnce oto Ccnihamnf ency.
- �` �f4�7 44
T Owner or awharine ugem w 9d, 'DyIAI.: ISS IIID BY:
V !/OFFICE