S 2170 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'TINO BUILDING-ELECTRICAL rr1T ND'
BUILDING DIVISION APPLICATIONQ'F,RMI'I' PLUMB INC.-MFCIIAN]CAL :J 2170
BUILDING PROJEC'1'I DEN'TIPICA'I']ON IIUILUING ADDRESS SANITARY NO. APPLE CAI'IONSUBMITTAL UAI'E
0 o d s ar <?9
OWNERS NAME: PHONE: CONTRACT'AVS NAM \ LIC NO:
NIC CONTROL It
• ARCHIMCPHIGINEP LIC NO: ADDRESS: Ilk ❑
CONTACT': ']PHONE, BUILDING PERMIT INFO
4y\}q�Ov,\i ❑ Cansullanl Eccs Paid by Applicant(Initial) BLDG ELECT 111;(BINIECII
Q_!1 CO x ❑
IJCENSED CON'TRAC'T OR'S DECLARAI ION Q'ry ELFCTRICPERMIT' FEE JOB DESCRIPTION
I hereby affirm Inco 1 am licensed under proviciam of Chapter 9(O mrencing
WO with Section DIviVm113otIllcBminr,sallld Pmftaslmlx Cad,.mainly liacnxc is l PERMIT'ISSUANCE I RESIDENTIAI:
Z �l
full Rarec and' I. _ ❑SIUN'h ❑KITCHEN REM(Illlil.
Ruu -n Clava hicg �� �Ln(,n AI'PLIANCIiS-RT:SIDI!NfIAI, OAUUITION OI'LUMBING RE PIPE
F,Z W Dae Conmecmr
'nQaARCHITECTS UITCLARA'I'ION ❑MULTI-UNI'F OSTRUCTORAI.
F D m PANELS MODIFICATION
OZ=Z [understand my,].c,,hall be used.,public mcaedx UP t'02011AMPS
DINTERIOR OCHIMNEY REPAIR
O
F 4LW Lic...d Professional 201-Iqo AMPS IMPROVEMENT' [:]SWIMMINGPOOLS
S,''j OWNVR-BUILDER DECLARATION OVER IINXIAMPS O BATH RENIPQELREPAIR ODEMOLI'HON
Y C Q 1 hercny.firm flm I ane exempt from the Contractor's License Law lin the Cr
'�aV tollowin (Section]0315.Business and l4ofessme,Code:Any city or county SIGNS ELECTRICAL. OOI'f11Jt
W3 a[- which qui a parmh to construct,alter.taproot,dcnollxh, n o,.i any.,sure i+-.\Z.IV RSC Q. A
^teapoor to hx issuance,also requires the applicant for such permit to me a signed statement SPECIAL CIRCUIT'/MISE. in,
lho he is l korai punmm N
un cpnntoonx(,ileanwM
a Crum's Grence I.aw Whacr a COMM-RCIAI,
cc C) (commXX11(commencing with Section of Division 3 of the Business and Prefeesinn%Code)or 'I T!MP.ME' OR MOLE INS,
K E e that h^is exeepl lhcret'nmm saddle basis far flat illegal eeeminio 1.Any einiation of O NF,W HLDG/ADDITION O DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penahy of FOWFIc DCVICP_S ❑TENANT OFOODSVIRVICE
inote Nan tivc hand md&Al:m(5500).
].asownerofthe n OTHER EMI!NT
l—I clots myeeptendes wiNwvgcsax lhci(Set.cannpeesul n, SWIMMING I'OUh ELECT RIC ODTHI.R
F. will An lou work,and ane smncuue is nalmmndcA.....Rcaed lin rale(Set.70,14,Ifacinos%
W 3 L and Professions Cwc:The Comraaor%License l,aw does tan apply to an owmef of OULATIS-SAF11CHI!S-FIX'IFE S
prpeny who buil(e or improves thereon,and who does such work h+msdf or Rough
his own employees,provided that such improvements are not immnded or uttered Inr NI3W ItI!SIOI!MI'IAL 171.1!CI'H SQ IT.
sale.❑.however,the building^r improvement is sold wilhinonc ycandeompinion.the (1(7.YT.PL( R: ti FP.
owner builder will M1ava ILc nuNcn of pnrving Oma he AiJ not buil)or ilnprovc for par- IDI
,oc A sale.). TOTAL:
❑L its mama ul''he pmpeny,am cadusivel.oata.mur,win Ii,Onced contractors to �/nV
smtrv<t 1ne project(Sec.,(Nd,Busincex and 1'ndmsions Gdcl TM1e Cnmreclors Li- IIII'11 1 199
cense Law,duce not apply fo nn owner mfryvgcny who bailie or iinprovu lhercnn.end QTY. PLUMBING PIiRMIT FEE 0
who contracts for such projects with a contractor(%)licensed pursuant to the Comraemr x
Lace—Law. PERMIT ISSUANCE
C1 I am exempt under Sec. .B&P C for Nis reason
ALTER-DRAIN&VI!NT-WATI[R(1.A) VALUATION
Owner Dme
WOIZK17R S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hercnyalarm under peony dperjury sure nlthe Edlmving declaudarri:
❑ I noe a willumanudn a Ccnillcae III Coastal xclf-insure for Waders Compm- / DRAINS-FLOOR.ROOF.ARI A,COND. STORIES TYPECfONSTRUCUON
tion,a%provided for by Section 3,1X1 of the labor C dc.lin be performance of ale
r which This Peru...is Ivsurd. FEXTURES-PER'TRAP
1 hov
w e and will maintain Wader's Conaos
pemmm In,cueas nee, required by Section
3700of the Labor Ca+de.forahe'PerErmarecofInc work far which that paamao''sued, GAS-LA.SYS'ILM-I INC.JOUTLCI;S OCG GROUP AI'N
M Wr:�m�.Coy est {Cps randyNo.
