S 2814 (2) LL
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1'ERMI'r NO.
BUILDING DIVISION APPLICATIONAIERMIT PLUMBING-MECHANICAL Q n Q q /)
111111.UIN(:PRO Fy'F I EN'1'IF'ICAI']ON O G 01 4
BULGING ADORES 1QQ s �/ Mirall1cn SANITARY NO. APPLICATION SURMIQPI,ALQDATE
(JW Irtsi t1\ * (H 257 1 CONTRACTOR'S NAA1E: LIC NO:
-0 N/C CON,TROhp
iLpID CI'/IjNDEEMER. LIC NO: ADDRESS: ❑ Z
rI 0.n QS `J
CONTACT: PHONI?: BUILDING PERMII'INPO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB- NIECE
❑ ❑ ❑
LIC6NtED CONTRACTORS DE ions of haat QTy ELECTRIC PERMIT FEE
iherebyaffirm Nut1amlittl eB underprovisionsof Chopmr9(cnmmen0eis JOB DESCRIPTION
BIZ innswrieneroffect. iFinn3 onhc Bnainess and rntmFvimsende,trodmy6..o,.i, RESIDENTIAL:
F in full farce and effect. PERMII'ISSUANCP.
QUV Liren.rc Claxs Comp GSIUWL C1 KITCHEN REMOl
�Q,a num Cnnoacun APPLIANCES-RESIDIiNT1AL ❑ADDITION ❑PLUMB ING RIi�PIPIi
L„pv. ARC(111ECTS DECLARAT10N DMULTI-UNIT OSTRUCTIIRAI.
ZO`"Z Iunder,mnJ to I:mv,hell be void as Mie orenrd, PANELS
02= y p UP'102W AMPS MODIFICANEEY TION
F4tw licensed lrafir,ionW ❑INTERIOR DSWCI IMMING POOL
2111-IgN1AMl'S IMPROVEMENT El SWIMMING POOLS
r<� that I am exempt from
mDECLARATION OVER COMAMPS D HATII RBMODBURFPAIR El DEMOLITION
fY.S, .
Q 1 Bunchy nffrm(hal 1 am exempt from the Contractor's License Luw fur the
following reason.(Selina 7031 5,IWeinc,s and Pi,fe.,ion.v Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to corrosion,alum improve,demolioh,or repro,any swcmrean
prinrlo it-sirslmnce,nl...o"ircnthoapp6coal For suchp annit to Bl..signednmremom SPECIAL CIRCUI UMISC. �7f y'
Nab Nat he is licensed punuanno the pnrvisiun,of the Comracarts License Law(Chapter 9
W@onnnencingwiln Section IllB0l nl Uivision3of tic 9usinw.v and l'ndcwinns Rulcl of TEMP MHTHR OR POLE INST COMMERCIAI:
Nat rte is ceempt therefrom and he nasi.,for Ne alleged awraninn.Any violation of 0 NEW BLDG/ADDITION D DEMOLITION
14^4th. Section 1031.5 by any applount for a permit subjects the applicant ion civil penalty it T'OW'ER DEVICES L l HNANT D FOOD SERVICE
Snot marc than five handled dollars WIFE)),.its
D1,as owner of the property,or my employees with wages as their wile compenxution. SWIMMING POOL EU-COR IC IMPROVEMENT
F wi 11 dome win k. IIll...I re:onntiatnoteJm nff.red fnrwle(Sce.JW4,Roof a... O(
3 and Profession,Calc:The Cortril rs License Law anew,not apply to rot owner of OU'FLGI;S-SWI'(CI113-19XTIIRE$
property who m hinli improves thercon and won it,.inch work hnlnvell or tnrough
his own employers,provided that such improvements um not intended or offered for NEW RESIDENTIAL ELEC'IR SQ IT.
sale.If.however,the building or Improvement is .Ili wilhinonayea,of cia letinn,the .PI'.FLOOR'IAR(E�A .FT,
ow builder will hie the burden of proving that be did not build in improve for For-
Ir.)
