S 1168 (4) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CILPERTINO BUILDING-ELECTRICAL P II NO.
BUILDING DIVISION APPLICATIONIPERMIT PLIABUN'G-MECHANICAL J 1168
IIUILDINI:PROJECT IDENTIfICA'1'ION
j��Atvc ]AP�PLICATION SUBMITTAL DATE
BUILDING ADDRESS: i
OWNERS-NAME: _ P NI: CONTR CI'ORN ME: LI CON'I'HOLa
AHC TPC-IENOEEE L C NO', A R 55'. �� /I�
TACT: PHONE: IYVS 16 BUILDING PERMIT INFO
f� /AJD� ❑ Consultant Fecs Paid by Applicant(Initial) HLU F1 ECT PLUMB mliCx
C/Iff�/ LICENSED CONTRACTOR'S DECLARATION QTY. ELIiCTRIC PERMIT FEE JOB DESCRIPTION
1 hereby uRmt that I am license)under provisions of Cnnprer Y(atmnrencia,
ZOZ with geminn2q)01 of Uivisinn 3.flhc B.,massand Pmfessians Crvi unJn:ylearcle is R"SID
ENIIAL
��� in full force an ,yA37 I'I:RMTT ISSUANCE: ❑SInWI, ❑KI'ICIIIiN RLMODIiI.
aU(, Liccnsc Cluvs I1Gk APPLIANCES-RESIDENTIAL ❑ADD]IION ❑PLUMBING RL'>PIPE
�ZW "me—
lam Comonou ❑MULE]-ON]T ❑S'IRUCTCRAL
d6 ARCHITECTS DECLARATION PANELS MODE:ICNI'ION
ZOyZ lundenuand my plancshall be tried.,public recnd, UPT020OAMPS
OZ 1Q IMPRIORROVE ❑SWIMMING POO
F4~W License)l'rofeoional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATA REMODEUREPAIR ❑DEIIO1.LTION
C 6 I hereby actionthat I am exempt from the Contractor's License Law for he ❑OTHER
K 6 U follmo ing reason.(Section 2031.5.Business and Professions C de:Any city or county SIGNS ELECTRICAL.
W 3" which reyuims a permit to construct,altar,improve,demolish.or repair any nmemre
1.1LL0 Prior to its isoance.d-requires the official rnrmchp.am file usigncdsatement SPECIAL CIRCUIT/MISC.
CGF that he is licenced pursuant o the provisions of the Contractor's License Law(Chapter 9 COMMERCIAL
al�'p0 (commencing with Section 700())of Division Jnrba Business and Professions Code)or TGMI'.METH ok POLL INST. ❑NIIW BLDG/ADDITION ❑DEMOI.1'1'ION
L X o e Inset he Is coal,Ncrefrum and'he Iasis for the alleged cwaal i.Any violation al
iC ro Ix, Seciion 2031.5 by any applicant car a Ewnni,s.hire(,the opplicanl IT a'I'll Penalty of POWIR UIiV ICES _ "ENAN'I' ❑FOOD SI?RVICI?
W tr'
.,it rnnrnhun Eve hundred dollar,(ASIX)). IMI'ROVFMENT
WIMMING POOL ELECTRIC
I,or owner of the pool or my employccs with wages as their sole mmparsocion, S
5 will tin the work and theswcwreis not intended or offered for sale(See.2011,Business ❑OTHER
WF- OVI'LITti-SWITCIIIR-Fl F_S
m send Professions Code:The Contracror'c License Law does not apply to an Owner Of
property who builds or improves thereon,and who docs such work himself or through NEW RESIUIiNT1Al. SQ IT.
his awn employees,provided Nat such impmvemems are not intended or offered for SQ.I FLOOR All $/SQ.IT.
