S 0659 APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES-USE BALL POINT'PEN ONLY -
CITY OF CUPF.R'PINO BUILDING-RLRCTRICA[, PERM IL No.
f BUILDING DIVISION APPLICATIONMF,RMI.1' rIA3 PROJBING. T mExrvIFIC S 0659
I - ' IIIIILDINE 1'R07N(.T IDRMTIFICATION. t '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2173 R� rnh� C*. C•, I' u
CA
OWNER'S NAME: )I„ (��1-. 33� CONIRACr(HIS NAME' r UC NO:
�Gn //, NIC C(y7120L��
:.HITI!CI'/1!NGINI31i : LIC NO: ADDRESS: - El ((TT,VV�'/�I S
COMPACT: - PHONE: BUILDING PERMIT INFO
c`li 7dd-dj7j ❑ ConsaHant Fees Paid by Applicant(Initial) BLDC FEC' PI Q.NipMSCI
RN' mot.
LICE NSIDCONTH RS DECLARATION QTY. .• ELECTRIC PL•RMIT,• a 'Flit°
I hereby alum that 1 f ,ad under pre+m w,of chapter 9(enm me g f J013 DESCRIPTION
{QyaZ whh Secl nt]IIfXOofp T a fine❑w nc,s and Pro[ess ons Cnde sea my l'acil RESIDE TIAI:
FOOI'I!It
iafell Rrrecandeffa4 M1115S11ANCE DWh ❑KHCNENREMODYa,
�UppF License Clan Lic.» A'I'LIANCI!S—RI!SIUENTIAL DI'I'ION ❑PLUMBING RI PIPE!
FZ Rl Dale Contractor -
tiQd UDI'FIJNI'I' ❑STRUCTURAL
yy AliClll'I'EC'I"5 UEChARATION
F y z I i dOwand ni a II hu a,d an M1Ir mr an14 I'ANI?LS MODIFICATION -
ZO YPTmxs ler pn UP 1020h AMIS
py�0 � � � 'I'IiR1012 ❑CHIMNEY 12Ltl'AIR
Licensed Prel'uvoowl 201-1000IMPROV FM13NT OSWIMMINO P001.5
rG�+
OW
NI3R-BUILDER DECLARATION OVER I(XNIAMI'S ❑BATII RIiM(IDlil./kIiPAIR ❑DF:MEhITION
•+CI�X1 I hereby union thin I am ewmpl from the Contractors License Law for the
�Y5 O W V following reason.(Section 7031 5,Business and 19ofasslonm Code Any city or c mmy SIGNS ELI!CPRICN, ❑OTI11!R
W 314 which requires a permit to construct,alter,improve,demolish,or repair any m or,mv p
0 prior to its issuance,also requires theapplicvm PI!CIAI.for such permit w file a signed martian, SCIHCUITIMISC.
�,y} IV
that he is licensed pursuant to the provixinm of the Contractor,License Lax'(Chapter 4 _
•I+I pO mommenci ng with Section]IXXgof Divi,fna 3 of the Business and Professions Cars)(it IRNIR.MHT13RORPOLEINST' �,[ �fy'.1I
L c that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑N G/ If i(ft®DEMOS BION
�Mto Section?031.5 by any applicant for a permit subjects the applicant a civil penally of 141WLR DEVICI!S np7{.�AMI' I/
not mor than five hundrW dollar,Mail 0?; PH�liMPNT
TSC ❑ Las owner of the pmpeny;nnny emPlnyccs with wagenas theirsole comcensation, SWIMMING POOL V1.17171 RIC UUYLh-(IGT/pp n
F will do the work.and the vlowlem is not intended oroBered formic Basins
❑O'f111iR C
uad Professions Cale:The Contractor's License Low donot apply to an owner of OUTLEIS—SWITCHM—FIKNRES
a 3 progeny who builds nr vide¢thereon,and eche nts m not
intended
or of lonmgh
his own employees,provided that melt improvements are Dol immnded m offered for NI!W HP_SIDIiNTIAL IJ.GCITI SQ FT.
