S 2864 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILD INQ 1!I,ECTRICAI. 1',RMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL
BUILDING PROdiiC'f IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLI11'I'IN SUBMII'1'A.IJA'1E
87 �;J c t. G� erf� Xaa �i 7
O NER'S NAME' I'1{ONE' X, Y)NTRACTOR'S NAME: LIC NO.
L G C NIC /� CONTROL#
_CHIr CTIQEN N'Ek: 5� LIC NO: AUU >$.S: ❑ ( ) '/
CONNNTG_AC. J PHONE: •47 BUILUI7N 1 PERMIT INFO
Oa(1 re r AaaR�/� ❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT' PLUMB MECH
u B_ Ift—
L]Cr!NSEDCONTRACORSDECI.ARNI]ON QTY EI.ECTRICPERMIT FEE
1 hereby am.that 1 an heeuvl under provisions of ChapraT 9(commencing JOB DESCRIPTION
"Z th Section of Division Sof the Business and Pretensions Code,and my he,.a is R VID #TIAL:
FW_ ntfull force and effect. b�7D1 PERMIT ISSUANCE E❑SFDWL ❑KITCHEN REMODEL
�Uf� L nsc Clwµvp Lic,# 4Q J {meq DDIT10N [I PLUMBING RF.-PIPE
FZW am L(��T"'09 Cmnmmor APPLIANCES-kGS1UF:N'1'IAh
'nQa, TvT�
F7 AR {ITF.CTS DIi RATION PANELS ❑MULTI-UNIT -1 STRUCTURAL
rn lunch I a �usele ord MODIFICATION
CZ=Q ry p _RAT PANELS UP TO 200 AMPS ❑INTERIOR C3 CHIMNEY REPAIR
FG�FW Licensc�wl / 201-100DAM0.5 IMPROVEMENT SWIMMING POOLS
ay ld
OWNEReIlliI.OER DECLARATION
o GGCCOVER If(H)AMPS ❑BAfII REMOUlii.IkliPA1R 0DIiMOLITION
Q I hereby affirm Ihm I am exempt from the Contractor's License law for the
{iy(O6 U following reason.(Section 70315.Business and Profession.,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Yl 3 W N which rcyuircs a permit ur conswa,alley impmve,demnli.,h,or repot-any„rvnurc
qF�y OQ prior to its issuance,also requires the applicant for such permit to File a signed xtammem SPECIAL CIRCUIT/MISC.
W aELLCthat he is licensed purstmu0 IAL;
no the provisions of the Conorcors License Law(Chapter 9 l (cnnmmncing with Section 7(XX))of Divlsinn P.3 of the Business and Prnf,,,4, ,Cnde)or TEM ME I ITR OR POLE INST
L y o C that he Is exempt therefrom and the M1asis for the alleged exemption.Any vinhiflor of ❑NEW NLD %&DITION ❑DEMOLITION
YX1 {t• Section 7031.5 by any applicant for a Persil subjects the applicant o a civil penalty of POWER DEVICES d�t�kLNANI' FOOD SERVICE
FZYno..11.'ban five hundred dollars($500T 'Pk0VEMENT
p=OQ I,mnwncrof he pmpcny,or my employees with wage.,us their sole compenm'ioq SWIMMING POOL ELECTRIC ,/f
will do'hew,,k.md ha„faeme Isnot intended proffered forade(Sec.9044,limine,, e0THER
and Pndussiens Code:Him Cnntramor',lecense Law does not apply In no owner nI OUTLETS-SWITCHES-FIX'I URP.S
A' pil who builds or improves thereon,and who does such work himself or through
his own employees,provided that such it pnwemeals are not intended cr oftered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however,the buildingetrimpmvement issold,ill intawycaro'compleam,dre ,(' SQ.IT.FLOOR AREA VSQ.IT.
