30796 (2) APPLIUANI IU HILL IN INFUMMAI LUN WIIMIN MLU LINLS-USh HALL PUIN 1 YEN UNLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT
'NO. 3 0 7 9 6
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
IILDINGADDRESS: SANITARY NO. APPLICATION SUIBHI'ITAL DAT Ii
�o NA P_►irllrL Lh �_Zw
O NILR'S NAMii; I'IIDNIi; ('(IN'IRACICIN'S NAME: LIC NO:
NIC CIIN'I H(ILX
HCHITECT/ENGINEER: LIC NO: f ADDRESS: ❑
CONIACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLIKi ELECT PLUMB bIEcN
LICENSED CON'T'RACT'OR'S DECLARATION QTY F,LECTRICPERMIT' FEE ❑ ❑
I bertb,amrnm dmt 1 bar Banned under provision:of Cbepenm
.9 m itmclag JOB DESCRIPTION
WccZ with Scadon](XXq of Division l ofthc Business and Pfofexsionn Code.and my license is RESIDENTIAL'
OQ vlfull force cod cRm. P12RMII'ISSUANCE�W ❑SFDWL ❑KITCHEN REMODEL
I" ",a aces, Li,. APPLIANCPS-R ESI DENI'IAL ❑ADDITION ❑PLUMBING RE PIPli
W Dme Counwosr
�py ARCIIIIIiCTS DECLARATION VANPIS ❑MU1,1'1UNIT ❑STRUC'TIIRAI.
L sX�Z Iunderstand my peamahall b,used as public mcords MODIFICATION
OZ�Q IIP IU 200 A MPS ❑INTERIOR [I CH IMNEY REPAIR
13t Licensed Pmfessionvl 211 J IXXIAMPS IMPROVEMENT
¢�d OWNER.BUILDF.R DECLARATION
Y w Q I hereby affirm that 1 am exempt from the Contractor's Llccoo,Law for She OVER❑MX1 AMPS ATH REMOUIiI/NEPAIR El UIiM01,1❑UN
Ow"'
following (Section BITI.S,Ilminaa and Padessions Code:An t FJOIDER
reason. Y city m county SIGNS ra.l[CI RICA(.
-^0 which itquinanpermit reernsweLalter.impmsudemolish.erre a repairany structure
O Bud in heits licensdpuoauureyuiro the applicant forthe Cnhmrmr' oEks Law(ed natemeut SPECIALCIRCUIT/MISE.
�} (hath)i.acing wit Pucwam 70th)of Division
of the License Proksaw(Chnpler0
(commencing he I,vernin heaianaand)the
Biinkfrmi The Bndnambiton.Any n,Codel or TEM1IP.MITI OR('DLC(NST. COMMERCIAL,;
L S o Y Seat he ix exempt 7hcrtfmm and The basis formic alleged applicant
to Any lineation of ❑NEW SLOG/MDITION ❑1001)DEMOLITIONSERV(
�m Section than
Shy any hundred
doll RutPermit.wbjnna he applicennnecivil penally of POWER DEVICES ❑TENANT ❑POOH SF:RVICF,
>, nm marc thin lire hnndrtd dollar l55(pl. IMPROVEMENT
wiLmownerk.leepopeny,or ley anplende wimwred frsale(Sec.annpensiness .SWIMMINGPOIII.EhIiGTRIC
andwildomework.and The The ctumCont a tors License Law down id apply
to an, weer of ❑(ll'IIER
yi]3 sod Rn,who builds Cnlr,ipCo%there .isms Law Amsnmapplymlfowner est OUTLEI:S-SWITCHES-FIXTURES
his own who oy ,,lir improves thereon,and who dna such wotk himself or through
his own enlPlnytts.provided that such immovatenb arc not intended or offered 1m NEW RESIUCNTIAI.ELECT Sp FI'.
tele.ILhouawr.mebuildlogn.iny rnmusuldwimiauaryenrnf compB6...i.the PUXIta AREA SISp.)9'.
rycaner-builder will have the burden or proving that he did not build or improve for pur- J
as of oJe....l. TOTAL.: AN 8j j
❑Lasowner0fct pmpcnP.InesnesnandcsmtmctingwonsensedcomooTv i- RfC�
crmwst me pmjem(Sec.](Nd.Bn,inms and i4nfesainna Cmka the Conumun's Li-
noel.awd«smmnpplymanownerofpn)edywhobuildsorinnprovea Be,nllb.nd QTY. PL M 1 PERMIT 'FEE C( Yut.
