S 2967 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1-17RMIT NO,
BUILDING DIVISION APPLICATIONIPFRMIT PLUNIIINf-MECHANICAL
-BUILDING FROJCCT WENT IPICNFION
BUILDING ADDRESS: L` �� �app�� //•,� •�.r�1 SANITARY NQ APPLICATIIfON SUBMITTAL
DA 1'If
OL 1Ly NAME: r f, PgpNE: CONTRACIOR:S NAME: LIC NO:
1U- 6 =2 NIC CON'IROLx
-�}+CHILI CI'It CINP.P.R: LIC O: TJ ADDRESS: ❑ C� 2-
CONTACE PHONE: 6UILDING PERMITINFO
,� i1„J ���_ ^ '�V J��'t ❑ Consultant Fees Paid by Applicant(Initial) nfL-DGG ELEEC'I' PLUMB MECH
V ` V IBJ I_l `U' ❑
LICENSED CONTRACTOR'S DECLARATION Q'TY. ELECTRIC PERMIT FEE
I hereby affirm mm I mea fianaed ander provisions of chapter 9(comrroroing - JOB DESCRIPTION
�a X. wiib Sermon 9fN0)ofDivision3ofineBwiness and Professions Covla antl my licenre 6' 91-SUDENTIAL:
Fo full Lirceaade0cct PERISSUANCE r )
IA- in ❑$T'DWL ❑KffCI11:N REMODEL.
QUU License Class Liex APPLIANCES-RESIIIRNT'IAL ❑ADDITION ❑PLUMBING RE-PIPIT
(F/1 a a Dae Comnmmr
ARCI II'I'ECT'S DECIARAI ION PANELS ❑MULTI-UNIT ❑STRUCTURAL
, P m
Z 0 O w Z I understand my Nan+aliall M used as public recordsMODII'ICAU0N
Ooy-^0 UP 10 200 AMPS ❑INTIiHIOR ❑CI{IMNIiY REPAIR
oy
Ff"ul Licensed Is fie-med 206EXXIAMPS IMPROVEMENT El SWIMMING POOLS
Yf OWNER-NUILDER DECLARATION OVER 1000 AMPS ❑ 1'HiIEMBINijilliN4iR�8DfJdOL13JD0
(y sY d I hereby air,.that 1 nm exempt from the Contractors Liccnm Law far the Y
x O y O following rersan.(Sectitin]11.11 5,Btuinesa oat Professions Code:Any city or county MONS EhECfHICAI. ❑THIN _
LY W�Fr wi : p 't t t t atm I- d mli 1''r any sutcu o 'f1 n�
grit Tons i I. q k :m applicant ppl' I b"mil II ' subteen,moci subtn, SPECIAL CIRCUIT/MISC. -~
h �r
}'a that he is Iecnsed arroura thep ism:of'IN C t emr.I Ww(Chapter 9 n
W CSO (commencing with Seciion9Bt0)of Division 3ofthe Business and ProfessionsCed0or TEMP METER OR POLE INST. •R' -•f LCl)q�
a S e that he is-cersa mem&ons tied the basis for the alleged excmpinn,Any violation of ❑ NLUG/dBrnT 1 N PM LI
I Secism7DI5 tray applicuni forapermit object,iheapplicnnt m evivil penuhyat POWER DEVICES ANT El FOOD 51 E
nett moo,hnn live hundred dollrrs(8500.
-~+Zed ❑1,to nwnerofthe Pmperty.onny employee wid:wugesas mete nJacompenuudnn, SWIMMING POOL HLEC'I'RIC 1'ROVHMI?N'f
2 will do the work.and the structure In not intended menaced for sale(.See 9011 Business Of il
W,3 m and Professions Cale:'ra,CentrectUrs License law docs net apply to an owner ailOUTLETS-SWI'1'CHflg-PXTURF_S
property who builds of improves thereon,and who does such work himself or through
his an employees,presided that such impmven ce s are not intended or offered for NEW RESIDENTIAL F.LECTR SQ EL
sale.It.howeveu the buildingar improvement is sold within one year ofcompletion,the SQ.FL FLOOR AREA 5/SQ.FT,
mar-builMrwill have me haNun ofpown g that he did not build...am we for....
Pmc el sale.)
