S 2674 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
FOWNER
Y OF CUPERTINO Bull.DING-HLFCl R1CAh PHRMIr ND.
ILDING DIVISION APPI,ICA'I'I0NA'1?KNIT vl.uuulrvc-alFcxnNlc,M, Q L'7 /I
IIUILDINC PR0JKCr IDDN'I'IF'ICRTI0y l7 6 1 4
SANITARY NO. APPLICRI'ION SU13MI TI'AI.DATE
DINO ADDRESS:
d 164 ac3
S NAME PHONE: CONI'RACIOR�YpMIi: LIC N6.
L / NIC C 'rHOLM
Car n
ARCHITECrIENGINEER: LIC NO: q $�� 1 / no ❑
CONTACT: I'IIONF: �/ ]LG/• C Il UI1,U1NC Pli0 71'1 INF'0
❑ COBsallanl Fees Paid by Applicant(Initial) BLDG ?I.ECT PLUMB MECH
El 1:1
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT EEE JOB DESCRIPTION
I h,.hy d ina that 1 am licensed under prnvi.iunr o1'Child"9(commencing
with Section 701A11 Of Div.dnn 3 of the Iw.ine,and Prufassionx Code,and my he m,is RESIDENTIAL:
fwd 0 c, PERMIT ISSUANCIi
C u1N imfullfouccand.11c, ❑Shim. ❑KI'T'CHEN REMODEL
aUU IJcemse clan Lice APPLIANCES-RESIDEI'DIAL ❑ADDITION ❑PLUMBING RIiPIPF,
9z. Date Comrector ❑MUI:I'I-UNIT ❑SrRUCTURAI,
ARCI{II FCrS DECLARA'I'[ON PANEIS
~onZ I understand my plans s6a11 he used as public records w b1ODIFICAI'IUN
ZOy—a Up 10 AMPS C- El INTERIOR ❑CHIMNEY R17PATR
OZ-0
Fl4tZB1 licensed Pml'msiunul 20I.I011AMPS IMPROVEMENT SWIMMING POOLS
.W ; OWNER-BUILDER DECLANA'I'ION OVER 1000 ❑HAIIIRI.
' I?I/RIiPAIR ❑DEMDL'I'IQ
W XQ I hereby dGmt that I ant excmpl tram the Cnntmcmr's Liconw Law lin the
3W U foffm'i
ong maven.pm,lwa 703L5.Bmia..s and P..l'casions Cotte:Any city or la-mY SIGNS ELF.=ICAL all
y which Icqui,roman m.....vast,alar.Improve demolish,or m, mr any nmaurc
prionoits issuancc,ai.w mquircs the applicant for such pernal to te
file a signedstaannl SPECIAL CIRGUTOMIsc. `
their he is licensed panunm to the pnniaions of the Cnmmctor's License Law(Chaptr9 COMMERCIAL;
Wp'q0 (enmmenung with Section 700()^(Diviaon 3 afthe Business and Pmfesuiom Code)or TEMP.METER OR POLE INST.
ly y a
'hat he is excmpl Ihercfmm and he basis fnr the allugW exemlain,Any stinal^n a1' NEW JR.UG/ADDITION ❑DIiM01.ITI0N
�-,w
Section 7031.5 by any applicant lira Penml w ajec0'be applicb a In a dvll pcnnlly nl POWER DEVICES TI? 'I FOODSERVICE
not more than five hundred della,($510). ROVI?MFNT
SSD plc es owner al the pmpenYnr mY employees with wages as lncir sole<ompcnseuna, SWIMMING )LFLFi RIC
F will dothe work.andtnesnucwm isnot put dedornrteor salemed fit 7044.Husinc, ❑U LR
Wm and Profesions Code:The Contractors License Law does not apply m an owner of OUTI.hTS-SWITCHES-FIXTURES
property who builds or improves thereon,and who dols such work hlmicli or through
his own ungtlayccx,provided the,web intptnvommlx arc oat intended or offered for NIIW RI351DENT'IAI.IiLIiCTR SV rr
sale.It.bnw i.the buildmm
gar pnve cot isand wi,h ane yearnfcn Fiction.the PI'.1:1.0 in
w rboldc will have the burdenof moving that hedid art lwild or improve tot par-
poD
le of soled. 'IOTA
❑1,as Owner of the pmpeny,am exclusively coatrecting with licensed contractors to MAR 0 2
,nstrucl the p.,jW(Sec.7044,Hmines rad PollCode:)The C^ntracmrs Li- 19 9
vc.,c Law doe,,um apply mowner ner of Property veno hall]'01 improves thereon,and Q'TY. PLUMBING PERMIT FEE
who contracts mrsach projects withaonntru,' licensed puma..mthe Cn m,aelur4
License Law. I'ITTIMI'I ISSUANCE
Ej 1 mat excmpl ander Sec. .H A P C for this rebwn
ACT 17R-DRAIN h VEIST-WATER(RAI
• Owner Date
WORKER C0M1iP1iNSAT1ON❑IiC1,AHATI0N RACK FLOW PHOTECI'.DEVICE
I hereby affirm under penally of perjury one of the following declarations:
