S 2911 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-RI.ECIRICAI. rlCAL d<Mrr NO.
BUILDING DIVISION APPLICATION/I'F,RMIT PLCPROJ- TIDENI'IFIC
IIUILDING 1'It(LIEC"I'IUF:N'I'It'ICA'1'[ON
BUILDING ADDRESS: - SANITARY NII. API'LICAI'ION SUBMI'TI'AL�DAD!,
OWNER:S NAMIi: PHONE: CONTRACTOR'S NAME LIC NO:
-� C Yh ! Q!4 1 1•' ) N NIC CIIM'R^lll.p
ARCHITF,CT/ENG NEEJC LIC NO: ADDRESS: ❑
M L 00 M:n 6
CONTACT: PHONE: BUILDING PERMIT INFO
�S Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG IJ.ECIPLUMB MEC11
LICENSED CON'FRAC'I OR:S DIiCI.ARA'1'ION Q]y ELECTRICI'ERMIT FEE
I hereby affirm that 1 am licensed under previsions of Chapter 9(commencing J013 DESCRIPTION
CaZ with Sm.inn]001Bol lfimkion 3ol he Busine,e and pone'sun,Conde.and any ikon¢In / RF,SIDENTIAL:
W O I'IiRMI'I'ISSUANCE
I-ol— in full foreeand tricot, ❑SFDWL ❑KITCIIRN REMODEL
aUV license Crix>s hlC C 17 Lie.N 7y•�f APPLIANCES-RF,SIUEN L..frDfflQN ❑PLUMBNG R6P11'li
c,t<W Umt f-fl+ Gmvut ❑MUO'I-11NI1' ❑STRl1C1'URAI.
A. ARCHIFE17CS DECLARATION
I'ANEI ti MOD[FICA'I'ION
'/+Z 1 r decrati my plane.,hull yet used:n public records
OZ`3`O tiP'IU 2Ix1AMl'S ❑IN'TERIOR ❑CHIMNEY REPAIR
F.tnFly. Licensed Professional IMPROVF�MFSTI' SWIMMING POOLS
2111-IIXX)AMPS ❑
that.FitII1cluto RUECLA cro OVEN IINHIAMI'S [�1MYfM!kifttp{2lff��fr N
C C Q I hereby aliinn that 1 am exempt from tht Conuadnrs Licensee Law for.hc LyJ/-•%\�\T—
'a0CU following reamn.lScnion]WLS.Ilusinc.w and Professions Code:Any city or county' SIGNS IiLECI'RICAI. 00 00'
1ER
m 3 w v wbieh redni a"count to coa,tiord,ah.,,imrnwe,tic h,r+ repair luny..matt
F'NDJ priors t I: 4 the ( 'n pe It fl 6 d.ttmend SPECIALCRGHfI/MISC.
COGS th.th licensed g t. theP of the Contractor's;1 La (Chapter 9 IF .2 .rte/\
�C,00 foot a ,walScoir 7000)ol'IJ'v,m l,l the Bus n..� llofuet sCJul+r 'fI,MP.MF I FIN OI11N)1.1?.NSI'. I`]u`�
shat he is exempt tncmfmm and the basis for the alleged exemption.Any otolmdnn of It 13LIAd/AUDITION DEML." N
�^, scrion7031.5 byany applicant hexe proml subjecnthe applicant to ocivil penalty of POWER DEVICES fiNANI' ❑FOOD. .t ICE
nm more than Gvc hundred dollars(45(0). IMPItOV1iM1?N'1'
�Sp 0 Las rwnerufthe pmpery,or my unpl,cc%with wages a,their suit compensation. SWIMMING POOL ELF TRIC '
.~m wAidt1hcanrzk,nnJ.M1ewOucedu Horn imm�dnl nrnRemtl finsaluftiee.]IW4.an.1ey ID1I
w 3— and Pmfc,ior,Cour:The Contractor,1„cn,e Law donee net apply m,rooster of i$ ou'r1.E'rs_swHcueS-Flx'1l1Res 7 �"
progeny who build%or impmxe,thereon.and who dues such won,himself or mmagn
hie own ando,o.,gn,61M shut ouch improvnnen,,ore not intended nr offered For NE?W RESIDENTIAL ELECTR SQ E.
