S 0171 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
,CITY OF CUPFRTINO - _ BUILDING-ELECTRICAL. 1'IikMl"['NO.
BUILDING DIVISION APPLICATION/PERMIT rLuntBiNr..Ml:cunNlr,AL S 0171
",BUILDING PROJECT IDENTIFICATION
SANI FARY NO. APPLICATION SUBMITTAL[)A'['I
BUILDING ADDRESS:
Blab Slww &-u.iU 611, �15ioo - euv�Ko Cal g6D4 G lq q
O N%R'SNAME:AI PH(INE: CONTItACTR:S NAME: LIC NO: NIC CONTROL#
e1/L Y4
ARCHITEC'I'IINGIN. - LIC NO: ADDIt DSS: ❑
CONTACT: PHONIi: B111LDING PCItMIT INFO
❑ Consultant Feng Paid by Applicant(initial) HLpCy ELELTPLGMR MEc ,
LICENSED CONTRACTOR S DECLARATION QTY , fl i.ELECTRIC PERMIT �, - .:+�•�FEE JOB ESCRIPT❑ION
I hereby of re that 1 n licensed under pcv s ons of Chapter')(comate ing
OCy with Section]WO)ol'Divisinn 9ofthe l3usincax and Profession.Csde.trod mylicense is RESIDFNTIAL'
WOO PERMIT ISSUANCE
2�� in full force and eRuk ❑SFDWf. ❑KITCHEN REMODEL�UU 4eenec Class _ LICkAPPLIANCES-RESIDENTIAh ❑ADIIITION [I PLUMBING RE-PIPIT
m Q 1 Dale Coal memr
ARCHITECTS DECLARATION PANELS ❑MUI:I'I-0NI'1' ❑SriµllCTUl1AL
F=N Inndcrstand my plans sh' - MODIFICATION
ml tee aaea,ta pamm reaorda
OZ-o PTO20OAMl'S ❑INIIiIt10R ❑CIIIMNIiYItEPAIH
2144'61 Licenced Professional 241-1000AMPS IMPROVEMENT ❑SWIMMING FOOTS
QhdJ OWNER"BUILDFR DECLARATION , OVER IOIlOAMI'S ❑BX[11 REMODEWREPAIR El DEMOLITION
C I hereby afftmt that I um exempt from Ne Ciott is Licenu Law hsr the ❑IYf11ER
�6 O d U following reason.(Section 70]1.5,Business and Professions Code:Any city or county SIGNS FLECfRICAL
613 a y which mature,a Penni(to construct.alter,iinprove,demolish,or repair any xlmemre
0g prior( !Is indomm.ats requires th,applicantf h verign,fl udid incoual SPECIA L CIHCU'TIM ISC.
y that M1 licensed p r a they f theC (con :L m 1 (Chapter 9
COMMERCIAL;
�a�0a (coat 6 with Sect ]11(X) I])!visioni IN II JP Cxlc)or TCM 1'.METIi1t OR P(11,E INS'('.
ti Xm 4 that he is exempt therefrom and the basis for the alleged exmnpuon.Any vr01atimu'd ❑ W BLDG/ADDI'T'ION ❑DEMOLITION
W�1 y Section 7021.5 by any applicant fora peril aabjees the applicant m.civil penalty of POWER DEVICES /I'�]NF,NANT ❑FOOD SERVICE
001 inure than live hundred foods Q.90()d. - f IMPROVEMEiNT
f � ❑'Las owner of(he pmpeny.ter my emplsyees with wages car(heir sole cnmrymmion, SWIMMING POOL ELECTRIC "
El OTHER
Is
Jo he wink,mail the structure is not intended or offered for sale(Sm.7YTL Business
cf UUfS SWITCHES MIXTURE
t n : h
W39 nTh Core t L 1 J : t l
papeny I b id' - S
p N J h J h stock If ,Ihroagh NE .SIDIi AL PLECTH SQ 14.
hi,a ply p dad that. himprovements Iintended Bred for SQ.FT.PLO R AREA I $ISQ.1'1'.
come 11 M1 t[hM1 Id 6 p pro t Id id Y I pluton the
owner bat Id ll have the burden of proving that M1 Td I Wild prof purr.