ar- APR 1 F/ 199w
puseyfsalc.). 00
r of the property,,Businessland
excluvi and mutate ing with O TI oed wmrncmrs m T
onmmct the project(See.]n1J,Buxincu and Rnfcssiorts Ctdcq The CommaoGc Li- i
crow 1-ilw does not apply to all culler of property who holds or Improves lheram.and QTY. PLUMBING PE
who contracts for such projects with a connections)licensed Purl to the Control INBy
6ccs¢In
Inm e.pmpt Wer Seo. ,II K P C fur this mason PERMITISSUANCE
QeV ALTER-DRAIN&VIiNT-WATER U!A) all VALUATION
+ •ncr
COMPF.NSA'ry oil DECLARATION BACK FLAW PROTECT.DEVICE
(hereby aNrm Baderpenahy oe(ifConnncofelcinlmwingdealafes Ctlil DO Q
](have proidel lot In,ncene.37amof me
lot lfnr Wnoncuretnt the DRAINS-FLOOR,ROOF,AREA,CONE' STORES TYPE CONS'TRUCT'ION
radon, r provided lot by Section J'l011 of Ne Lehnr RNw for the noncurrent the
work far which this palmi is i aFIXTURES-PER TRAP
❑I have and will maintain Wages Compensation Insurance,as required by Section
37010 ofthe Labor Cale,Fir the Fund manceof the walk for whim Nispenmitls ivsucd, GAS-EA.SYSTE -I INC.4 OUTLGfS OCC.GROUP APES
My Worker'.,Compensation Insurance carrier and Policy number are:
Corticc Iidicy No.: CAS-hA.SYSTEM OVER 4(EA)
CER MEICATE OF;EXEMPTION FROM WORKERS'
COMPENSATION INSURANC9 GliEASIi/INDUS'(RI,WAS I E INTERCEI'I'OR
(I his Banton nwdnot he e O,Iced iftne Irotlt is tonne haroned dollars I$Into BUILDING DIVISION FI?BS
of le_wsJ GRBASI3 TRAP PLANCI IECK FEE
7.
Loy any pert in N.any
the worklistwhiNis the Workeundrs'
shell SBwER-SANITARY-S'I'ORM EA,200 F. /
nota.Law,any person in any manner sit as m become subject the Workers'Cnmpen-
ENIiRGY Ig31i
Z scion Lvws of Califnmia.Dmc
�O A licmu WATER HEATER WNEN'I'IELLCTR
PP GRADING Plil?
N
NOT ICE sp to'i'l APo dup it 'E 11,C making his Conasisio ,of of Exemption,you should WATER SYS'rEAf/TRligl'ING
h forthwith
h court ht the Wnrh r. i,i...inad, proma l,n.v of the Labor Code,Ynu most SOILS PL'C
L[7 Ibnhwith comply with such provisions nr Nis permit,hall bedeented rcvokuJ. WATER SERVICE
Q
P UO C(JNS'IRUCTION LENDING AGIiNCY NEW RIiS1nIiNT1AL1'LMB. SQ En PAID
I horebhichinNato...iio. ed(Sec.30lending egeney Iiatheperrormmaenl Dam ReceiptM
D) F thewors Name lin Chia pcmtll isissueA(Sec.3097.Civ.CO
Q L) 1<nder's Name
w I.uu1.r`,AJJrc,s TOTAL:
� Cy I certify that I have read Nis application and store that the ebrve infnnnatinn in BUILDING PHE
rp enned.I agree mcnmply wllh all city and countyordin�nces and,tmc laws reludngm QTY. MECHANICAL PERMIT FGE
U buil Jing consumption,and hereby aphorist reprownmti ves of this city to enter uptm Nc SEISM IC El
above-mentioned property for inspection purpose,. PERMIT'ISSUANCE
(We.)nine.In smc,indemnify and keep human..the City of Canada.against ELECTRIC PER
Iiabiinies.jidgrnems.co,Isand expenses which may m my way acemeagain.+t said Cil, ALTER OR ADD TO NIECII.
yucncc nl'(itc gunning of thi,perrol. PLUMBING pEE
PPLIC.V'I'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HOOM CFM)
5 URC tEOULA1'10MECHANICAL FEE
N/ a v5� `�-- AIR HANDLING UNIT(OVER 10JNp CFM)
I� CONSTRUCTION TAX
Sib c4A+ ' i/Commemf Date T EXHAUST 11001)W(DUCT)
,r HAZ RDOIJS MATERIAIS DISCLOSURE HOUSING MITIGATION FEE
tl WIII the applicant or linurc building nespi, t,lorea handle hvandous ntat.riul IIhATINCF UNIT(TO I(fall)11'H1)
aadcfnal by the Cnpenino Municipal Cock.Chapter 9.12,and N.Health and Safety
C61a,Satlon 25592(.)? HIA)ING UNIT(OVER 1110,001 B'I'U)
al I C]Yes gjRt PAID r"]
VIINTILATIfIN PAN(SINGLE ROSE D) Dm. R t N `CJX
I Will the applicnt
i iaanfiwhich
emit bauNom air conmmnans as defined by tm Ba Area Air Quality Management
BOILER-COMr(311POR I00J0U
D nvlcP / BOILER-COME 100.0m)❑TU) TOTAL:
Yes �o
I hale matt the helardom oreacriul,m - AIR CONDITIONER
ymrcmentn undc'Chopmrt.95 of the Cali- ISS ANCE DAT
fir is k VthS S.rdy Cade,Sections 25505.25533 and 25534.1.nderstond Nat if the NEW RESIDENTIAL MECIT SQ.FT.
b dal(avian Imovely Live aI maul,Inas it E my rcslwnsiniliry mnotify the nttm pant
uircnenm whicl be met prioneisxuanceada Cenilicate of(kcup:mcy.
Vte
t ran notation gent TOTAL: ISSUED BY u
\ OFFICE