who contracts for such Nbructs with.ampursuant uactonx)licensed pursuano the Contractor's UU):,'L
Licence law. PERM]r ISSUAN h I)ryp
I ora aemin nnJm Sec. .D ilP C for this m.vm
ALTER-URA AVENT- RIBA) VALUATION
Owner Hum
WORKER'SCOMI'I?NSATIONI ATIO BACK PLOW PROTECT.DEVIC
I hcmhy slam under penalty of perjury linear me following desI mti0n
API have and will maintain a Certificate of Consent to self-insure for W'orkds Cnmpen DRAINS-FLOOR,R1,K'�AjIllfA.CO STORINS TYPE CONS)R UCIHON
,Inion,a,Provided for by Section 3700 of the Ulsu Gde,for the pertonnance of the ,
work for which this permit i,taxed, I'1%'TURES-PCR'(RAI'
❑ I have and will maintain Worker'n Compensation Imumnce,as required by Section
l]IXl of the LaMrCmk,fm the penarmemeof the work lm which Ibis permit ix iszocd. GAS-EA.SYSTEbbIINC.4G r S OCC.GROUT' APN
My Wmker's Compensation Insurance carrier and Policy number are
Cartier: Policy N., GAS-IA.SYS'I EM.OV ER 4(FA)
CIiR'I'll'ICAIE 017 IIXEMI'TION FROM WORKERS'
COMPENSAI ION INSURANCE GREASIJINUUS TRI,WASTE INTIiRCEPTOR BUILDING DIVISION FEES,
(This warm nmd not hecomplcted ifine farm,i%for arc humlmi dollars($1001 GREASRI'RAP
or le".) PLANCIIFCK PIiC
I ccnify,that in the pedonnnnoe of the work for which Ibis permit i.,issued.l shall SEWER-SANITARY-STORM PA.2p PT.
not employ any moon in any intoner so as In become subject m the Workers Compers ENERGY FEE
� Z radon Law,of California,Date WAI FR IWAfER WNENI IELECIR GRADING ITT.Z o Applicant
y NOTICETOAPPIACANT:If,after making this Cenificamof liacmpiun,You should WATER SYS I r:MOREAIING
become subject to the Worker,Compensation pmvrrirns of the Lrrlmr Code,you MOST SOILS rim
4x1 rs forthwith comply with.own provitinna or this permit shall b)denn)d revoke, WATER SERVICE
Uz GUN$TRDQIDN L[NUIN(i AGENCY NEW RESIIIr:NT1Al.1'LAtll. Sp,FT. PAID Unm eccilaN
V z I haebyrifinn that there iso cnnamainn Bodul tgencl,prime perfonnunce of
the work for which ibis perant is ksued(See.VX)],Co,CJ
(vender's Nam) TOTAL:
O U Itndeia AJdrcs., TOTAL" �-a
I ccnify mat I have rted thi.aprifcadun and xwta thin ma.Mae Information is BUILDING 11
eonen.I agree to comply with all city and county ordinances and state lawn relating to QTY. MECHANICAL PERMIT FEE
I>� building congmction,and heathy aullunise mpresentatives of this city to enter upon the SEISMIC PT:.
KU I
arevbasciaoned prupeny for inspection purpnms. PERMIT ISSUANCE1Welagrte m.....iodenmify and it,,h.rmlc,s the City d Cupertino.,ain't ELECTRIC FEE
Iiabililics.judgmi cmnaMeapeavcs which may irony way aamcagainst said City ALTER OR ADD TO MECIL
in omequence of me granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI.1,NON-PDT NT AIR HANDL(NO ONE I(10 1 1,IXM)CFM)
MIiCIIANICAI.I'Eii
SOURCE RT:GULAI'IONS.
ALR HANDLING UNIT(OVER 10.010 CPM) CONSTRUCTION LAX
Signammof ApplicanVContmcun Date 17XIIAUS'TDO(H)OVIDUCT) HOUSING Kill[(;AT ION ITE
I IA]ARDOUS MATERIALS DISCLOSURE:
Will the applicant lir future building occupant nitre or handle ha andoun mulcriul IIEATI NO UNIT(TU IIXI,(XX)BTU)
as defined by the Cuper inn Municipal Code.Chapter 9.12,our the Herlih end Sokty
le.Section 255I2tm? IIIi
DoAIING UNIT(OVER 100.000 ROT
Ye, No
VENTILAfI(IN FAN(SINGLE RGSID) PAID Ume ReaeiPlN
Will Rat epplicnnt err rumor building occupant use equipment in device,which
.Til haradous air comae inane a,defend by tic It.,Area Air Quality Management BOILER-COME(31111 OR 1(X0,0011 BTU) TOTAL:
istricl? BOILER-COMP(OVER Ia1,IMM)BTU)
[:1 yes E]No
I have mail the lnmnlou,mncrials acquirement,under Chapter 69501 the Cali AIR CONDI TION ER ISSUANCE DATE
fmmia Thalia A Safety Code,Section,255(15.25S71 and 25534.1 maktnaod had if the NEW RGSIDI'MIAI.MECII. SQ.Er.
building docs ma currently hast a imam,mut it is my marymaibiliy to,rcsify the meupunt
of the requimm)ntn which moa he met prim m k,iinme of a Cmifi,mte of(krnrymcy.
Dwmr or emho.imd agent Date 'TOTAL: ISSUED fly:
OFFICE