S 0166 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD.Msi-ELEICRICAL PF:, IT No
BUILDING DIVISION APPLICATIONIPERMIT 1'LUh11UNG-MECHANICAL J O 1 F�6
BUILDING PROJECT IDENTIFICATION .L V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'ITAI.DATL
O 2 Z J —108T Wo P.0 Cv •co �7Q7
IOWNER'S NAME: I'll)NE: NTR Cf0 S NAM LIC NO:
/' Y S ASSOU NIC corvTHOLa
LH DTLT NGINEER: LIC --..-rD7WST ❑ Q O
�t kd v Z O h t eta V O C7
C(NTACT. PHONE: BUILDING PERMIT INFO
_ .UnsullaDl Fees Paid by Appllcenl(Initial) til ELECT PLUMB 0
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
a9z Ihsmtinn]IXNgof Divixion3 of the Bu.ine,,mul Profovwions Cad...ndmylieenseis RESIDENTIAL
4100 w'I ll p PERMIT hl'Sl1ANCli
CLLF nfull farce and, ttt. '-1'� TJ ❑$FOWL ❑KITCHEN REMOIIITI.
Q,U\y License Class Li<.a APPLIANCIS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
ION
FFZµ1 D Contra,
F. AHCHITECI'S DF.CLARA ION C.oay�'QJr�Tad ❑MULTI-UNIT' ❑STRUCTURAL
ZO'r'Z I umlenchad my plans shall be used as public ruord ` PANELS CHIMNMODIFEYREPA
C)Z UPT02W AMPS El INTERIOR [I CHIMNEY REPAIR
Licensed Profeasiaml ^_fill-IOW AMPS IMPROVEMENT SWIMMING POOLS
CI hereby ffiml OWN am exdmpt(rnmEthc Contractor's License taw for the OVER 1000AMPS [I HATH REMODEIJRI3PAIR IlIiA101.1'I'ION
< Y a ❑OTHER
x1x10 a U lidlowing mason.(Section 7031.5,Bu,ine,s and Profession,Code:Any city of county SIGNS ELECTRICAL.
W 3 LL y< which requires a permit In conGmcl,alter,improve,demolish,or repair any structure
I�'u'0J primtoits issuance.alsore,dow theaMlicantforrsuchpemit tofilea signed statement SPI7CIAL CIRCUITIMISC.
F!!(} that he is l ecnmd pursuant o the provisions of the Contractnr's License Law(Chapter 9
LL aapO (commencing with Section 7000)Of Division Sof lire Im,inev,and Pn+l'cuionx Cod,)uf 'I'ITM P.ME I'ER OR POLE I NS'K OMM�IAI"
CcF n C that he is cxcmpl therefrom and the basis for the alleged exemption.Any violation of ElNF?W BLDG/ADDITION
❑DEMOhfI'ION
�wSection]03L5 by any applicant for a permit subosv%the applicant u+a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
m morethan frv,hundreddoll...S510). II PROVF,MENT
fF00I.axowncrol he mopid,a,my employee,with wagcx.x thei,w1cunnpcnmtion, SWIMMING 1'00 HIC 1V ��f,V1i\OPT -1f-
wdId.flm mk.md thesmuclurei,mol imma"malfcreJ forsale(Sce.](H4,Business O'1111iR
6 3 and Professions Code:The Contraction's License law does not apply to an owner of OUTLETS-SWI FlXTUR&S
property who builds or improves thefam,and who does such work hinsself or Ibnmgh
his own employees,provided that such improvements am no,intended or offered for NEW RP_SIDITN L ITL SQ for.