I have and will maintain a Certificate ofC^nsem..sell-imurc far Worker'u C) twit- DRAINS-FLOOR,ROOF.AREA,COND. S'I0R17 TYPFCqNS"1'NICTI0N
%anon,as loovided fia by Section 371101 I the Labor h Col,lor the perhonaturce Af We
work I whichhil lemall : londL FIX'I 11Hi S Plat I'I1AI'
❑I h 1 will initiation Workers C^ pe . I n Insumance.as acquired by Section
371041 ofth Laywr Code.for theeflonnowe offl work for whichthi Pennon is issd. GAS HA SYSTHM-I INC.4 OUTLETS OCC GROUP MIN
My Worker's Compensation lnsumnce canierand Puhey numher are: VGAS-�.SYSTEM-OVI:YSTEM-0VI: 4(EA)Ciam, PolicyNo.:CEBTIFICATF,(IF RXBMI'DON FROM WORKERS' DUSTHh WAS'1'P TERC131'I0HCONIVENSAI'ION INSURANCii BUILDING DIVISION FEES
(I'he,,,,iiunnecd not bent....c ,rf,he Prcall(is lunar hundnd dulls,($Ila) APPLANCHECK iil3ttnily lbm in theperfonnm, ofthe ssno cfrwnichtnispermitiyor C0.1lver, NITA -STORM FA.31X)il'. ENERGYIIiE
nor em ymanna w usto becomemhjeanaInc f� i Compensai LA' WNI3NT/ELELTRz Q plicanl GRADING FGE
zICE IAI'PLICANT.IL after banking this CCnilicum of Esnmptmn.you shnu Tf?Mll'HIiATINGSOILS II:Gbaht iffula to Ibe Wndcr's Gwopwssmion pro eio ns of the Lnhnr Cudc,y..t manto lib cumq,ly with such mvixinn.lir 0if,pcnn xlist be dmmcd Icv^ked. VICE
PAID
CONSTRUCTION LENDING AGENCY NEWHESIDENTIAI.I'LMH. S0.PI'' Umc Hmcipt p
U0 Iherehyaffrm that'hem is a construction lending agencr the y foperformance of
U. — the worper
man for which this pcnn is issue([(See.3197.Civ.C.) TOTAL
O U Lcadcr's Hanle 'IOTAh
,r WLenders Addle, BUILDING J;F
y I eeday ohm I Imvc read IhL applleaeob and steno:'hal the above all"m Imian Is
Pyr In c rzcd.l ugmc urtornply with al)city and county ordinanc..and sate laws mlat'ms I^ QT'Y. MECHANICAL PERMIT FEE SEISMIC PER.
C.1Z building consanxion,and berahy amh^rim rcprcmmamec,ofthis citymemerumdlhe
a ove-mentionocl prepeny for inspection purport PERMIT ISSUANCIi ELECTRIC FEL?
(We)agree m save,indannify and keep hamdem the City of Cupertino against
Iiohilitic;judgmcnh.cons and cxP.nas which buy airy way accrue again,,said City A 1:1 ER OR ADD TO M PEI I. PLUMBING 113L'
in ...yu.me of In.bemain,of ods permlt.
APPLICANT11ND1:RS'IANDS AND WILL COMPLY I'TII ALL NON-POIN'I' AIR 1IANDLING t1Nl'I'('IO JO,ah)CFM) M1.0 IANICAI,PI?E
SOURCI, . 0l,AI'IONS.
AIH DANDLING UNIT LOVER III,IXRICIo C0NSTHl1G00N TAX
nat of ApplicardCuntmnnr Date IiX11AUST H00U(W/DUCry HOUSING MITIGATION IFF
HAZARDOUS MATERIALS DISCLOSURE
WIII Ibnappllcamor future handing tw,femxmn of handle hueadanemmaial HIiADNG UNIT IT01101.(XgB )
m depned flyupert
y the Cupertino Municipal Mucipal Code.Chapar 0.12,and Ibe 111,1111,and Safcty I IPArING UNIT(OVFR I mlo BTII)
Code,Section 25532004
❑Ycs E]No YIN)ILATION FAN INGLE RESID) PAID
Date Ri N
e Will the applicant or future building Occupant live equipment Or devices which BOILER-COM 111'0H I(q,(H01 HITT)
mit havatdoas air conmminanh:n defined by the Bay Area Air Quality Managernent '10TAL.
Dlmrict'I IIOILIiR-1 Mp(QY13R l(IRIKKIBTU)
E]yes C]No
"yCANCIi�I
I have real the hasvdnus..aerials reyeimmcnta under Chapter 6.95 of the Cali- AIR C(1N01'1'1(INIDi �j�j�
ATE
fom .Ria calthSafcty Codc,Seetionn 25505,25533 and 5534.1 uO&,mth
nd at if ane NIIW RESIDENT IAL MICH. SQ.IT.
mosla dmo a0lerrantly harcaaminL that it is ray responsibility m ratify the occupied
I or ynirencoast un n.meta ranee nraceaireme of Occupancy.
er orawnofi'eed agent Date 'TOTAL: ISSUED By
OFFICE