sale.If,however,the building or improvement is sold within one year of completiun.the
wof
will bavc Ne hoo to of proving that he did not build nr improve lit put-
pow, ^ / _—�A
co
f sale J. 'IOLAL: - I w�f 1 /o'
.;is owner,of the properly,ton unclusivcly contracting with licensed mntmerc,in
msuoal the pnsjcot(Sec.7011,Business and I'Ofi"I mal Code:)Me Conwmurs Li- PEE
se Low,ms nm apply m art nwns.m'properly who bei ldo nr improves Narcan,and QTY. PLUMBING
who Contracts forsuch projectswith aaontraeOrt(O licensed Persunm le.the Convector's
Liccme La, PERMIT ISSUANCL
0 1 an exempt under Sec. .H&P C for This reason
ALTER-D VENT-WATER(1?AI VALUATION
Owner Date //-
WORKER'S COMPENSATION DECLARATION BACK PLO (TfECT.DEVICE / /O� O
[] I hereby
affirm under penalty of perjury one-fine following revaluations: ^ `
I have and will maintain a Ccnificam ofCumenuo self-inmre for Workcea Conquer- DRAINS-I:LO( R F.A.COND. S'IY) FS '1' I'Ii GDNSTRlICf1Ol
sntion,as provided for by Section 3210 of Ne labear Code,for the perfotmancc of Nc
work lit which this Permit is issued. FIXTURES-PIiR TR
1 have and will maintain Walker's Cnmpensmion Inwmnce,as reyuired by Section f
J2(N)ofthe Lohor Code,for Nc perkinamnce ofthe work for which this permit is issued. G ..YSTLi I INC. 'H. S OCC4C AI'N
My Worker's Compensation Insurance carrierand Policy numberace: GAS- S'I'CM-OV:R1FA) CA
Carrier. Till icy No.: V
CERTIFICATE OF E%I:MPIION FROM WORKERS' SIYIN L WASTE I NTERCEPTON
COMPENSATION INSURANCE UILDING DIVISION I'I!IiS
(Thructionruedn completed iflhe pmmit is Ramo hundred do][.(S E(0) GREA, PLAN FEE
or law.)
I acalfY Nati It cdor once tltt :orkforwhichthi veratit,iscoal lshall SEWER-SA ARY-ST IEA.200 Fr. ENI: ) iF
not employ any pe y m any onner 0 Femme auto a o t se"'or,
0 z stein In c ,I. WA'1IiR fir:ATIiR YTIELE GRADI l I:lu?
O applicant
z tiNOTICE 0 (CANT inti nmking s Cenific a c li mnptt",you should WA'IliR SYS'I'IiMRREA SOUS Eili
henmse xmbj 't m the WI ers Compans, t po,rou, of Nc LaMt C de.you must
fonnwiN c: ply withs ch Provisions er t is Permit shall he deemed revoked. WA'I'L:R SI7RVICH,
PAH)
CONST
CONSTRUCTION LENDING AGENCY NEW RIiSIDHNTIAL PLMB, SQ.PI'' )aLL Hctt pt ��
`y 'Z' I hereby affirm that them is u consartion lending agency far the Performance of
tUL C the wink for which this permit is issued(See.3097.Civ.C.) At.
0 lenders Name TOTAL:
} Uendcd Address _ B111LDING FEE
I certify thin 1 have read this application and site chat the above information Is
F rasiN
il corwct.l agree to comply with all city and county nmimanee,andafine laws aching to QTY. MECHANICAL PERMIT FEE SHISMIC F12H
U Z building consmmion,and hereby amhodm representatives of this city enter upon the
uMrve-n¢miuned progeny for inspection purposes. PERMIT ISSUANCE III.I:C1'R11 :EF
(wet agree m save,indenmify and keep haonlcss me City Cuirenlnn against
liuhllllies,pulgmenu,cnus:m:lcxpt�n.es which rn.y in any way accro ue against said City AI TER OR ADD 10 MIiCH. PLl1M NO
in consequence of the granting of this permit.
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(,to IN(NN)CFM) MIT A. A.FET: Owe
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.(NN)CFM) CONSTRIJ 'IONTAX 01
Signamoof Applicant/Commmaf Date F%HAUSTHOOD(W/DUCID IIOUSIN( MITIGA'I'IONFEE
HAZARDOUS MATERIALS DISCLOSURE r
Will theupplicamot lmumbuildingccc.part nutembradle m.okinsmatedal HF.AI'1NG UNIT IT01(OAW BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Ile.hh and Safely HGTING UNIT(OVER 100.0(0,BTU)
Gde,Section 255]2(.)'!
❑Yes ❑NnVENTJUNE[ON PAN(SINGLE RESIDE PAID �
Drrlc
Will lhe.pparean n,mine,louldingner.,ml me al,apmanloNevl¢s which BORER-COMP OHP OR 100.(X10 it GI)
mit h...dom,air mmmminnnts ns declined by the Buy Area Air Quality Mm r,ounat 'TOTE,:
Derid? BOIIJ?R-COMI'(OVER 00.000R1U)
❑Yes Fl No
AIR CONDITIONER ISSUANCE DA' E
I have mad the h oda.Sections s 2 5 requirements order 5. .I and 1,to of Nc Cali-
Wildigdoes&Safetytlyha ar are25505.is 533 myand25531.1 unnotifyIth Natif Ne NEW RESIDIiNIALMF,CH. SQ.UT.
Wilding Jces no¢urnndy have a Irnant.Nm it is my responsibility to ratify the cecupam
of the m niremems which must rte met prior Ito issuance of a CmlOcme of tkeupanry.
Owner or amhnneed.gem
Date 'IUI'AL: ISSUED BY.
OFFICE