S 2647 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINESZ USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^/\ r�
HUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL C 2 6 4 7
BUILDING PROJECT'IDENTIFICA4.W
J L V T
BUILDING ADDRESS: SANT"['ANY NO, APPLICATION SUBMITTAL.DATE
�(3 6 R Ct9 TSNO
E 'S Ti: Xx PHONE: CONTRACDOR'S NA Ii:
M ,V4,F/ NIC CONTROLX
ARCHITECTIENGINEER: LIC NO: ADDR 5: �
COM'ACI: PHONE: BUILUING PERMIT INFO'
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PI UMB MECH
via-. ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FIiE
1 hereby amrm that 1 am licensed under provisions of Chapter 9(eminrlencing JOB DESCRIPTION
tom wm^iearee 700l Olvirom3.1L.Im,aaaes,and Prafe„mr,Cadeuad my license is RESIDP.NTIAL
1 p w PERMIT ISSUANCE
F n �: C3 ❑SPDWh El KI REMODEL
Uss 3G a APPLIANCES—RPSIDF:NTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Z ma Cnmruan
'Dad ❑MUGA-UNIT ❑STRUCTURAL
F,D rn ARCHITECTS DECLARATION PANELS MODIFICATION'
Z C y 4 I naden'land my p m,,t all be used.x p.Nic roan& UI"10 21X1 AMPS
pZ'4 ❑INTERIOR ❑CHIMNEY REPAIR
I=0`lE'W Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
OVER lgX1AMl'g ❑BATH REMODEVREP IR DEMO (TION
—WW, I hereby affirm that 1 em exempt from the Contractor's License Law for the A.
0:6 U following reason.(Section 9041.5,Business and Professions Code:Any city or county MGUS IiLECTRICAL ER
W 3 LL y which requires u Permit to con.stmet,shot,improve,demolish,or repair any structure
i—:O< prior to it,issuance,also requires them,icant fo...on peri,to file aigncfsartment SPECIAh GIRGGIT/MISG. (s�sl a LJ rZsiA-`!6
thatheislicensedpursuanttotheprovisionsoftheComrarousLicenseLaw(Chapter9
W�Cc IcnmmcncingwiN Section]gMl)nf Division7ofthe liosines,and Prom,,iom Codnor THMP.METER OR POLE.INST COMMERCIAL:
0. c That he is
exempt the
and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
sill Section Section 9031.5 by any applicant for a Permit subjects The applicantn a civil penally lir POWER DEVICES [:]TENANT ❑FOOD SERVICE
t more than five hundred dollars 1550B). IMPROVEMENT
❑ I,as owner ofthe properly,or my employees with wages as their sole compensation, SWIMMING POLL ELECTRIC
XX CC�r_ will do the wud,und locarucmrc is not intendedordfmd far auto(See9(044,Business ❑OTHER
13 and Professions Cafe:The Contractor's License Law does not apply to an owner of OI TLEI:S—SWITCHES—FIST USES
property who builds nr improves thereon,and who does such work himself n,through
his own employees,provided That such improvements are am intended lir olTered to, NEW RESIDENTIAL ELEC'Ii
sale.If,however the building orimpmvemcnt is sold within one year ofcompletion,the SQ.FT.FLOOR AREA S/SQ.Ief.
ner,milder will have The ambleas of proving door hotfoot build or Impnrvo for Tar-
,so of sale).