owner-builder will have the burden of proving Bad he did not build or improve for par- r I` e
I,as owner of the prcany,um exclusively contracting with licensed cononaors m TO e
coast mal the project(See.7044,Busine,x and Profession.,ColcJ The Contmalor,Li-
nseLew duesnnlapplymanowner of property who buildsor impmve,owner.and QTY PI-UMBING PERMIT FEE
who contests for such projects with a mmmclnr(s)licensed pursuant to'he Companies
License Law. PERMIT ISSUAN
❑ I an)even,,under Sec ,B&P C for thinalwar
Owner [)areN
AFTER-DRAIN T-WAIIlk(EA) VALUATION
r WORKER'S COMPENSATION DECLARATION BACK FLOW PROTE CF
I hereby anion under penalty of perjury one of,he following declunuinv:
b)-lhave and will maintain a Certificate ofConentto self-iosure for Worker',Comped- DRAINS-FLUOR,RODE D. STORIES TY PE CONSTHOCT'ION
sa,ion,as provided for by Section 37M of the Labor Code,for the perfornanec of the
work far whichthis pe non is issued. FIXTURHS-PPR TRAP 2 v/J
Q I have and will maintain Worker's Compensation Insurance,as required by Section
37M of'heLatin-Cele.for the perfmmaresof he work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP W
CynWorky(I CpnEens lgy' n once carie Pa'dYoNlicy pturt�r�re_..— m cL GAS-EA.SYSTEM-OVF.Ri(EA) //��//� w
CERTIFICATE OF EXEMPTION 17ROM(WORKER Fi ,�` T - ' � ~
1,3
COMPENSATION INSURANC17 (C / OREASE/INDUSTRLWAS'fl?IN'fERCEM)R BUILDING DIVISION FIFES
ITInk ec'ion need dol beoompla'ed iftbc parmil is forrmc hundred dollars(S1W) GREASETRAP
or less.) qD _EE 20
I eciify that in me performance of the work for which this permit is issues,i shall SEWER-SANITARY-S'FORM EA.2W IT,
not employ any person In any manners as to become subject the Workers'Com,en- /
Z ,Z Honor Laws of Cdifim is Data WA9'ER H1;AfHR W/VFN'f/HI.i?CI'R 1,
Appliesin NOTICE TO APPLICAN'E If,ager making this Certillcale of Exemption,you should WATER Sys rEMOREATINGbecome subject to the Workers Compensation previsions of the labor Cole,you must forthwith comply with such previsions or this permit shall be deemd revoked WATER SERVICE111.
CONS'I'RUCION LENDING AGENCY NEW RESID1iN'I'IAI.PLMH, IT.,�Ca e keecipt#
Up I hereby ammvhatttlon here is acsmsouclending ageoay for the perfrrmanceof
_, the end for which tho,cm'it is issue)(Sec.31X7,Civ.C.) O
LLLeddcrs Name TOT L: is
fyl7 U4
W Lender's Address A
Ir er I sanity that I have mad this application and state that the above infornsa'ion is BUILUINC
IT..
TA c rect.I ngrec pt comply whh nal city and coumy oNinurms ord store laws rclaningm QTry, MECHANICAL PERMIT FEE SHISIs IF
U Z building ctmsmucfiommW hereby malimmrepresemmlve,nf his city to enter upm the e J
above mentioned property for inspection purposes' PERMIT ISSUANCE
(We.ngrmmsavc,in and keep lamalas-he City
of Cupertino again,, F.1. 'TRIC "EE
habili,ier,judgmants,mst. den x which may in say way areme against said City ALTER OR ADD TO MECH. P M GFEE
inttmcequence 'he ring 'his`,enni'
All TCA O' STA SAND WI(I I'IT AL1,NON�POINT AIR HANDLING UNIT GO 1(1,1X10 CPM)
MGC ANICALFEfi
SOURCE 'G L 'Ifl
AIR HANDLING UNIT(OV13R 111,000 CFM) CO 'TNUCTION TAX
Sig u o pplicanUCrmraanr Uute IiXHAUSTHWD(W/DUCT) HOUSI GMITIGATION PEE
HAZARDOUS M ERIALS DISCLOSURE
\ Il the applimam nr totemhn n"weupnnt.mna a or handle Fore'lnux nmicnal HEATING UNI T(TO 100,000[1
I
dell by the, Manic vl Code,Chapter 9.12,and the Health and Safety
Codi,xd.255721vT1 HEATING UNIT(OVER 110.000 BTU)
❑Yes PAID
VENTILATION FAN(SINGLE RESOD) Date ReceiptX
Will he applicant or morm building occupant use cthipmen'or devices which BOILER-COMP(3HPOR IOBOW BTU)
mit hernnlous air ennna amoral,ns dclined by the Buy Arco Air Quality Management
Dlsoim7 -�11 BOILER-COMP(OVER 00.00)BTU)
❑Yes P<.
I have read the zardonsno Ism
nater Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Sof tau,Sc a 5525534.I understand that if the NEW kIiSIUliNT1AL MIiCI I. SQ.IT.
M1uilJing do von only hue nant.tmsihilitymnonlymenmupard 7 ( ( r
ofinem a I .theme, ant Certificate f 5func
wnerm tlatired solift Dae ISSUED BY:
OFFICE