S 3966 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING.MECHANICAL C .� C
J':: ^ -BUILDING PROJECT'IDENTIFICATION " r t J U
BUILDINGADIIRESS: SANITARY NO. APPLICATION SUBMITTAL DATN.
1 RNOL RwE 6 -/if-9
OWNER S N F:: PHONE: CONTRACTOR'S NAME: A _ 1 IAC NO:
R GGYk�JTF(�`TI LYS' S $j N" CONTROL p
RC EC GINEER: LIC NO', ADDRESS:
'
T✓tN /.I.x-P//r✓✓ /r'/1, n0 G
'CONTACT. PHONE: 'f; j''"'I'BUILDING PERMIT INFO',,
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
Wv/t-, QuRc,H 65b-2-2-1f-Oi3 R`- Ef- f�- . E!r
LICENSED CONTRACTORS DECLARATIONQTY,'sb ELECTRIC PERMIT ( t PEE
I hereby of ono that l licensed d p f Chapter 9(commencing _ �, JOB DESCRIPTION
03'2 Ih Section 7000)of Dl 'am 3 ofthe lint ndPnfess ns Cale and my lw i RFSIDFNTIAL-
Wr00 wi PIikMIT ISSUANCE -
n full force nnJ died ❑SFDWL ❑KITCHEN REMODEL
FtFz�r= uap 6 Lic.OrstI
F-ZW Umc O Contmc!or YL /e+`eSTR*aLY/ON APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT. ❑STRUCIVRAL
ZOyIL IunJecstunJ my plans.hall be used as Public record. 7 MODIFICATION
O'2.-.O 3 UI'T03110 AMPS ❑INTERIOR []CHIMNEY REPAIR
F�Fu1 Licensed Professional & ]OLUKOAMPS IMPROVEMENT SWIMMING POOLS
4$d 5-1 OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEL/Rlil'AIR 0DEMOLITION
py C W sr I herehy uffim eh:u I um exempt from the Contractor's License Law for the
9=F following reason.(Section 703 1.5,Business and Professions Code:Any city or county SIGNS ELEC'T'RICAL ❑OTHER
W_O which requires n permit In construct.alar,improeo,demolish,or repair any structure
primlo its isxuaner,also requires Nenppliernt fmorch permit file.signed sommum SPECIAL CIRCU UMISC.
Q� That he is licensed pursuant the Provisions ofthe Contractor's License Law
(Chapter 9
1t1rp0 (commencing with Section]!100)of Division 3 ofthe Business and Professions Code)., 'TEMP.METEk ORPOLE INST. COMMERCIAL:
a a e Nat he is exempt thereon.and the basis room alleged exemption.Any violation of C1 NEW BLDG/ADDITION [D DEMOLITION
�d
Section 70U.5 by anyapplicant fora perinitsubjeceitimap,licant toacivil pvmI,ym POWER EVIGIS
are
more TENANT ❑FOODSERVICE.
nut than five hundred dollars($5001.
xa0 ❑1,us owner of the pnspety,or my enlpinyees with wages ns lh<irsnle cmnpcnsntion, SWIMM NCIPO ,ELECTRIC IMPROVEMENT
F willdothework,and The
Compactor's
om anotintended nr it.,
im Business ❑OT R
43 end Professions Cede:TBe Conxrannr's License Lew does not apply to nn owner a( OUTLET' WITCHES-F TURES
property who builds m improves thereon,and who does such work himself or Through
his own employers,provided that such improvements are not intended or offered for NEW RESIDEN ELFWR SQ Ff.
role.IL howevernhebailding mirepmvorrom issold within oneyeurafemopletinn.the Q.FT.PhOfIR AREA fISQ.FT.
or-builder will have the burden of proving that he did not build or improve for pur-
[2 1 L of soled.
ns owner of the y,em excessively eumrtainwith ed contractors to TOTAL:
nn I theproject(Sec.7044.Business and Professions CnJ:)TheContractor's
Ll.
- -
censeLa doe:notapply t s(property who builds or Improves thereon and QTY i 1� 'PLUMBING IT
i1
who contracts such j t with nmradr(s)licensed pursuant to doe Contract
El Ia L. ' UL 14 1999
(]1 Leexempt under Sec, .D&PCfor this mason PERMIT ISSUANCE
Owner DateALTER-DRAIN&VENT-WATER(Ead VALt N
WOR K ER:S COMPENSATION DECLARATION BACK FLOW PROTECP.DEVICE D,O
1 hereby affirm o
under penalty of perjury Inc f the following doelarue ions:
I have and will maintain a CertiGeam of Consent mself-i...mfor Worker's Cnmpem DRAINS-FLOOR,ROOF,AREA,COND.
