S 1160 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILI11N1:.FLECTfRICAL Plt�+n'No q C
APPWCA'1'IONA'ERNI T PI,unRHNr;.MECIIANICA1, J 1 O
BUILDING DIVISION IIUII,UING 1`RIIJE6T IDF,NTIFICATION
SANITARY NO. APPLICATION SUBMITTAL UATE
BUILDING ADDRESS: /�
37o0 �i9tiom� C T
UWNIiR'S AME:n^� 1'�)NI C(INTNACTOR'S NAMB. LIC N1) NIC CON'I'llokli
�. N Th'� .SNr Wo�P x5 Y.53 6 ❑
ARCH[rECr/ENGINEER: LICNO: ADDRESS'.
�7S 1,7, 6L CfJnjir>u M. d
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant F"S Paid by Applicant(Initial) HLDGPLI ML`CH
ELE
❑ OWL
LICENSIiDCONTRAC OR'S DECLARSI'ION QTy, ELECTRIC PERMIT PEE JOR DFSCRIPTION
I hereby affirm than I nom licensed under provision,of Chapter 9(cnmmcncing
OpZ wiffNc,...i700(not Divlainn 3ufthc Malin...and to I ox.ian,Code.and my lilemc PENMIT ISSUANCE? RESIDENTIAL
ad F ly O In full force and effect Cl SFDWL ❑KI'ICIIEN REMODHI.
Rui" Liccasacl... �- G / Ism, 5`153 3�
r;Zu Dale. In-�// -Comm TE,Q� APPLIANCES-HESIDIiN'1'IAL ❑ADDITION ❑STRU TUR NLPII'E
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑$TRUCI'URAI.
~yZ Iumlenedial my plainshall Mrecdas aliic records CHIMNMODdppEY
PAIR
OZ-C UPT0200AMPS ❑IMROVERIOR E)S IMMING POOL
OZ-0
.w4 Licensed Professional 2111-10(MIAM1I PS IMPROVEMENT SWIMMING POOLS
0.' OWNER-BUILDER DECLARATION OVER IM)AMPS ❑HAITI RI?MOI IR i 1 1 1
J
p� Q 1 hereby aIs Ihvt I inn exempt from the C11ntrucmr's Liceroo Law for the ❑OT111iR
X 0yU Inllnwingnomon,(Section 703IS.Bmint's and Pon„its is Cook:Any a'ny or,ocaly SIGNS ELECTRICAL.
W a n.E- which requires a Parton m congmn.dmr,improve,demolish,tar repair any structure
.:Cprinrt,,it,issuance.-1111 requires the applicant for such permit In thin a signed statement SPGCIAL CIRCUI I'IMISC.
} that he is licensed pursuant)the provisions of the Contractor's License Law(Chapter 9 OC MMFRCIALz
WyQc (cnmmcncing wird Scctirn7W0pof Divkcinn3 of the Business and Pmfcssiom Cmdd nr TEMP.METER OR POLE 1NST.
a a ea� that he is exemPm Nne(mm and the land,for the alleged cncmption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xm4 Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES E]TENANT TOO[)SERVICE
ad V. out more Nan fro hundred dollars(S500). IMPROVEMENT
f20 ❑ I.as owner of the propety,or my employees with wages an their sole compensation. SWIMMING POOL ELECTRIC
❑OJ'I{I:R
F. will do the wank and the unmmrtis tot intended nr nRercJ for sole(Se,1.tmoateroa OUTLETS-SWITCHES-FIXTURES
3$ .rid rromv.;nn,eala:'Ihc Contractors License Law dna,not apply m an tomer nr
pnmpeny won builds nr hnpmve,durum,and no due,von,eh work himself nr though NEW RESIUEN'rinl.ELECT SQ PI'.
his own cmPlryese,.nro.mcd Nat,nen mtpmvontenu aro it, intended 11r nnbred I,,, sV.IT.FLOOR nWSA srsQ.Fr.
.ale.IL bowever,Ne building ar improvement is,dd within one year of completion,the
cderwillhavetheburdenofmovingthathedidnetmildorimproveforpur-
pose rfsaleJ. T(1'1'AL: y`
owner of Ne progeny.am exclusively contracting with licensed contramrs to P w ,
contra the pinjen(Sec.7044,Business and Profession Cada:)The Contractor's Li- - K D
came Law Nes not apply to an owner of propcnY who builds or improves thereon.and QTY. PLUMBIN IT FEE ��
who cadet,for such pmjcen with a mmmetor@)licei od pumrsuant the Conti-cpnd A.80
Liccnsc Low. PERMIT ISSUANCE ,e
[] 1 an excon't under Sec ,Nffi YCfar this.,,,a
AI:I'IiR-DRAIN Nr VIiNT-WAfEH(. / Uf A JAHON
Owner Data
WWORKER'SCOMPENSA'DON DECLARATION NACK FLOW Plan iC'I',DEVIV) L`rCry fpY
I hereby affirm under penalty of perjury one of the follnwing declarations:
❑(have and will maintain Ccnifr anal Consent o slf-insure for Workers Comer' DRAINS-FL ROOp.ARP.A.0 S'H)RIES '1 YI'Ii CDNSTRUC'1'IOP
cation,as provided for by Section 37M of the Labor Code.for the psefommnce of the FI%TURES-PER TRAP
Is fm which this Permit is issued.