bD�ras owner of the pmpeny.:nn exclusively contmcting with licensed comments,m
nmra ma proem(Sac.EDW,Business and Professions Codrp The Contracmrs Li- -
selawiiiesnotapplymanownerofpropertywhobuildsoriniprovexmercad nod QTY _ PLUMBING PERMIT Flifi
who contracts lot such projects with a curiosities)Recused pursnanuo the Commemr'x
License Law. PEWL6ITSUANCE 3
❑ I an Exempt under See. ,11&P Cmr misre:uon
Yt _ _ 1R- VIiN'1'-WATER[EA) VALUATION
Own1 TV
WORKERN
S COMPENSATION DECLARATION BACK FLOW PROTE I VIC
I hereby affirm under penalty of perjury one of the following dsclurmians: 9 Q
. D I tovenal will maintain aCenllleward Connen,owlf-To one for Worker's Compel- DRAINS-FLOOR,RUOPA i COND. STORIES TYPE CONSTRUCTION
sal os provided for by See Bn 13700 of the Lubar Codc,dor the per.iamnnce ol'tM
work fear whiehmis permit is issued. " FIXTURES-PERTRAP l �`�'�
❑1 have and will maintain Worker's Compensation Insurance,as inquired by Section
3700offielaborCse.fnnbe Performance of the work for which this permit isissucd, GAS-EA.SYSTEM-I INC.a OUTLETS OCC GROUT• APN
My Worker's ComPenuttirn lnwrance,carrier and Policy number am: .� t7
Carrier Policy Nr.: OAS-EA.SYSTEM-OVER q(PLA) "1
CEID IFICA'I'17 OF EXEMPTION FROM WORKERS' L�
COMPENSATION INSURANCE 01t IiASEIINUUSTRI.WAS'IP.INTERCHI4flR
81111.111NG DIVISION II!ILS
Hllils scaion nceJearnMmmPletsifthe permit isfrrona hundreJ dollarslRltO) -- —"--
r Iris 7
GREASETRAP PLANCHECK FEE
Ioyany that in the any Performanceof
ascwmk0a which subjects perthe iii Wrkes'Center. SEW17R-SANITARY-ST(IRM EA.200 PT.
not employ any person in any nmm�er.co m ri M1arime subject m the Workers'Compel. ENERGY FB -
z cation nws of Cnliforn'nt.Dam WA'I'F it 111?AI'ER WNEN'I'/HI,ECTR u
Q Applicant t G11AD1N( GE
s NOTICE TO APPLICANT.II;alter making this Certificate of Exemption,you should WATER SYSTEMG REXI'ING
becrme subject,o the Workers Compensation Pmvisinns of the Lnbc Cale,you must soil S E
forthwith comply with such provisions or this Permit hall The deems revoked. WATER SERVICE
0. 0
CONS'TRUCT'ION LENDING AGENCY NGW RESIDENTIALI'LMB. SQ.IT PAID
z Ilwmby worn,tom d¢ru iso crnntmcHnn landing agency It,,rtM1c parformunca of nate RcuiPIA
'heve k fit,which this panni,Is Issas(Sec 3001.Civ.C.)
I•ks H LemEA Name OT
L) Lender's Address OP
I certify that 1 have mad this application and+mtethat the above information is r BUILDING FTai
FtA correct.)ugmcmrnmply wim:dl ciryand counryordinnncesunJ cont laws rlwinRm QTY, MECHANICAL PERMIT FTE
L) ,7. building cousuvction,and hereby ntuhooz mprcxentati ves of t his city to enter upon the. SEISMIC PEE (900"•� above......at am prepany for imPec,ion Purry..a,. -^
(We)ag.m coo,indemnify and keep harmless the Cim of Cupertino main,, PEI2MI'f ISSUANCE ELECTRIC PEE 15 r S V
Iiabili,ies,jadgmenn,costs and expenses which may in any way eters against said City ATTER OR ADD TO MECI I.
in inimence or the granting or permit, PIAMB.G zy,
APPLICANT UNDERSTANDS AND WILL.COMPLY WD it ALL NON-POINT AIR HANDLING ON[T'(TO 10.000 CFM)
SOURCE REGUL IH S. q/ MECII N AL FTE
VI. 14 i �� � gg AIR HANDLING UNIT(OVER 10.03BCPM) CONS I ICTIONFAX
Shoommod AP,heam/Continernt Data EXHAUSTHOOD(W/DUCI) HOU. NG MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applitamar future building overpaid store rehandle haandoes material HEATING UNIT ITO 100,000 BTU)
as dalinad by the Cupi:nino Municipal Code,Chapter 9,12•and the Health and Surety
Code,Scotian 25532(a)P HIA'IING UNIT(OVEN 100,010 BTU)
[3 Yet VMI LAI ION PAN IS ING LE REST D) PAID -
Date Receipts
Will areicam onantst I t definedding by the ed use Bay ArequiptnQuor lityMireswhich HOILER-COMPLIHPOR IW,gIDB'11H
mit h:anrJnm air comaminanns as def ncJ by the Bay Area Air Quality Managmncm TOTAL:
Dintrim,1 __�// BOILER-COMP(OV ER IIXl,aO IT ULT)❑Yes L/"
(lave read the hamNmis materials requirements under Chapter 6,95 of the Cali- Ant CONDITIONER ISSUANCE DATE
forma Health&Safety Cade,Nations 25505,25533 and 255311 undersand that if the NEW RESIDENTIAL MITCH. SQ.ET.
lending docs our m cant,have a tenant,that it is my responsibility is meaty me cecrpuit
oft drtenentax her Moro, mlXumnce a fa Claim it Gccu y. q
IKw - brrc S-ti Dem
ow crmrt dmd,Te agent nam - Itn'AL: Issuer BY:
OFFICE