soft.If,Inwoimposition,
'er.the building or mis.old whninane yearcmo
ofpletio i.the SV IT.Id.00k AREA SISQ I'1',
er-builder will her a me burden of proving thud he did nm build or import,for Far-
-11 rosown owner qct 8 y
1,at r of my.e pmpenam exclusively contracting with Iic, seJ ncontinents nnnon. )I
onstruet me P cy.(Sec.7044,Boniness and Pmfeoiana Code lbe Contractors U-
selawdcesnotagplymanowocrofproperty who numbs or improve,durum,and QTY. PI BI rPERMIT FEE
who contracts mr,uch po j,c,with a contiuctor(s)licensed parmant to the Contractor,
License Law. ( PFRMI'I'ISSIIANCG �tJ
1 ant semin under Ste. .13&P C for mi,on"In
AhTER-DNAIN&VIiNT-OK -k IEA) VALUATION
Owner Ince (J
S WOkKlik'S C(1MY13N$AI'IUN UECLARATIIIN HACK 110,FEEUl!Cf.DIiVIC 7 DO
I hereby affirm under penalty of perjury one of the liJlowing declurations-
IIhavemidwillumin,on a Cemil,uteuf Con,an ,u,,II'.Insure lin Woner9 Cun.pe.- DRAINS-pLOOR,mpE7ARIz COND' S'TORIHS TYI'H CONSTRUCTION
sem .p J d I r by Section 1700 of the 1,N),Cale,forthe p f of the r^�
work 'Inchilt:p o l L 1 t FIXTURES PER TRAP 3 V Z r
EjIh J will Ind W k :Cn o,r,m+n Inwru+u 4 Jby Section ( I O--
3700 fish l.abon Core,for thepecrommunce of M1e work formlachdh_p t :issued. GAS-EASYS'IEM-I INC.4OUTLTeIS U- .GROUP AI-N
My Worke!r.'s.Gnngensnumlmuol rte carrier anA l'ol.cy nnmh,r art p /CJ �O ( (,2
Cartier:ala C� �bl^ Policy Nn.o<.r �y-f� (y+� GAS-EA.SYS'ILM-0VI31<dfFA)
CIiRTIPICA'IE OP :KHMPr ON FROM WORKERS' GREASEYNDUSTRI.WASTE INHiRCEMOR
COMPENSATION INSURANCE I IITING DIVISION FEES
(Di,section ntdnm be completed it fire pmtlt it lar one hundred dollars($100) GREASE TkAI'
PLANCHI iii
I tenify.hul in dbt lwrlonnunceuftha work iiawhich min lsnnit6lwd,I,hall SIiWER-SANITARY-S'IORM EA.200 Ft
nemploy any Amon in airy mannenom do Mcome,.hNrt c the Worker,Cnmpen- ENFR' 15
F
Z naliun Law.,of Chl.gn WAJ Bit IIEA1 ER W/VENTMLECI'k
m GItAI N I:IiIi
OO Applicant
Z (�/] NOIlCEM AA A '.IC.after making this Cend.catc of Exemption,you shorn NATER SYSTI?MO"BEATING
hecnnm,uh',rct to he Worker,Cu.npemalinn provisions nfmc Lat, Code,you must SOIL-S 'H
� > fonnwim comply with such provisinns or this lennid,hall he deemed revoked. WATER SERVICE
PAID
CONS'1'NIICfI(IN LENDING AGENCY NEW BESIDE TIAL PI,MR, SQ.FI'. Ulnc Rmcl q
U z Ihereby uffimuhnuhere is a contrunion lending agency for Ne perimmance of
EJ F .roe work for which this permit is ismuJ(See 9W],Cie C)
OIwmder'.s Name •I l TA L:
W 1<nder',Addm,s 'I' TA r
r d I certify.had I have rend this agplicntin I and rate shat the aMwe infommtion i. BUB FEE;
FTA arrtcct.l,gree hrcomply wish allcity and mun.y nNinanccsund,etc law,rclwing n+ QT'Y. MECHANICALPERMIT ITL Slil., 1'PIiE
U building consauc.ion.and hereby authuvc repm%cnmtivc,of this city to enter upon the
ubarvcnmill uncdpmperty for in,cccr puI,— VFRMI'I'ISSUANCE IA.° IG IEH
(We)agree m save,indemnify and keep hum x,me City of Criterion aeain,t
Iiuhilidies,judgnsems.cnasandeepares which tnayin any way uccmcaguinst said City ALTER ORADD TO MECH. N.U. LING FEE
b mmcyuunec til'me gmming nl'II i,petrel. x
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL.NON-PONT AIR HANDLING UNITED)III.000CFMI MEC NICALFEE e LO
SOURC'MeGUILNEONS.
1 AIR HANDLING UNIT(OVER 10.000 CPM) CI INSTIt( 'TION'I'AN
Slgru.umafAU,,acclumrdclor Dam l EXHAUST HOOD IW/DUCD 1 HOUSING MII'IGAIION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant s.nre or handle h:vallous material HEATING UNIT CTO IWJXXI RTU)
Code,
aldebuld
by
yn tire
Cux1 inti Municipal Cn 1,Chaser 9,12, o I.ext Ilealm andSuRy
GW
`v� IMA'1'INO UNI T(OVER Horton)[I'I'U)
D1,n VF.N'I'I LATION FA N IS ING1.17 R ES1 U1 PAID —Dane Receipt It
Will me applicant or future building uceu land use Wuipmmut or devices which ROII.EiR-COMP QHPOR 1110.000 RTU)
Ir l by:nd ur cnmmctinam,as defird ny the Bay Attu Air Qraloy Management T'A..
District? HOILHR-COMP(OVER IXLIXXI RTU.
ye,
I Into,—it otic hmatdoos:ruerialk requirements under Charter 11)5 of the Cali At N CONDITION Hk ISSUANCE INVIE
forma Ilealdh&Safety Crede,Sections 25505.25533 anti 255311 understand that if the NEW RES IDHN'f1A[,MSCI I. SQ.ET. 22
building o,' ,tante dy havu.trnan.,1hat ibis Illy.c,polmihili.y do miry the xerngam
ohne n u,t ne met prior m i....ance of a Certificate rod Oc ran y.
r' `-" Y iii
-�q o
�4 nadagnn Dale )I'A, NSUEDBY:
OFFICE