sale.IL hrmvever.the building.improvement is sold within one yearnfcompletinn.the SO FT'F}v,(l0 AR11 ASQ.ITT,
cr-builder will have the humen of proving that he did not build o.improve for par- • •�
ocon
Pwn of sale.) O'TAI,:
71 1,as Owner Of the proPeny,am exclusively contracting with lice+ud contractors to q
construct the project(Sec.TkU.Business and Fordo Code:)lTe Contractor's Li- JUL 1aaaY 2 RE1-11
cease Law does ern applym.amwncrol'ma,my who b.Jd-uunirove,lhensm,and QTY PLUM rP IT FEE Y
who contacts for such projects with a contmenns)licensed pursuanuo the Contractors CITY
Lu h�
License law. PERMIT ISSUANCE CI11 VF UUVLIiTII\Q
Imo cwth wade,Sec. ,B&P C fm this reason
ALTER-DRAIN&VIIN'1'-WA R(ITA) VALUATION
Owner Dae al 1
WORKER'S COMPENSATION DECLARATION RACK FLOW PR(YI'IiCT.DEVICE {`u1 -O oo,�
1 hereby of0rn+under penally of perjury enc of the tbllawing declarations: A
Iheve and will lnaimain oCenificmc of Cnnsenuo ttlf-insum for Workers Compcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES 'TYPE CONSTRUCT ION
moan,as Provided for by Section 37W of the lahta Cale,(,,,,he perfomta rec of the
work for which his more,i,issued. FIXTURFS-PERTRAP
❑1 have and will maintain Worker's Comp,nsatiOn Insomnce.as inquired by Section
3701Oofthe LMv Code.for the performance Of the work for whichlhis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLI71S OCC GROUP MIN
Y
Work. Com�p+ee eII��In.sumav cerrierand Policy nV ben Qt(�
Cartier: C^tObIs MGCE PoIRy No.'.T� Irt3i FT S- GAS-EA.SYSTEM-OVER4 UTA)
CERTIFICATE OF IIS EMPTION FROM WORKIiRS' GREASE aNDUS'TRL,WASTE:INTERCEPTOR
COMPENSATION INSURANCE G DIVISION FREES
1'Ihis section now,not he camdemil ifthc pemat is loran,madreddellnrs($IW) GREASE*TRAP_
nr lea.) PLANCIII!C
4001
I certify that in the performance ofthe work for which hi%pemtil is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner no as to become subject to the Workers'Compen ENERGY FEIi
z mlianlawsof C"orria.Dam W\'I'ERHIiAIERWIVENEDELECTR GRADING 19iIT
'z
Applicant
OTI�' N NCE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTFOFTREATING SOH-S FEE
heroin
LQ xuhjcti m the Wnrkcr'n Cnmpcnmtinn pmvisinro of the LaMn Codc.you mull
LQ fnNtwith comply with such provinions.obis pemtit,hall be dcmneJ revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SO 17, PAID
I hereby affirm lhuuhcrc inmmnxtmeinn lending ngcncy l'ur the performance of Date iptM
WF the work for which this pcmlil is issued(Sec.3119],Civ,C.1
C) Lcodte,Name '1 OTAL:
U Leulcrx Address TOTAL: _ A '
Y' I certify Thal I haver d this application and state that the mew,mlbnnadnn b BlP1.UI 4�C
Fa
' Z Cmdingco bactio ,andw allcityrepresentounty ativesnowes of
stem lawtr upon the
QTY. MECHANICALPERMIT FEE SEISM 'F -
O � building canstmction.and ho eby am@niu rtprescnmtives Of this city to contr upon the -
abavonmaaaneJpmmayl nimpell purso,wo PERMI'I'ISSUANCC EI.IIGIRIC ITIJ
(We)agree to save, th mody and keep harmk,s the Clly of Cupeoinn against
haaitics,judgments,cost : al expenses whichmay in any way rectae against said City ALTERORADOTOMECR PLUMBING IM
in nnsoquenm of the grit,ti ,Of this permit.
APPLICANT UNDERS'A IDS AND WILL COMPLY WITH ALL NOF INT AIR HANDLING UNITUO 1+,000 CFM) MECHANICAL ILL
SOURCEREGULATI
t � AIR HANDLING UNIT(OVER IO.IAOCFM) CONSTRUCTION TAX
Signature ppllcam nt actor Dae EXHAUST HOOD DVIDUCT) HOUSING MI'I'IGA ION 17E
HA DOUS MATERIALS DISCLOSURE.
Will the applicant sure M1uilding nuupum stem nrhmAlchau aux material HEATING UNIT LTO 100.(X0 BTU)
as definW by the Cuperth u�Code,Chapter 9.12,and the Health and Safety
Calc,Ssation 25532(a)? HEATING UNIT(OVER I(XI,IXN)tll'U)
E]Yca VENTILN'ION FAN(SINGLE RESIDE PAID
Dam Receipt a
Will the applicant or future building Occupant use equipment or devices which BOILER pHPOR LW.oW B'I'LIE
�m+it harardous air contaminants as Jefinal by the Bay Area Air Quality Management 'DOTAL:
Digricl? BOII,EIt-COMP(OVER 1111,N)OBTU)
II Ycs jw.ant,
rc
(have read the hasas rtyw meets under Chapmrb YS of the Culi AIH CONDITIONER ISSUANCE DATE
famla Health&Safety Cod505,25533 and 25534,1 under,tand that if the NEW RESIDENT[A],MITCH SQ.FT.
building does no cutmntly at iii mymsix+n,ibilitylanotifylherccupanl
of the r^yairtmcntc whicM1 ¢+issuance nfaCenificNc J( 'out cy,
oraathn'-' 1 a c
'I O'i'AI,: IS
Owner Sl11iU RY:
OFFICE