1 �
Pon foal L TOTAL:l V
Ica f proper
property,,Business excess ly ( f g (I 1 t'� t I
II
cnI Itheprj ((Sec t)an wnerofandProfession nCode:)The C Inco i' -
cen: Law .not hptymun with
a carproperty whoh Ip pursuant
he Cr and QT'Y + 1 ',PL RMIT f P{N',
who contracts for:such projects wnhnnommemgs)ntcnsed purxuannolhe Convecnvs ! e"
License Law. PERMIT ISSUANCE
❑ I in.exempt under e . .H&P C fort kmetan
Data .7-11_ ALIER-DRAIN&VIiN'f-WATERHiA) A U /
Owner \ pRK�' COMPF.NSA'I'ION DECLARATION BACK FLOW PROTECT.DEVICEHTINO
Ih
a""from
undL penalty of pe jury one tel the fnlhnvin6 Jcclara(ions:,
0 ,0[h and will maintain a Krublede of Cnnwnno self-insure for Warked's Compnm DRAINS-FL(IOR,ROOF,AREA.COND. STORIES TY PE CONS'I'RUCFI01
anion,as provided for by SmIam 3700 of the Labor Code,for the pmformande more
work for.I ich this permit is issued. IIX]T R_ES-11178 TRAP
❑I have and will maintain Worker's Compensation lnsumnce.as require]by Section
9700 of the Labor Code,for the performance of wremark the work for hich this peit in issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCCG 'P AI'N
My Workees Cominnmdon Insurance carrier and Policy coroner are:
Carrier: Policy No.: GAS-LA.SYS'TEM-OVER 4IEA)
CEM IFICATE O[:EXEMPTION FROM WORKERS' CREASIIINIli1S'1'RI.WAS'1'H IMfF.RCEI'fOH
COMPENSATION INSURANCE + UILI 0DIVISION FERS
Ondausedien need no,be a aple(ed life Permit is f0rnne hundred dollars($1001 GREASE TRAP
ter PLANCH PEE;
Ices.)
I cerify that lathe perfnranee.fthe work fen whichlhE permit ie issued.[,hall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as to become subject m the Worker;Compen, L'NEHG
Z edion Lows of Clifmnia.Dam WA'I'BR HEN[Idt WIVBNTIE6ECTR
Z2 Applicant ORAE 1PEli -
ti c4 Not ICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should WATER SYS'I EMOItHATING
h ' became suhjecn the Wmkmis Compensalinn Provisions of the Labor Code,you most -. SOILS BE
n
a' tti Ommoolh comply with Each provisions or this pednit shall W deemed revoked. WAG IiR SERVICE -
Gi Q
t1
. CONSTRUCTION LENDING AGENCY NEW RF.SIDI;N'1'IAL I'LMIi. SQ.Trp PAID
I hereby afOra that thahem is a construction lending agency for perfonuance of [)[,,a Haecip(M
W H the work dirt which this peril is Issued(See.3097.Cie.C.) TOTAL: -
' ULander s Name
{la Lenders Address IOIAL:
certify(hal I h d this app( 'I d ,am(h he,the hinformation -.,y t I BUILD G FEE
. UZ corral lagrecus comply hemby ehYi evuntyoN'mne!this
cel li yi+ QTY.' Y MEC({ANICAI PERMIT? '/) FEE
U Z building construction,and hereby amhofee representatives r f Ihrs any it)eater spm the i � SEISA C FEE.
uhovo-mcmioned properly for imxpeclion purposes. -.PERMIT ISSUANCE P.LE( CF:.
(We)agree m save,indemnify unit keep harmless the City of Cu'doo amino _
liabilities.judgments,costs and expenses which may in any way scame against said City ALTER OR ADD TO MECH. PLO MBING FEE
in censeptcoca or the grueling of this peon. - -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR DANDLING ON["I'(TO 111,100 CFM) MECHANICAL FEE
SOURCE REGULATIONS,n
AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUCfION"I'AX
. gra( ren pI mmeror - f0 [Ihat� EXHAUST FOOD(W/DUC) HOUSING MITIGATION FEE
1A'AIt DOUS MATERIALS DISCLOSURE -
Villlheupl 'c orfumthuildingoveupmaid eorhandlehazallousmme+Tal 1{EA'1'INC UNI'I'(TO I(Xhlxq NTU7
as defined by the Cupertino Municipal Coda,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER Iob,opp B'fof -
Cile,Section 25532(a)4
C]Yes El No VENTILATION FAN(SINGLE RESID) PAlll
Da¢ µcceip(X
Will the upplieant or fumm building occupant use equipment or devices which BOILER-COMP(31111 OR 100,000 BTU)
emaeNit haous mina
air conantx as defined by the any Area Air Quality Management( TOTAL:
Dinner? BOILER-COME(OVER 100,000 BTU)
❑Yes No
I have rend the hantrdems marefiala reyuircmm�e under Chapter 6.95 of the Cali- AIH CONIII'1'ION13H ISSUANCE DNI I,
Lucia Health&Safety Code,Sections 25505,25539 and 25534.1 understenJ Ihm 11"the NEW RFSIDEN'UAL MECH. SQ.ET. '
building does nocurrently have a tenant,that it is my responsibility as notify the amomm _
of the reyuirementa which mush mel prior m ixsunnce aLr Certifcme of Occupancy.
Owner or vulhmi)<d agent Dale 'TOTAL: ISSUE])BY:
OFFICE "