S 2214 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO LI11 MB NG-ELECTRICALMECHANICAL PIiRy1T NO.
BUILDING DIVISION APPLICATION/PERMIT rINGPwGCTIDEN I IFIC l`J
nuu.lnrvr,ruoJF:cr u)EN'rlFlcn'nory 2214
BUILDING ADDRESS: SAN]TARY NU APPLICA'T'ION SUBMITTAL MATH
OWN H 'NAME: ONE: COKI'RACT :SN Afl' LCN /� ��
NIC COKI'ROLp
, ARC TI:T - GI . LIC NO.` DRI!S'' ❑
l
' C/(�IN�TAC"I': PEON- BUILDING PIil2MlT INFO
/yI- /,( a �� ,1 �f5 I ❑ Consultant Fees Paid by Applicant(InitM. 0
G ELECT PLUMB ME�CII//
lI t VVINMi/ `1'IV/Ire l{/ ❑ ❑ LJ
LICENSGDCON'HOACTOR'S DECLARATION Q9•Y ELBCTRIC PERMIT
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing )�R DESCRIPTION
Qa7 Is Samoo 7gX)o0Sswlou 3 nrtile Holmes,i H'rnfe—noxCode,ural my were i, NTIAL
111- in PI!RM111I'ISSUANCE KH
F-U� fullfomc and f Ilr / �I GoL ❑PLUMPIN RF;MODIiL
�U iccnseC s: ldaM 110 AITLIANCES-RESIDENTIAL El ADDITION
E3 PLUMPING RE-PIPE
y< Dmc Comma„r M �d-�?M�'L.- ❑MUITbUNIT ❑$'I'RUCTURAL
RCUFFEC'S DECLARAI ION
p.,Om PANF.IS MODIFICATION
OO-q mndeamnd my plans shall he oxen us public raoNs
02—M UI"102(NtAMI'S ❑INTERIOR ❑CIIIMNEY REPAIR
Licensed Professional 201-I(MMIAMPS IMPROVEMENT L3SWIMMING POOLS
CY ; OWNER-BUILDER DECLARATION OVIiR I(M)IIAMI'S O BATH REMODEUREPAIR ❑DEMOLL"P[ON
1 C W Q I herehy'Warn that I um exempt from the Commanr's License Law for the
O q V following mnsnn.(Section 90.11.5,Business and Profusions Code:Any city , SIGNS EI.FCTRICAL OTHER
3 W vFi wh b y perm t t construct,aIle J o1i pu ny xwcmre P
^w�;
prior to its ,also requires the applicoldf such permit rile a signed statement SPECIAL CIRCUIT/MISC.
�jWN Ihmh I' Ipurx It II p vlsm. fa L t nor, l' Lw(Ch.mfr9
E�Iy pO (commencing with Section 7000)of Division 3 lathe Businessland Pndesanns Caric)", IEMP.MEI'ERORPOLCINS , COMMERCIAL'
q efl
that be b exempt therefmm and the basis fur the alleged exemption.Any violation of ❑NEW FLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant lin a permit'aeject,the applicun(m a civil penally of POWERUEV]CH' t ❑'TENANT ❑FOODSERVICE
�Qand mora an.five hundred dollars P600), IMPROVEMENT
�] Las Uwncrnathe property,or my employees with wagesus(heir sole compensation, SWIMMING'POLELIiCf
will do the work.and the stmmurc is not infnded oroffercd fur adoc(Sce.IlH4,)....one ❑OTHfiH
L 3 ae and Professions Cwle:'Itic Commeror'x License law cuts not apply to an Omer of L�C $WI I'CI IX •S
properly who builds or improves Ihcmon,and who does such work himself or through
his own employees,provided that such improvememz ate not intended or offered for NIi a Ii5 'I'I !L' 'It SQ IK.
,a]..If,hes clt, he budiingouimpnrumnen(is sold wadnnne yennd comple io to SQ. FLUOR AREA SISQ.PI'.
