S 0146 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.MECRANICAL S 0146
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMI'PI'AL DAIT
764�f RAIIV80LV Pl? - C' sR7f✓v Cfl gsoi� � �1�1
OWNER'S NAM..CII: PHONE:1 CON'I'RACfOR'S NAME: LIC NO:
�N M• /7�C 25!'15 2 NIC //���'rC�ppp�NTROL«
TRCIIITLCI'/ENGINEER: LIC NO ADDRESS: ❑
CONTACT: PHONE: C j BUILDING PERMIT INFO
nsRllant Fees Paid by Applicant(Initial) T ! e RLDG ELECTPL MEC
it
LICENSED CONTRACTOR'S DECLARATION QT y ELECTRIC PERMIT FEE
I hereby affirm that I am licensed ander Provisions of Chapter 9 hommencing JOB DESCRI ION
DW O 0Z with Section 700Tof Division 3ofine BusinessIiRMIT ISSUANCE and ProfProf..iansCMe,rndraylicmacis RESIDENTIAL;
FSO in full fora and atom. ❑SPDWh ❑KITCHIiN REMODEL
TUU in
Class « APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIiPIPP:
p...''yy k, Dan Cananctor
TJ RAL
,Dm ❑MUCfIANI"1' ❑MODIFICATIO
�7y ARCHIT1iC1'S DECLARATION PANELS
Z O ro z I undeamnd my plans,hall be r,tut. public records MODIFICATION
OZ4O UPT02()IAMI'S ❑IN'I'IiRIOR El CHIMNEY REPAIR
F—v, Licensed Professional201.IIMMIAMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDFR DECLARATION OVER["AMPS ❑RAI H REMODELIREPAIR ❑DEMOLITION
Q 1 hereby an.that 1 sic eaenpt tram the Committers License Law for the
K06Ufollowing reason.(Section]N1.5,Business and Professions Code:Any city nr county SIGNS ELECfRI 1. ❑OI'IiliR
3which requires am,it mma,
peco .seer.improve,demolish.m repair any saucmre
".0
.5 pr onto itzissusacgalso regoircs theupplicam formch permit to Glea signed utdement SPECIALCI 'U1' 1.
W p. mtheislicensWpn
usuann the provisions of the Contractor's License Law(Chapter9
W'd�. 0 frommcncingwith Section]0fM)1nf Divisinn3nfthe Rosiness and ProfessionsCnJe)or TEM I'.M. IiR ON I'OLF, NST. COMMERCIAL:
pl that he is exempt therefrom and me basis for me ullegod exemption.qty violmlnn of NEW BLDG/ADDITION C DEMOLITION
fiaC y
Section 7031.5 by any applicant torn ponnit subjects the applicant touclvll penally of POWER DEVICES TH '1' ❑FOOU til?ItVICIi
a more then five hundred dollars($5M), OVEMENT
O ❑ I,as owner of me property,or my cordijee.with wages as their sole cntnpcn.wtion, SWIMMING POOL IiLECTRIC Of
:R
_ will dothe work,andthesuicmre knot intended mothered for sale(Sec.A144,Business
G 3 uad Profession.Code:The Cammmur's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves theme ,and who does such work himself or through
his awn employees,provided that such improvements art not intended"'noted for NEW RESIDENTIAL ELECfR SQ Pf.
sole.i4 however.the builJing or improvement is sold within one year ofnmtpininn,the SQ.FCF RppR LSQ.Ff.
nerhuilder will have the burden of proving that he did not initiating ro.c far pun- tO ^
16
E]1 ofsale.).Iona 22.5
I,m owner of the property,um exclusively contracting with licensed cnnvactna m ]
onsauct the project(Sec]1144,Business and Professions Cndc: n Camratl'f,— - 5 Ell I
cense Low does.not apply to on owner of property who builds oY,r improves therum.and QTPLUMBING PERMIT FEE.
