S 2166 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPER'TINO BUILDING ELECTRICAL PE ITNO.
BUILDING DIVISION APPLICYI'ION/PERMIT TING.MDCEwICAI. 2166
BUILDING NG P1'RO.IEC'1'IDENTI4'll'A'TIUN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
\\ "—C Qe-Te.
OWNI3 'SNAMH: I-IION17 CON'TRACTOR'S NAME LIC NO
.� 5 �I NIC CON'I'Rol,k
/ ❑
� ANCI{II'P.CT.NG NISIt; LIC NO: ADDRESS: Oil Pe_o
CONTACT: PHONE: BUILDING PL'RMITINFO
❑ Cunsallanl Fees Paid by Applicant(Initial) BLDG �ELLFF�CF PLUMB MEE7CIH
Ell Rea r-- ElY ❑ yu
LICENSED CONTRACTOR'S DECLARNU)N, QTY. ELI:C'[RIC PERMIT FEE )
1 hereby ofina Ih:o 1; Immfo
eed ander pikin i—I Chapter 9(emamenciag JOB DFSCRII TION
QceZwo� wthiler, 90gpof Awkin 19nl'the Baminessand 11 he.nlnm.Code,occur,In,,r,c lr I'IiRMIT ISSUANCI3 RESIDENTIAL;
- an lull force and 9c t. ❑SFUWI, El I'I'CI IEN REMODEL
Gis
VU Lcer", ' Lic.#4� APPLIANCES-RES JOHN,]AL []ADDITION ❑PLUMBING RE-PIPE
IFa6 DYIe '� Conlreclnr
ARCHITECT'S DECLAkA'I'ION ❑MULTI-UNIT ❑S'1'kUCI'URAL
zo.z IuadersmdrI...shall bea.md as public reeords PANELS MODIFICATION
0X4-0 UP TO 200 AMPS ❑INTERIOR []CHIMNEY REPAIR
F4 t:W Licensed Pndessional 201-1"AMPS IMPROVEMENT [3SWIMMING POOLS
�a7� OWNER-BUILDER DECLARATION OVER INX)AMPS ❑BATH REMO 1./REPAIR D DEMOLITION '
I�''�a I hereby of oor Ihm I am oxempt from the Crnunecon,License la vv for Ibc p 1
?G5�OWV following S trao 9011,5,Business and Prohe...nn.v Cn fe:Aa,,ay N ❑01HER VSO\QCie 5
lu 3 w Fx which ns reason 6 u In a,ltevna,ober Im rove,aclm,I'Ixh,nr re irezn orwemre slGrvs e1.BcralCnl.
y 'aloe,a pcnai P p' yc �—�} Q.,
prior to its iasoanee,also rotaries the applicam mrsncb permit to thea signed statement SPECIALCIRCUITIMISC. Y•N .1 �\ Ql�
W�" that he is licensnJ punauuB mth.provision,of the Commernrs License Lnw(ChnPlcr9 �i�•�N
1+1 p'GC) (arm mencin,luhSmion lgXB of Oivision3of rbc Bsmcaxand Pmf.dmr,Cade)n, TEMP.METER OR 1101.11 EAST. COMMERCIAL
6 a e C that he is exempt themfomt unit the basis for the alleged cxwanion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
SI 71131.5 by any applicant for a permit subjects the applicant to a civil penalty or POWER DEVICES [I TENANT ❑FOOD SERVICE
art more than five hundred dollars(5500).
F=Q IMPROVEMENT
❑Las nwner.ftheproperly,ormy employees with wages as their.sale compensation, SWIMMING W)O1.131 .0 RI
F will do the work.unit the ametre is not intended.rnNTered for sole(See,]01Y,Businetw ❑OTHF
mand 1'mf.dine,Code:The Contractors License Low does not apply to an owner no OUTLETS-SWI'I'Cl11iS-T T R
pro, ry 1 hld,n :d m, I h :rO kl Ira,thnnel
his npl y P ' I 1 I h i p I.' n r' (.,led offered Nor NEW It ESIDEN'1'IAL I11.EC'IR SQ
lc If h [lie limiting(it improvement - Id within an year f pletion the SQ.FVVLIO RE S/SQ.FT.
owner builder 'll have Ilin harbor f proving that he did not build or'mpreve for put
plow'd,&r.. Qv 0
C] as1. mmer,of the propect,am exclusively comment,with licensed commm.rs m TOTAL
a : /• 7
customer he perfect(Set.II44,Business and Ponfi nm Cash:)The Comucmrs Li- p
c se Law does not apply to an owner of pmperly who ImBde or improves motion,and Q'rY. PLUMBING PERMIT FEE ./ V
who contracts rot such projects with a contractor(s)licenced pursuunuo the Connannr's n
License Law, l PERMIT ISSUANCIi �
J
E] Iran exempt under Sec. ,li&P Cf or thi,vreason
AI.TFR-DRAIN&VENT'-WATER(EA) VA. ON
Owner Wee
WORKER'S COMPENSATION DECLARATION BACK FLOW PRUTI3CI'.DEVICE
Iherad will nn under penally of perjury one of the lidlnwingderker'som: __•^� ly rj
❑Ihave and will mainuim CeniOcare of Conxnnn ml6inmac forworkda C.mpem DRAINS-FLOOR.ItO01e,AR ,COND. V STORIES '1'YI'P.0 STRUCIION
sari..,as provided for by Section 3I00 of the Labor Code,Ln the Error..toce.f the
w i,for which this pe.air is isamd, FIXTURES-PHRI'RAI'
1 have and will maintain Workers Compensation Insurance,as acquired by Section
"FOo 'IT.
