S 0417 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'PY OF CUPRRTINO BUILDING-ELECT RICA PERMIT No
BUILDING DIVISION APPLICA'1'ION/PRRMIT rl.unnnnr.-Mvcunau.AL S 0417
BUILDING PROJECT I DF.N'i'It'll'ATIUN
BUILDING ADDRESS: SANITARY N I. API•LICATION SUBMITTAL 1) 1'H
S 46 Alo rmnjmA U' y
OWNERS NAME: I'll( E: CONTRACTOR'S N ME LIC N(-
NIC CONTROLp
Le lylasop r
ARCHITECT/ENGINEER: LICND: wl) 'S�S' �1 ❑
CON'T'ACT: PHONE: •/t` (/ BUILDING PERMIT INFO
D J I C C 6 5=�6 6 ❑ Consultant Fees Paid by Applicant(Initial) 1.1 ELECT PhDMH MINCH
❑ ❑ ❑
LICENSED CON'I'RAC'I'ORIS D[!CLARA][ON Q'TY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provision of Chapter 9(commencing JOB DESCRIPTION
Z with Sectbn ViN)(EnTa tsiom 3ofthe Business arta vrolessinm.cnee.and my license ix RESIDENTIAL:
Woo PERMIT ISSUANC12
FIB in full force and eB I / 2 '33 g� ❑SFDWL ❑KI'ICIIIiN RIiMOUEf.
U~ Eocene lacy Li,b O
Q U L AN QY OUrs.r APPLIANCES-RESIDENTIAL ❑AUDITION �PLUMBINGRE-PIPE
tFaa Dun. Cnntm< ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PAN1iI-S ODIFICATION
OZ`,1Z us
Iunde,lamInry plare,hall he ed as PbI is rewrds OPTO20(IAMP$
❑INTERIOR CHIMNEY R17PAIR
Q„F-,W I......ed Professional 201-1000AMPS IMPROVEMENT WIMMINC POOL
OWNER-BUILDER DECLARAI)ON OVER IIMNIAMI'S ❑B61'HREMODEL/REPAIR ❑DEMOLITION
owC C Q I hereby affnn that I um exempt from the Comrucmrx License Law far the
3 a U following reProfession Code.(Section]031.5,Business and ProfessioCode.Any city()I county SIGNS ELECTRICAL ❑OTHER
yQ which requims it"and n,construct,alter.improve,demolish.or repair any swcturc
prior to ts issuance,also requiresd'e applicant ff Permit file a signedstatement SPECIAL.CIRCUIT/M ISC.
} Neth I Jpurtu II hetp roan:of the C t tors) L (Chapter9
u� COMMERCIAL
A. (cam 6 'th Section I and
a basis
i flhce cas am Profession, err fEMI'.MIiTEH OR I'UhE INS'1'.
G.ad d rG Ih:n he is exempt Ihcrclrum anA the kueix ler the alleged cncmpuon.Any nnlmbn of ❑NEW BLUG/ADDD'ION ❑DE OL,
Xn Section 7031.5 by any applicant for a permit subjects the applicant o a civil Penally of POWER DEVICES ❑TEXAN'[ ❑FOOD SERVICE
FZY not more than five hundred dolhas($5O). IMPROVEMENT
�=O 11,as nwncrnf the pmpeny.nrmyempinymswith wage.av thcirwle asmpcnwnon, SWIMMING POOL F 1_ECrRIC ❑OILIER
% will Jo the work,and lhexnmamms oat imcndedocotnered Resale(Soc.]044.Beincax
L 3 m and Professions Code:The Contractor's License Law does not apply to an owner(IfOU'1'I.EI'S-SWHCIIE% F 1'URT:S
prupeny who builds or Impmvex mccon,and who docs such work himself or through
his own employees,provided that such improvements am not intended or offered far NEW RESIDEN I'IAI. .:CTR SQ FI'.
sale.It,hawcvcr,the buildingor lmpmecmcat ienold within mm year ofcarinetion.lhe SQ.IT.FLOOR AREA S/SQ.FI'.
mer-builder will have the burden of proving that he did not build or improve for pun
psse initiate.). TOTAL:
0 L as owner of the propony,am exclusively contracting with licensed contractors to
instruct the projeel lgec.9044.Business and Prolessimry Cod,)'I'he Cuntfamnrs[,I-
se Law does not apply to an owner of progeny who huidds or improves then and QTY. PLUM I -R. T FEE
who.'acct,for such poleccs with a commelarfs)licenced pursuant the Comrunnr's
License Law. PERMIT ISSUANCE
❑1 um exempt under Sec. .11&P C fir this reason
ALTER-DRAIN&V EM-WATER I. VUATION
Owner Dam S/
WORKER'SnePerot,
DECLARATIONefollowing BACK FLOW YROTELT.DEVICE /1f
hereby allirm under penalty of perjury one of the following Jcclarution.a: v
�Ibuas provid Yarn ScomilicateofCnnanu,Code.