who ennlruetx for Such pnjreas wllh n umintclnr(.)Ilcenscd pur,utml In the Cnnvnnnr'x
License Law. PERMIT ISSUANCE
VIIY VT 1iUrL'HI'IN
1 am eaempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date OLIR
WORKER:SCOMI'ENSATION DECLARATION BACK MOWI'R[yfECf DEVICE /
1 hereby alarm under-penalty of perjury ane N the following declarations::
Cur
❑Inoue end will forbine Cefn 371X)of he La ,Code.for for WmkeYc Ce of,he DRAINS-FLOOR.ROOF AREA.COND, STORIES TYI'Ii CONSTRUCTION
wrist, r provided for mi Section 3]IIB of the Inbar Code,for me perfnmmn.c of the
work ran which this permit i,issued. Fl%TURL•S-1'13R TRAP
-❑ haveend will maintain fon Worker Compensation ofIhe work
for which this md by
Section
t]IXl of the Labor Code,for the Perlbrmmnce of the work for whicM1 this pertnit is is.wed, GAS-EA.SYSI'IiM-I INC.4OUTLETS OCC,GROUP APN
My Worker's Compensation Insurance carierand Policy numbentre: -
Currler. Policy No.: GAS-EA.SYSTEMAVBR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRCASI%1NUlISTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE. BUIL ) )N FEES
o1disciamirnbalroaMaunpletedifthepennitisf...o hundreddollua(SIM) GREASE'fRAP 1
or less.) PLANCIIIiCK Iyi
0.
Loy any that inthe n any performanceofwork for which this immit the Wrkersued,Ishall'Coarsen- SEWER-SANITARY-STORM EA.20()PI'.
not employ any person in any manner so m m become subject to the Workers'Coarsen- ENERGY 19i1i
� Z nation laws of C.1ifnmiii.Date WAILR IIP.ATER WNENT/ELECIA GRADING FEE.
Applicant
y NOTICB TO APPLICANT:If,after nicking this Certificate of Exemption,you,houW WAFER SYS'I EMOREATING SOILS FEE
bre or subject to the Worker's Cntn ormadon provisions of the Labor Coda,you mull
Wba-hwith comply wind such prackionxnnhis permit shop be deemed msoked. WATER SERVICE
Q
Pr
CONSTRUCT ION LENDING AGENCY NP.W RESIUIiN'f1A1.PLMB. SQ,PC PALO
IJ .zi Due ecu «
L) 0 I for which
thi that is sued(Sudion lending agency(none perinrmanre of
the work for which this permit is issued(Sec.31)97.Civ.C.)
u" f~ Lender,Name - TOTAL:
WLI Lcnder,AM Jdresx I IA
}
(.., Icenify met I have read this application and state that the native information is BUILDING
In correct,l agreem comply with all city and county ordinances and.state laws minting to QTY. MECHANICAL PERMIT FEE
U ,Z building cnnstmend ction, herehymahorim representatives of this city to entcrap,nme SEISMIC iI t
- am,c.menaoned property fo,impemanpu,,.v.
(We)agree to save,indemnify and keep hamdeV,the City of Calendar against P13NMIT ISSl1ANCE ELECTRIC 1"I'l
Iiuhilities,juJgmenls,....assort expenscx which may in any way accrue again.vl., cud City ALTER OR ADD 10 MECII.
tPLUMBING EI?li
In cl nnc,mee fthe grantingol this pcnnh.
APPLICANT UNDERSTANDS AND WIL1.COMPLY WITH ALL NON-POINT AIR HANDLING UNJET('f010.000 CFM)
MECHANICAL Ai
SOURCE REGULATIONS. 1
AIR HANDLING UNIT(OVER 10,00(CFM) CONS'TRUCI'I NTA%
Signature of ApplicanUC'ntractor Date EXHAUST 11001)(WIDUCO HOUSING NI IGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will me applicaat or future Wilding occupant store or handle hsraNans material HEATING UNIT IT 01 W,000 BN7 -V44 to
as dcfned by the Cupertino Municipal CMe,Chapter 9.12,and the Health and Safety
Code,Section 2.5532(a)] 11 EA'T'ING UNIT(OVER IN)TOO BTU)
❑Yes C]No V EN'I LATION PAN(SINGLE RES I D) PAID Ua,, ecmry
&I Will the applicant or future building occupant use egnipntc l or Jeviers which
emit annardaus air contaminants as dc0ned by me Bay Area Air Quality Munugentrd BOILER-COMP(3HP OR 100,00()BTU) 'f01'N.
Dlmrlctl BOILER-COMP(OVER 100,000 BTU)
Yes F1 No
I have read the hrdim turyuirtmermi, rd
is oer Chapter 6.95ofthe Cali" AIR CONDITIONER ISSUANCE DATE
ford.Heahh&Safety Code,Sectio T1505,8533 and 25534.I undemttmA that if the NEW RESIDENTIAL MECH. SQ.14.
building does not con eady have a amend,that it is my responsibility to notify the tce,up ird
of the vyuiremems which must be met prior m issuance of a Cenifcam of Oesm,mry.
Owner or amhnrizcl agent Date )T ISSUED BY:
OFFICE