S 1746 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PEST NO. 1746
BUILDING DIVISION A Pl CKP N/PERMI PLUM11BINf.-M1IECIIANICAI.
BUILDING PROJECTIDEWIF'ICATION
BUILDING AUDRLSS: SANITATNO. APPLICATION SUBMITTAL DATE
lOf�9 6--
DINNER
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OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
NIC ONTROLk0 ADo
CONTACT: i/• PHONE: /D BUILDING PERMIT INFO
❑ Contrition Fors Paid by Applicant(Initial) NLD. ELECT PLU 11 MEC/
LICENSED CONTRACTOR'S DECLARATION QTY. GLECTRIC PERMIT FEE
I hereby altirm mm 1 am licensed ander prommons ser Chap ar 9(commencing JOB DESCRIPTION
C eGZ whn sa ran 70ap nrniviainn3mnne da.mus.rota rrmfesxmn,coda and mylicense k5S'ANi' RESIDENTIAL
m O p IT'ISSUANCE? O
F in full force andeRecl ❑$I'DWL ❑KITCHEN REMODIiI.
�UF' hicanw Clu. Lich ����� ANCES-RIiSID1iNTIAL ❑ADDITION El PLUMBING RF>PIPF.
F Dom Con)r¢mr
h ❑MULTI-UNIT OMODCfURAL
ARCHI'I' SUIiC1.Al1ATION
!., m � PANELS MODIFICATION
Z O Z l uyy��Jhr d my p F shat seta as public reu s
OZ�� (moi , •S�s 21roAMP5 2, .Zo ❑INTERIOR ❑CHIMNEY REPAIR
F,F'..F.f,1 Licensed Pntlesstnnal MIAMPS IMPROVEMENT E]SWIMMING I'OOIS
e4 GL 6 1 herchy nlEms thmN a.exemptImlm he Commce is License Law for the IOXM AMPS ❑BATH RF.MODfiL/RIiPAIR DEMOLITION
nOaU following reason.(Seetion7031.5,Business and Professions Code:Any city ar county ELECTRICAL ❑OTHER
I+130.in which requires a permit to construct,aper,improve,demolish,or repair ony sunmare
'n., its issuance,dunequiresthe applicant fonu<h permit mfilevsigneJ uatemenl IAI.CIRCUIT'/MISC.
W',�y thaheilhcrowdpursoon(totheINionsuftheContractorhLicenseLes,(Chapter9
waQQ (commencing with Section?000)of Divisfnn J ofthe Basinne and lhofesdoes Cartelor .ME]Elf OIt POLE) COMMERCIAL:EINFA'HLDG/ADDITION ❑DEMOLITION
SR DEVICE$ IiNANT OFOODSERVICE
nIMPROVEMENT
[ . MING POOL ELECTRICwill do0eworkands: he Corrixmes Liensorat.dostomu(Stm.]T an li.a,ox ❑OTHERril Professions Code:The Cornmmara License law does not apply ss an owner of ETS-SWITCDIiS-1'I%TURES eprogeny who builds or improves tlmmnn,and wnn tines such wnrk nintsm or uffichroughhis own employeese building thussuch imams sold w are not intended ofsabered for RISIDIiNI'IAL ILEC'I'R SQ I'I'.cIe.ILhnwever.the M1uilding or itnpnrvement ixudd within one Year al cnmpltllnn,(he SQ.FI'.FLOOR AREA SIgQ.( Eder will have the burden of proving that he did not build or improve for par- //Q LOG
M ole.).
rw r of the propert,am exclusively contracting with licensed commmon to 'OT 3df
to a,mml the prowl(Sea.70,14,Business and Pmfesainns C,A,)fhe Contnnnnia Li-
,a Law does not apply it)an ownerofpropeny who builds or improves ilamon.and QTY. PLUMBING PERMIT 17EE
who cnmrtwts tar such projects with a contortions)licemed pursuant to the Commclot's /yam �y�� /
Lipes Law. PEiRMITISSUANCE ' C1 9" �70 `4?/
lam encmpl under$u, .B&PCfor This reason
AITER-DRAIN&VEM'-WATER(FA) VALUATION
Owner �iL�9Ye- Dam �_
. S WORKER'S COMPENSATION HECLARp'r10N BACK FLOW PROTECT.DEVICE 1.2(DU 000
1 hereby dRrmunder penalty of perjuryoneoftherommior loar-linm:
leve and will mninmin uCenilicmamf ConsennosolGinmre for Wnrko'x Cmmpen- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
smian,as prnvided for by Section 3700.f the labor Coda.for the performance of the 0 �
weak for which this p`rmit is issued. I'IXTIIRE$-PER TRAP
❑ I have and will maintain Workers Compensation Insumme,us requital by Section
PINI ofIM LaMu CuJC lnrlhe ger0vmaneanf the work for whichfnkfarmitisisvmd, GAS-EA.SYSTIiM-I INCA OUTLETS OCC GROUP APE
My Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4 HbO 19S
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFANDUS'rR1.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDIN VISION FEES
0 his section need mW completed ifthe permit is formic hundred dollars(16100) GREASETRAP
orlexs.) PLANCIIECK ''1 �V
Icenifylhm in the perfmrmancc of the work for which)his permit is ismad.],,hall SEWER-SANI'T'ARY-STORM EA,200 Fr.