sale.If,huwexer,the building or improvement is sold within one year of completion,the SU Irl'.FLOOR AREA $I'
cr-builder will have The burden of proving that he did not build or improve for pim
Pace r:l )
L. ❑I f the propert ly contracting th licensed contractor,TaAL
construct th project(S 7M4 .Bi Pmfessi Code:)The Contractor s 1
creel d I apply to net fp pony h tile. improvesIherent d QTY. ' S L MHINGPERMIT� - FEE I I
ohormaractstorcohf ectswth actr sto)liensed aromatic lie Contractors
Li,tow` I'IRMI115. IA
111 ❑ Eat xcnpTUWvr Ssc B&PCforlbs asst
r �� x Date /sl:l'BI<—DRAIN&VL"' A'1'I3R(HA) - VALUATION '
voo
IiR'S COMPENSATION ECLARATION BACK FLOW PI2OI'LCL DE
x crchymfi trader penally of per jury one if the fill twingdaelumtio., - (� T; �
I have and will maimuin a Ceniticam of Consent o self-insure for Worker's Craa cn- DRAINS—FLOOR,ROOK AREA,CONK' g'IORIES TYPE CONS'IRUCI'ION
ssdon,ae pmviAal Iia by Section J]tNl of the Lrbor Cale,far the performance a(tha
work for which this Ipmtit Ix iasnerl, Il X'FUR17S—1'1!R TRAP
❑1 have anti will maintain Workers Compensation Insurance,as require)by Section
]]pintthe Urn,Code Innhc lerfennanceof the work for which this pcnan, ;sued, CAS-1!A.SYSTFM-f INC.40UTLETS MCC.GROUP APN
y My Workers Compensation Insurance carrier and Policy number are:
Combat: Policy No.: OAS—EA.SYSTEM-OVER 4(FA)
+ CE:Rl'IIICATR OF EXEMPTION FROM WORKERS'
f COMPBNSATION INSURANCE GREASU NDUS'I'RL WASTE INIERCEPTOR 11.1 G DIVISION FEF_S
or lcsJ Cnismation need not be completed flow permit is for one hundreddellars(SHXE GRHASWI'RAP
1'LANL 1 .K !I!
I cenify that in the p�Anmm�ce of the work fine which this permit isisucJ,IshaO SEWHR—SANITARY—STORM EA.20)FT.
t urn aMlny any person in any Donner m us m Marne muhjem m the Workers'Comlen. 1!NEHOY iii
_O00
z sation lnwe nfCuGfnmia.UaaWATHR HHATI:R W/VENT/LLECTR GRADING PI!
Z L) Applicant
NOTICE TO APPLICANT.If.vflie naking Ibis Cenificme o'Exemption,you should WATER SYSTHMO HEATING ILS 111411.
t ain become nuhjccT m the Work,,,Cour pensalion previsions of the Labor Cede,you masa
Da fonhwith comply withsuch powisin i,o,his permit shall M deemed revoked. WAU!R SERVICE
a Q
[ CONS*[
tthem 1,armom.ENDENGAGENGY NIiW RfSIDI!N'TIAI.I'LMB. SQ.14. PAID
U �" Ihcrcby afllrmtlunthcrc lnuctnawefinn lording agency for lbc perfonnuncc of 0n ceipl p.
U O the work for which da,permit is mal(Sea.3097,Civ.C.)
� Lauda',Name TOTAL:
r W Lel Ardor,
d " I dythalI ITh:applicationand Bat that the above utl rat l . . I,r • -( p IIUILI lila
rn
correct.In
on I gr I c ply Ih ll lyand Iy d' ' dsrmin Fi gt QTY. MECHANICAL PERMIT !'f�' rITESINS .F
C.) Z aMve-mentiowd pmpeny or inspection umrnev h dd gcotstructon,and hereby authorm representatives ofth,city to enter upw the -
fp
(We)agree o save,indemnify and keep harmCityI'RRMI'I'ISSUANCE:less the City wCupertino against 13LCC1'NIC Fill
1. liabilities,judgmens,cnsBandexpenses which may irony wayaccme against said City' Age BR OR ADD TO MRCL I'.LCIit sill
in com e,marec of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDIJ NO UNIT(TO 10,1XXI CFM) MHCI IA CA.FF.B
SOURCE REGULATE S.
10/4 4- AIR HANDLING UNIT(OVER 10,001 CFMI CONSTRUCII T
Signal fAp c n`Cmnlruche Dal HXILAUST HOOD OVIDUCT) HOUSINGMI'UGAT NFEE
HAZARDOUS MATLRIAI S 11��11II CLOSURE
Will th up licualoomumhuildingoacriterm macwhandlehaatNnusmmcnd Ifl!ATING UNIT(TO I(I,M)BTU)
l as define)by t :ulwnine Municipal GNe,Chapter 9.12,and the Health and Safoy
I Code,Section 2553200? HHATING UNIT(OVL'R 100.000 BTU)
❑Yes ❑No' - PAID -
VIiNTI1.A1'IONFAN(SINGLERESIU) Date Re =p»
WIII the applicant a furore building occupant use equipment or devices which
it hatardnus no commonanes as defined by the Be,Area Air Qualily Management BOII.FR—COME,(3111'OR IM."BTU) TOTAL'
);miner^
E]Yes ON. B0II.IiR—COMI'(OVER 100JNXIBTU)
ii
e
' I hwrcn
ed the hursarchm, ownak recriminate,under Chapter 6.95 ofthe Cali- AIH CONDI'TI(INI!R - ISSUANCE DATE
I Limits Health&Solely Code,Seadun,25516,25533 anti 25534,1 understand lost if rho NI!W IZ17SI UI!N'TIAI,MFCII. SQ.Cr.
- huilAing dies nal aarernly haven mnanl,IhuT it in,Tym,powibihIy to cold,tho........a - -
iftherequaememswhichtinml he amt prior to marea 91 a Certifreasof Oecupaney,
Owner or aphorised agcm Date .A ISSUIiU By:
OFFICE