f lheLab Cmle,(rt theperk
r `on`, ePN11bal laieix iswcJ. GAS-CA.SYSM-I INC.<OUTLE-TS OCC M
GROUP N
Ca War
'
Cirrir ^Bal,',1', alk q
/-� GA1-LA.SYS1I3Md1Vl?124(BA)
CERWrilziCAl'E(OTz 13XF.MPTION FROM W01t KT3RS'
COMPENSATION INSURANCE GREASE/INUUS'I'Rl.WASTE INTERCEI'[OR
BUILDING DIVISION I1U39
(Thissecri9n recd nal he mmplmeJ if rhe permit is for tine hundmd dollars(4KEEP GREASE TRAP
nr Ins.) PLANCHECK PEE
I certify that in the terfarmarccofthe work fnrwhich this permit is issued,l shall SEWER-SANITARY-STORM 13A. 0FT
20
not employ any peaum in any moaner so it to become subject to the Workus'Crimper- ENERGIFEE
0 2 xminn Laws.f Calif.mi..plate WATER HEATER WNENGUELECIR FEE
Applicant GRADING PE
NOINCE TO APPLICAN'C it.after making this Cemmeare if Bxcmptim,yna bodd WATER SYSTEM/IREATING
F hecnnm subject r.the W..ke,Com,cncalum pmvixion.c or lire Later Cade,yna nnlfl SOILS IyiE
!� InrNwhheomply with,unlr Pruvixi nrlhivparnaiI a hall tede,n,decroked. WA'I£R SERVICI?
W Q
CONSereisa construction
LENDING AGENCN'RESIDEN'I'IAI.I'LMIt. SQ.I§'. PAID
Z Ihtaffirm
hereby mmthere iso c.nstction leng ngcnm ptM
Ocy fm the performance of Doenci
U the work or which this panda is insned(See.9099,w.C.)
1" Lenders Name TOTAL
U Lenders Addres, TOTAL: (gsI, 1
W
I certify that 1 have read this application ani ,are 0mt the move information is BUILDING ITE
F rp correct.1 agree tocomply with all city and county nNinanee.c and state laws relining In QTY, MECHANICAL PERMIT PF:E
C.) ,7. buildiage.mmletloo,and herdrysuthnrizerepreaennitivesofttlisdty merecruponthe SEISMIC FEE
ahn e-mom tied property lin llaiwction parallel. as _
(We)agree in save,indcrmify and keep harmless the City of Carton,ugainsl PERMIT'ISSUANCE ELECTRIC FIBS
Ilnhilitiec,judgmcnts,rinse and enpcnsm which may In any wxy:mcmcagainst sail Clry AMER ORADD'IOMECILr
in course, c of rhe grating of mix peroof PLUMIIING 11313
APPLICANT UNDERSTANDS AND WILL COMPLY WE HE ALL NON-POINT A IR HANDLING UNIT(TO 10,000 CFM)
Sf aRCE REGULATIONS. MF.CIfANICAI.PEI: !
1f`I1�Iwy AIR HANDLING ON]'1'(OVER I0,000CiM) CONSTRUCTION TA
Sagnmr cnfApplmwmi Lnullac orir •� \` � e EXHAUST HOOD I W/MUCID HOUSING ME]GANGS FEE
HAZARDOUS MATERIALS DISCLOSURE
Will meopalicaolo,Rome hodidio,accepatrtmmnr handle lwzmd.n',melenal HEA'T'ING ON(1'(11)I(X)jS0 IT I U)
:,defined by the Cu,sainn Mllnlc lad Codec Chapter 9.12,t d the Health and Safety
Code,Section 25532(a) r-��/ 1iHA'I'1NG UNE(OV 1311 100,ex)if I U)
❑Yes VENTILATION FAN IS I NO L2 RFSID) PAID
. Will thea licit ser 1'mme buildin t u.ve e m mm�t m devicea which Can, Receipt a
carpp gby then y p BOILER-COMP OHP OR IID,gD BTU) yy
District' BOILER
air contaminants as defined by the Bay Arco Air Quality Management TOTAL: //
DinrieC — / BOILER-CGMP(OVI3R 100,000 BTU)
❑Ycc
Ihave rcarl the ha,aohn,maleards ner,incruent, Clutter 695 fthe Cb AIR CONDI I IONIE ISSUANCE DATE
rum H a1Nh&Safety C J S f 25505 25531 125531 l understand ilia,it ba NEW RESIDENTIAL MI3CH. SQ.FI�
budda,do.act cruciallyh learma.lhlt is acy I.'.. 'hilil,tonutdbeiscO,am
f aeyr�1' nwh ch nuxrbe ncr po or Ya
uancenl a C.rill"re of Occa po ey.
ns
Owner br au�z d ager Oat TOTAL: Iso SSUI?D BY:
OFFICE