1I have and will maintain Workers Compensation Insurance.a,inquired by Section GAS-EA.SYSTEM.I I NC.4 ODTLETS OCC.GROUP APN
Ax)of the Labor Crile,for the performance of one work Bn which this permit is i...ad.
My Worker' Cnmpenmlinn 8inuronce cyym r and Policy nmpbr5, aN:7�// GAS-EA.SYSTEM OVIiH d fPA)
Carrion `Tq-r b M /'t-Policy No.: I tl I
CP.RTIFICA'TE OF EXEMPTION FROM WORKERS' GREASFIINDUS"rR1.WAS'MINTERCEPrOR
COMPENSATION INSURANCE
NUILDING DIVISION PERS
(Thl.secmion need net ne couplet,,ifthepmmil isfornnehundrcddollan(SIN)d GRIiASETRAP PLANCIIIiCK PHIi
or less.)
Loy anyNin performance offs to ciarnwhich Nis ithe W rkero' Qlshall SEWER-SANITARY-STORM F,A.211(1 FT. ENIiRGY Fl31i
not employ anyidiperson in any manner sn as to become.ubjcet m Nc W'11dcts'Cnmpcn-
0 �
Applicant
ncaLnal.of Califnmin.Da¢ NATER HEATER W/VENT?:LECfR GRADING I�EIi
H NOTICE ID APPLICANT:If,alms making Ni..Certificate of lixampbon.You.haul) WATER SYSTEM1I/1'RIiAIING SOILS I I[li
.v lwemne object to he Worker's Cnnmpensnti11n pantimemof the Labor Cale,you must
Iso dn0with comply with such provision,or this patio shall he decaud revokod. WATER SERVICE
G Q PAID
.� Z CONSTRUCTION LENDING AGENCY NI?W RESIDENTIALPLMN. SQ Irl'. Doc Rccciptk
UQ I hereby affrtm that is a compaction lending agency lou the pefourmanm of
'J,
C) the work for which his permit is issued(Sec.3099,Civ.C.) TOT
�U 1<ndcrs Name TOTAL
>0
U I.erder's Address BUILUENGI'EE
W I certify Nm I have read this application and state that the above information is rA correct.l agree to comply with all city and county ordinances and state laws minting to QTY. MF.CHANICA L PER4[TFjEES17ISMIC FEES
U Z building connwetion,and hereby authorize representatives ufthis city mender upon Ne,nave-mcntimand property lim inspection purposes PERMIT ISSUANCE HLEC TRIC IobI7
(We).greem svve,indcmnily and keep hamdessthe City of CupcNnoagainstIiahildics.judgments,ce.as,nd cxPenseswhichtnayln any watymemc again-saidCity ALI'ERORADD'IOMECILPLUMBING ITH
in asequence of the granting at this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]1'00111.IXMMECHANICAL Fr e
SOUR WLATIONS.oc— - - AIR HANDLING UNIT(OVER IUCONti'1'RUCTI(. 1'A%
of Applicant/Condrumr Dare ESHAUST HOLD VODUCI) HOUSING NIHIGA NTT.E
HAZARDOUS MATEWAIS DISCLOSURE HEATING UNIT tiro IIXhIMMI Ii'rU)
Will the applicant or future holding occupant store or handle hmachav m,¢rial
us Jcfncd by Ne Cupertino Mumlelpal Code,Chapter 9,12,and the Health and Safety HEATING UNIT'(OVER 100.000 BTU)
Londe,Sea.ien 25532nd” I'AIIJ
❑Yc. 0N VENTILATION PAN(SINGLE RESID) Roc Be, iP10
Will the applicant or future holding occupant use equipment or devices which BOILER-COME'131{I'OR Infor)( 1 BTU)
mit hvancous air contuminants as Jcfncd by the Hay Area Air Quality Management TOTAL
41-1-1? BOILER-COMP(OVIR 10(1.1100 RTU)
❑Yes 71 No
AIR CONDITIONER ISSUANCES DATA
1 have sod the h oordom muss 2S5 5,255mcm,under Chapter 6.95 of the Cali
limmiu Ilealth&Safety Calc,Senior.25505.2557}and 25514.I understand that it NF.W RES1DIiNl'IAI.MIiCH. gU.14'.
hnilJing Jce,nrn uurmndy huvmmmmnnt,that his my mspm.ihility.notify thcavvPum
of the requirements whicham,w toed prior m Issuae a into Cenhicate ol'Germancy.
TOIAL: ISSl11iU 11 V:
Owner or authorized-gem Dane
OFFICE