not employ any person in any Sommer so as to bccome.wbjacno the Worker"Croatian- tiNIiRG ZQ
taboo Law,of California.Date WATER HEATER WNENITTLF.CTR
O APPRcant - AN RADE •E
NOTICH TO APPLICAN'C If,after making this Ceeifcam of Exemption,you should WATIiK SYSTEM REAPING S FEF:
become subject to the Works,',Compensation provisions of)bt labor Code,you-all
fnnhwith comply wi0such pmvisinm or this pcmtil xhall he deemed revoked. WATER SERVICE
CONSTRUM(ON LENDING AGENCY NEW RESIUENTIAI.PLMIi. QIQIIIV. t `• Vase Recaipl / a
I haf0
ersbyno that there is a conwineian ltndingagency for the performance of U' b
U
the work for which this permit Ix Ixsncd(Sec 3097,Civ.C.) v
'
F-' TOTAL:
Ledcrs Name
,[`1f'g•L➢J LeaJcr'x Address TW& C
1t 1 certify Ihm[have read Mistyapplication
and coup and stmt that the starve intimidation rehi ing is BUILDING PF.F. �e
Z) correct.IagreetocomplywishillcityandcountynrJindnecsnnd>mlelawsrelwing'o QTV. MECHANICAL PERMIT FTE SEISMIC FEE 1�
(J ? building coronation,and hereby amhorim repesenmtives ofrhis city to enter rpm the
Ad
a1Nwe-mentinned pmpcny for inspection poHsoas. PERMIT ISSUANCE ELECTRIC Vice
(We)sad.m save,indemnify and keep hmmless the City of Cupcnino against
liobilaw,judgments.cast,and expenses which may in any waY accmcagxinst said City AETERORADD'IOMECIL PLUMBING .E
comeyuence of rhe granting n[this emtit. D
APPLICANT U'DERSTANDS A WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT fTO 10.000 CUM) MECIIANICA MEF.
SOURCP RE LN'10 5.
w AIR HANDLING UNI'(OVER 10.000CPM) CONSTRUCTION TAX
Signaturenf APPlicoMCoboutor D c EXHAUST HOOD(W/DUCT) 72 IOUSINGMITIGATIONFEE
HAZARDOUS MA'I'F.RIALS DISCLOSURE
Will the applicant or fraise building occupant trate or handle hazudnus material HEATING UNIT(yO 100,000 BTU)
as defined by the Cupertim Municipal Cato,Chapter 9.12,and the health and Safely
Code.Second 25532(x)7 HEATING UNIT(OVER M0,018 B'fUI
L]Yea ❑Nn VENTILATION PAN(SINGLE RESIDE PAID
Dam Receipt
Will lherpheonl m future milJingrkcapant use equionent ser duviems which BOILER-COMP(3HP OR 1000)(0131'11)
it hazardous air contaminants as definN by the Bay Area Air Quality Management
Atmel? BOILER-COME(OVER RNI,00013'1 U)
❑Yes ONo
I have read the hazardous mmerials requiremcoN under Chapter 6.95 oflhe Cali- AIR CONDITIONER ISSUANCE DATE
made Health&Saby Cade.Sections 25505,25533 and 25534.1 uad...land Ihot if Ilot NI7W RESIDPN'ITAL MI CH. SQ.PE 3
W Idingdoc,y¢' rteadyhuvenl•Abu,it is mymxpsnsihithy to noufy pant
oflheyquiq�fntswhi ptusl 'oro issuorrce afn CenificaleduF B '
/ - Cw.r>.i9z f o!� /gA/7...�A/C.0-C•
Owner or amhnrizM agent / am Tf AI•I ISSUEDBt
. I OFFICE