tfor Wdourace of h- DRAINS-Fl.WR.HIX)P.ARIA,GOND. j• S'T GS nam IYI'E CONS'IRIICTIUN
scorn,
as hath thi for mi$s I... 3]fNl of the LuMr Calc Ins IM performance of the
work for wM1lch this pcmril in isoed Fl%TUH13-1'ER TRAP (au
I have and will maintain Workeh Compenaion Insurance,as mqm and by Section r
3)1X1 of the Labor Code.for perfonmunce of the work for which this psormit is issued. GAS-EA,SYSTEM-I INC.4 OUTLETS OCC.GROUiFIVU APN
My s .on tenwti nsur er"d YsN myID �71 � GAS-EA.SYSTEM OVERJIEA)
CEHTII KATE OL'F. EMPTION FROM WORKERS' GREAg!%INUURTHL WASTE;IM'IiRCIiYfOH
COMPENSAHON INSURANCE BUILDING DIVISION FLUS
(This section need notMwmpteed ifthcpermit is Tonne hundred Jollart lS HNB GREASETRAY
:1)
IiCK 1:LE
or loss)
I cenify lha in he Normarromceoftbe work forwhichtbis permit is issued,I.ImB SEWER-SANITARY-STORM LA.21X1 FT.
mat employ any portion in any manner so ac to henna.sebt,o m the Wnd.en'Compun_ ENERGY TTI?
Q Z smion Laws of California.Date WATER HEATER WNVISTIELECL'R G.ITE
Z O Applicant
NMICF-TO APPLICANT:If,after making this Certificate of Exemption,you.should WATER SYSTEM/TREATING SOILSE
a ; become subject us the Wnrkcr's Grmpensaliun provisions of the Luhor Coda,yon umsl
a '. forthwith comply with such provisions or this permit shall he deemed revoked. WATERSERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FCDa Be pt b
1 hereby affirm be, is a enmsuuction lending agency nor the performance of
DUs. 0c work foo which this permit is issued(Sce.3097.Civ.CJ
O li' Lenders Name TOTAL: '
V lender's Adder, 'IUTA1,:
} a 1 comity that 1 have read this application and state that the above information Ls G F! ,UJ corrmt.l agree to comply with all city and county ordinances and state la,serldingm QTY. MECHANICAL PERMITFIiE ITE
(.) Z building construction.and hereby authoriec repoxweattives of this city to enter upnntbe �a
shove-nantionul property ke inpenion genuses. PERMIT ISSUANCE. NTAX
(We)agree to save,indemnify and keep M1ermless the City of Cupertino againstIiabilities,juJgments,ensu and eeperoc,which may in any woyacemeaguinilsaidCity ALTER OR ADDTO MECH.in ennequoneeof rhe craning of this pemrit.APPLICANT UNDIiRSTAN S AND WI L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ILUX)CPM) E.SOURCE REGULATI(Y:S. /� r�?Cj AIR HANDLING UNIT(OVER 10.000 CFM[ T,U�j Dat`e EXHAUST HOOD(W/DUCT) ATIONft
HAZARDOUS MATERIALS DISCLOSURE
Will theopplieantor more M1uildingoccupantstore or lendle hmuram,material HEATING UNIT(TO 100.000 BTU)
as JefineJ by the Cupertino Municipal Cod,Chapter 9.12,and the Health and Safety []RATING UNIT(OVER 10(1.00(1 BTU)
Code.Section 25532(a)'1
❑Yes ON. VENTILATION PAN(SINGLE RISTD) PAID
Date Recorpl
Will the applicant or future building occupant use equipment or devices which 11011 liR-COMP(3H1'OR I13B.INp BTU)
mit h.,d.,air containment'as outlined by the tiny Arca Air Qual'ny Manager cut T< 'AU
Dislricf7 BOILER-COMP(OVER 100,000BTU)
❑Yes No
I have madthe lummudea,ltuit coorclnenb,under Chapter B95 all the Cali- AIR CONDITIONER ISSUANCE DATE
Lomat HealO&Smay Glide.Sections 25511.5,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECIL SQ,FI'.
building does not currently have a mount,that it is my respnnibility,to mxHY the occupant
,I the requirememx wbw1u puma be met prior In I....nec of a Cenilicam of Occupancy.
Owner armill ivaad agent Dam TOTAL: ISSUED By.
OFFICE