Carrier: lGl{__� _,_c \�\sic Policy Nnyl � GAS-EA.SY59liM OVLRdIF,A1
CI;R'I IFICAI'1?(1F EXEMPTION FROM WORKERS' GREASEIINDUS'I'RL WASTE IN'I PROMPTER
COMPENSATION INSURANCE! BUILDING DIVISION IBIS
(Ilo-rctionneed na he annplcleA iflhe permil iv f,I.sure hundred dollnn(SI(X) GRIIASP.'I'RAI'
PLANET BECK 111E
or lccsJ
scally ilial in line perlbranfie of N,work tat which this permit i k rs Co shall SEWER hiR-SANI'fARV-5'IYORM PA.211)FP.
not anpiny anY pennn in any maonenu xs m became subject m he Worker'C(,mpcm LNI!RGY PEIi
Z s-flon Law—f California]late WAGER I II!ATERINPIENT/ELECIA GRADING FEE
z O Appucanl
N01 FIT 10 APPLICAN'II IL after making this Cel ifmcee of Exception,you should WAFER SYS ITIA TREATING SOILS FEE
F" becomerbjec o the Worker's Compensation Provisions of the Lmoar Code.you must
Q fonbwilh comply whhsuch plavisionx nr this permit shall be deemedeevoknL WATER SERVICE
CONSfRUCf10N LENDING AG12NCY NEW RESIDENT[At.PLMlf SQ.FT. PAID
I hereby off nn ohm lhcrcire comlmatun lcreirl-leacy knihcpurformameof Dale. eceiplp
Fthe work for which this permil is issued(Sec.3097,Civ.C.) TOTAL:
O U tenders Name IOI'AI:
r Isndcrs Address _
y I trimly lbw I nave read This aPPlicaunn and stale 111.1 Ne aMrve interuct^lion is
BUILDING Flili
F-' N creel.I agree to comply with all city and count ordinances and stale laws miming to QTY MECHANICAL PERMIT' FEE SEISMIC ET
U Z building,orankromand herby act I,,r,ar,,mmi,r,otln,city m emeT.pon he
above-men1loned pmpery for insl+'etin^purposes. , PERMIT ISSZ(OVERII)OX)
F.LIiCI'RIC PI.1. i
(We)agree n'ao,,inde nail,and keup h^nnlecs fhc Cary of Cnpenino.,:ansa
Iiabilitics.rydginenls,costs and expenses which may in anYwaymcrae against said City ACTER OR AI. PLUMBING FEE
in xGIUCIlt'e of the grmning of 111aS permil
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALI.NON-POINT AIR HANDLIIB,000 CPM) MIiCHANICAh PI!,
S a'RCE IYEGULA'TI(ONS.
p � �J -����
AIR HANDLI!R IILfXNICPM) GINSTItUCI'ION'IAX
gs
SignamrcufApPacamVCnnlmclor IJuwEXIIAD$'T 11p HOUSINGMI1IGA1ION FII!
HAZARDOUS MAITR1ALS DISCLOSUREWill the applicantnr fema malm.goc,ceam store or bundle hanwdnus Imanal HEATING UXI E'I'll) /
as defined by Ne Cuper al Municipal Code,Chapter 9.12,and the I Iea11h and Safety
Cade.Section 25532(x)2 f HI!ATINGUNIT(OVI!RI(q,NX)BTU)
p Yes No VENTLAfION PAN(SINGLE BESIDE PAID
Ilam Receipt p
Will the applicant or future building mecmpam use equipment or devices which B(IIhEH-COMP 1311P OH I W,(XXI UTU)
mil hu'rardue,am cI an+ana n,ac delinal by it,,Bay Arca Air Quality ManagementA. TOTAL:
District! BOILER-COMP(OVER 100.000 BTU)
❑yes
fomia Ilhas,tcadflc haneWusmmeraaly rcquirnnenn under Chaprerfi95 Ili'he Calm A IR CON FITIONF.R ISSUANCE DATE
cahh&Safety Code.Sectio.25505.25533 and 25534.1 understand that it the NEW RESIDENTIAI.MECH. SQ.FL C)I A
III it nolumrvatlyhavea lentil hal if is my responcihlEty ha notify the rrenpana JJJ
ted, With oma he mel prior m isonee of a Cen'ficwe of(kcu
uLNSrSmiranxr��`�^ - - c rS Jst§l 'IY)fAh: t ISSUED fly:
Owncrorrmhnnzedrgem 1lY..a�' O'I'llle�
OFFICE