Zion,as provided for by Section 3703 of the Labor Code,for the performance of the STO 1 TYPE CONSTRUCTION
k for which this permit in issued. FIXTURES-PER TRAP
ISYI have and will maintain Worker's Compensation Tnsumncu,as required by Section ��LT Vr
3�]IXl ofthe labor Code,for the performance of the work for which this pemlit isissued. GAS-RA.SI'STEM-1 INC.40UTLETS OCC GROUP LIyV
My Worker's Compensation Insurance carrier and Policy number a
Comec�LlpsNL6 Policy Nn.: Zyg?Y(, GAS-EA,SYSTEM OVER A(EA)
CER71171CATE OF EXPMPDON FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
(Thissxtionneednotbecomplet difthepermitisforonehundtcddolim($]MI 5 9 '$ " ,BUILDING DIVISION FEES,,
ii
or less.) GREASETRAP PLANPCE `j
I certify that in the performance ofthe work for which this permit is issued,[shall SI3WER-SANI'TAkY-STORM EA,2(IB tT.
not employ any person in any manner so us to become subjectto the Workers'CoriENE a! r 20
scion laws of California.Dam
WATER HEATER WNENT/ELECI'R
Applicant OfEE
y NOTICE TO APPLICANT:IL after tanking this Cor iOcme of F.semption,you should WATER SYSTHMUREAFING
become subject nI the Wonkee,Compensmian provisions of the Luber Code.you must SOIL FEE
forthwith comply with such provisions or this permit shall be,deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDEKI'IAf.PLMB. SQ,PI'. PATI
I hereby thi thin is eilending agency iia the Performance of Date ReceiptM
Lts the work for which this Permit is issued(Se309],
Civ.CJ
ULenders Name OT
FSI Lent AJJ .. TOTALIBUILIcYfy thin lh this af: o h . DING FE� l V
U1 correct.I agree to comply with ntl city andcounty ordinances mad state lawsuchad.,l QTY. ' MLCFIANICAL PERMIT FEE s'
V z building connmainn,and hereby euthnnze presenmtives o(Nlz city menmr upon Ne -6 SEISMIC FHG ` �s
above-mentioned progeny(or inspection purposes. PERMIT ISSUANCE
(Wo)agree,.save.Indemnify..it keep of ties,the City of Cupertino against ELECTRIC F
Liabilities,judgments,costs and expenses which may in any way accme against said City LEER OR AGO TO MECH. Noll.0 PLUMBING :E
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT p1µHANDLING UNIT(TO 10,000 CPM)
SOU/RRR���/E/o EGULATIONT /
p// _ A
/9--l'/—,
9 — !//5�9 AIR HANDLING UNIT(OVER It1,IHNICFM) CON RUCTI NTAX
Si amre of ApplicaHAZARcmr ^'E( r'4// G� EXHAUSTHOOD(W/DUC) HOUSINGMI GATIONFEE
HAZARDOUSMATERIALS DISCLOSUREInfac
Will theeCapernr Municipal
ooccupantatomor handle Health anmaterial IEA'fING UNI"I'(I'O IOti1N))BTU)
as de,Setl by the Caperton Municipal Cole.Chapter 9.12,and the Health and Safety
Calc,Section 35512(a)? }� HEATING UNIT(OVER I OL"BTU)
❑ 'te
Yes a VENTILATION FAN(SINGLE RESID) PAID --
am eiplk
WITI the applicant or future building sy he Bl use equipment or M.c. which BOILER-COMP(3HP OR Ugk000 BTU)
it hvardous air comaminams as AcOned by the Bay Arcu Air Quality Management TOTAL:
trio?
❑Yes Wis. HOLLER-COMP(OVER 1110,0008'fU)
I have read the hazardous materialsATR CONDITIONER
requimmeunder 6.95 of Cali ISSUANCE DATE
(amia Health&Safety Code.Sections 35505.25533 an and 25534..I and understand that
if Ne NBW RESIDENTIAf.MliCll. SQ.Fr'.
hullding time nm currently have overact,lhm it is niy responsibility to notify the«cupam .,
of Ner ncnts whi Jr munb ey�n1 priorlo .....re of.Cetlilirate/ /%/cd7lry. J
Owneror authorized Lagent //3/-✓e%_ (•fir'/ Dot' a ISSUED BY: `f , 2
OFFICE