er-builder will have the burden of proving that he did not build or tnrym cis"T
rjpio e oa sale),
❑L ax owner of the pmpva,I i exelnsivdy armn¢Iing with licenwcd co nous I 'I'AL
construct the pmjec[(Sec.]0al,Business and Professions Cole.)Use Conh
de Low does not apply to an owner of prepeny who builds(or improves the nd QTY. PLUMBING PERMIT FEE
who convvc[x linrsnch projects wilM1ucnnnudar(x)Iidensel pumaunl les be Cont is
License Law. PERMIT ISSUANCE
I um exempt under Sec. ,B&I'Cfonhis real
ALTER-DRAIN&VENT-WATER WA) VALUATION
Owner Date
'- WORKER'S I oll up NS AT ION DHCLARAI'ION RACK PLOW PROTF.C'E DEVICE
1 herehy effinn under Penalty of perjuryone ol'the following declarations:
]bout and will maindin a Cerdficncid Conscm msslTinwref nr Worker's Compcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
,rient,as provided for by Section 3700 of Ne Leber Code,far the perfnnmmce til da
work lin which this pemnit is issued. IIXTURFS-PER TRAP
rl I have end will mainmin Worker's Compensation Insurance,as required by Section
3900o1(he Lvbnr Code,IF (for perhrmanceol[he work for whi,h(his pmnill is lo,ma. GAS-IEA.SYN3'EM-I INC.40U'I'LIPTS OCC GROUP APN
M Wyyrke� Fr�mpcnsn(ion ins'�•'ncc ryryt��cCCyyrrrrdd fBlyy
Cum'S T /1eNl_�fy'1 Jnr GAS-IEA.SYSTT:MOVF.R4(13A)
CERTIFIC COMPENSATION
INNPROAL W(RKI!R5 GREASMNDlis TRI.WASTE!INTERCEPT OR
COMPENSATION le,uniANCL BUILDING DIVISION FEES
('This eeeinn need nn(1,c mplmed ifthcpermi(is for one hundred dollars(SI INP
or less.) GREA$I!'rRAP PIANCfII!CK PIH!
I rein I that in the pa,trouneof the ,,,it for which on,Penni[is issued,l nhall SEWER-SANITARY-STORM P.A.2191 let',
not employ any person in aay manner so as to hcmmc avbje t to the Workers Comped ENERGY FEE
O Z ration Lowe of California.Date WATER IIEAl ER WNF,NT ' 7-- UCRADINGF
Z 2 APplipmt
ti
rA NOI'ICETO APPLICANT:11;after making this Centfieam of Exemption,you should WATER SY91'HM/IRFATI A ZZ
hcmnm subject loose Worker's Coanpe or ibis pmvisions b the Lown Chile,you nnam
lonhwith comply wi(h such provisions or this pennil.hull he Deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGI!NCY NI!W RESIDIiNF AL 1'1. SFKT.V O l hershyaffion that he,,isoconsauaion leadingagirmy fonbepedemm�cenf m eciptp
F p . ,W Lender's NameRIO TOTAL:
Ij
V Lender'sAddress1 eraily thus I have read thisa,hcatin i vnA xttethat theabove infrmail is - EQTY. MI3CHANICahovemm�(innut properly tri'arePeaula FaH'nws. 1'ERMI'I'ISSUANCE(W'e)eS.m sot,indemnity end keep[amdes,(he City of Cupertino against Ii �J
liuhililios,judgnmms,cns(s nnJ cxP:ncew which may in any wry accrue aguimtsaiA Ciry ALTER ORADDTO MECH.
in causeyuence of the goading of Ibis Perot[. PLIIMtlING FliE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINTAIR HANDLING UNI'F(TO 10,00)CFM)
SOUK1�I`'fl�tl[GIILA'I'U)NS. IF A11!CHANICAI.IEE e
I�" \l�� �lY� r / II� � NR HANDLING UNI'I'(OVRIt]0,1111)CPM) CONST RUM[ON TAX
5ignnla�{c ofY pplicunt/Conlr-I `�'�) ��w1 I 1!XHAUST HOOD(W/DUC'D HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURI!
Will tile applicant or future building our,sausme orhandle hareashms mdenal HPAHNG UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Coco.Chapter 9.12,and the Ileullh and Salcly
Cade,Sermon 25532(v)'! HEATING UNIT(OVER I)DdMM)BTID
El Yes El No ('AID
V13N1'11.A'fION PAN SINGLE REST ID
Dem It
W fie air contaminants
inanmre defined by(lie er Bay Area Air Qat or lity Mees cuum, BOH.HR-COME(3HP OR 100,01)it IT)emit ict?hazardous sir<nmaminaots es Jufiocd by[be Itvy Area Air Duality Munvgunaem / TO
Drstda^ No❑Yn” BOILIR-COME(OVER HXF00I
It
❑
I have toddle hazardous materials reyuimmems under Chapter 695 afthe Cali- T
AIR CONDI'1'ONES ISSUANCE DATE
Ennfa Henl(h&SeCny Cale,Satinns 25505,25533 and 25534. underswW(hat If Ihe NEW RI1SHA N'HAL MECI1. SQ.FT /-7_ s�J
building does not currently have a tenant,that it is my respmsihiliry m no[ify'he occupant
ofthe reyuirenmmx whichnvm bemer priorm issuanceof a Cenificumof Occupancy. '-�"-'+�7'N
y
Owner lie submitted /
d agent Date 'OTA ISSUEDBY: ' L/
OFFICE