❑ 1,as owner of the properly,am exclusively cautioning with Ileenxae enmmc¢rrs to TOTAL:
construct the project(Sec.9044.Business and Prol'essiore Col'ILe Cnntractods LI"
ase low saes not apply ro un owmr of properly wM10 builds or improves merton.sod QTY, PLUMBING PERMIT FE
who contra",tartach pros with a contra l Leonel Turanian mile Contractors
Liam Law. PERMI I'ISSUANCE
❑ 1 an exempt under Sec. .B&TIC for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
owner Date
WORKERS COM 1117NSAI[ON DECLA RATION BACK PLOW PROTECT.DEVICE
I hill ininn under penallyof perjury oneof the Jollowing dexha ons:
❑ Ihave and will maintain a CeniGcmc of Consemmsclf-insum do Worker's Compton- DRAINS—FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
ration,as provided lin by Section 3700 of the Lahr Code,tn iThu pafor a nce of the
466,f or which this Tomtit in issued, FIXTURES—PER TRAP
1 hate anti will maintain Wader's Compensation Insurance,as required by Section
AWa]the Luder Code.for the performance of the work for which This peril is issued OAS—EA.SYSTEM.I INC.4 OUTLETS OCC GROUP APN
My Workd,dy�iyy^app'^�g11w �xmier and Planey nwnlwryr/AeOefD�� GAS—IiA.SYSTEM-UVF.R4BEA)
Carrier: IL�f..' 11 1 Policy Na.�Mgig
CERTIFICATE OF HXEMP-HON FROM WORKERS' GREASUINOUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE tlU1LDING DIVISION IF.IiS
(This scetinnnced not be completed t"The Permit is Toronto hundred dollars fSION GREASE TRAP
or less) PIANCI IF.CK ITC
I cenity that in the performanceofme work for which this permit is issued,I shall SEWER—SANITARY—STORM En.210 IT.
not employ any person in any manner so as to becoune subject to the Worker,'C.,I,,a- ENERGY FEE
Q Z talion he. Cali n 'a.Ila WATER HEATER WNENTIELECTR GRADING FEE
z Q Applicant -
rN., NOTICE TO APPLICANT.If,truer makin6 this Cenificatc of Exemption,you should WATER SYS'TP,hVfRIiATING SOILS[ZEE
a , hecume subject to labor Crude,Worker's Compensation provisions of the laCrude,you must
forthwith comply wth such provisions or This peolI shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION[.ENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U O I hereby arfir mat mere iso commelioa lending agency l)n the pararmtce of lime Receipts
H the work for which this .it is issued(Sec.3099,Co.C.)
O U Lender's Name WMECHANICALkE
L:
ILL Lemich AdJrtss 'I'OTA
1 cenify that 1 have read this application and state mat the above information is
BUILDING
Ir y correct.l agree m comply with all city and county ordinances add slate laws relating m QTY.EAL�ROERADDTOMECH.
PERMIT FEF.
U Z buildingconswction,andherebyauthorizerepresentative,-fthiscitymenteruponthe
above-mentioned pmporty lit irepecdan purposes.
(We)agree m save,infemnily and keep females,the City of CiT iso against
liabilities,just ,costs and exfenses which may inany way acemeti,mrst said City .inAPPLICANT DGR . )S AND XI L CO PLY WITH ALL NON-POINT 10,00 CFNE
SOURCE y� I TATS S
^ AIR HANDLING UNI'1'(OVI?R 10,1X10 CFM) CONS'I'kUCI'ION X
Signature of Applin UCm I Date EXHAUST HOLD OVMUCT) HODS ING MITIGATI NFIiE
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicamor future budding oecupant store or handle hazardous material HEATING UNIT CTO 100.001n)BTU)
as defined by the Ctinamon Monlcipol Code,Chapter 9.12 and Ilse Health and Safety
Cade,Section 25532(0)? HEATING UNIT(OVER 100,000 It I'U)
❑Ycs 94K VEN'I'I IATION PAN(SINGLE REBID) PAID Date Receipt IT
. Will the applicant or future building occupant use equipment or devices which
BOILER—COMP(3HPOR 100.OWBTUI
emit bamrdous air contaminants a`Je sued by tine Bay Area Air Quality Management A.:
Dinner BOILER—COMP(OVER 100.(1X)BTU)
Ycs
I have reaA the hamrdous material. AIR CONDO TONER ISSUANCE DATE;
rtyuirtnrcnts under Chapter 6.95 of the Cali
fornix Health&S.fey Calc.Seniors 255(15,25537 nnA 25534.I understand that if the NEW RESIDENTIAL MECH, SQ.ET.have.lea
rot c
boiling /�� O
las mrtntly anl,Ihm n is my responsibility to notify me reception
(pt �jss
of The requirtmentnw me m issuance afa Cenificam of Occupancy.
Owncmintulurirods,rt QQ Dam
TOTAL: ISSUED BY: � r�
OFFICE