S 3239 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ✓
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMTF NO.
BUILDING.DIVISION APPIACATION/PERMIT PLUMBING-MECHANICALDIS 3239
BUILDING PROJECT IDENI'IF'ICATIIN
BUILDING ADDRESS: SANITARY NO. APP LICATIONSUBMITTALDATE
!29bl:35 C K �d h, cR g5ol5l 3,v ��
OW 'R'S NA PHONE C RA TOR'S NAM LIC NO:
• ✓` C/153-- Z II ' ,�tj NIC CONI'R(lLp
\RCHI'FF.CT/BNGINEE LIC NO. ADDRESS: ❑
atiunal Rve. . IL
way
CONTACT: PHONii: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMS MLCII
❑ ❑ ❑
LI ENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
WN Z I hereby uRirm"hal 1 am licrnxd order provisions of Chapter 9(can mencing DOB DESCRIPTION
F1ct with Sm"ian 7000)of Division 3 of,he Business and Professions Code,and illy license is
_ in fall farce andeB A PERMIT ISSUANCE RESIDENTIAL'
W UZI- License Cl Le.I s � l ❑SITWI. ❑KITCHEN REMODEL
yQd Dare Conwcin-1 S�trO APPLIANCES-RESIDENTIA[, ❑ADDITION 1:1 PLUMBING RE-PIPE
ARCHITECTS DECLA AFION PANELS
❑MULTI-UNIT ❑STRUCTURAL
Z O N,7j 1 understand my plans shall M1c uxd as pohlie reactors
0z O UPTO 2W AMPS MODIFICATION
F�n E'.LLD LtcenscJ Professmnel ❑INTERIOR ❑CHIMNEY REPAIR
Y � and I am exempt.R mDECLARATION
2o1dtg0AMP5 IMPROVEMENT C]SWIMMING POOLS
y hereby affirm thin 1 um exempt lion tM1u Contractors License Low for the OVER IOW AMPS ❑BATH REM��O�DE.�II�REpPAIR ❑DEMOLITION
x 3 o FV• which res reaysn.(Section]OUSE Business mp ve.de in li Cole:Any city or ancium OTHER u(,ptlea-
41 which i a I In consuuc",alter,int p y s SIGNS F.hECI'RICAL 4�
F LLO yWe
a rtqu res pcnhd prove,demolish,or repair any tm<hare
y..lprior ah its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUFUMISC.
y that he is licensed pursuxnun the pnwisions uf,he Contractors License Law OChaprer9 66111
SCO (commencingwah Section 70p)0)of Diviskm3 mfthe Businessand PndessionsCode)m TEMP.MUHR OR PULE INST. COMMERCIAL'
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [D DEMOLITION
1�IUCC11 k- Section]o.315 by any applicant inrn permit subjects the appliuimrn u civil pen:Jtyof POWER DEVICES
not more than Eve hundred dollars(SSW). ❑TENANT ❑FOOD SERVICE
< 01,as owner ofthe property,or my employees with wages as their sole cont IMPROVEMENT
f]Z=0 ,Busi less SWIMMING POOL ELECTRIC ❑OTHER
y� will Nothe time,:and the he Caro Le am intended Law dos snlc(Sec.,un a L exalr ser
63 anderty who
Col e:The Costhere's License Lowdcesnotapply himself or
OU'TLP.TS-SWITCHI35-FIXTURES
his..who builds or improves, ell and who dues such work dad un a "hough
his own cmployecs,provided,bat such impmvehhtcmn ore oat intended nr offered for NfiW RESIDIiNTIAL T:LF:C!'R SQ F1'.
sale.Il;havever,the building or improvement is sold within one year of completion,the SQ.FII FLOOR AREA S/SQ.FT.
mer-builder will have the human of proving that he did not build or improve for pun-
,,a of sale).
0 1,us(owner of the Pmlwr"y,am exclusively contacting with licensed contractors to TOTAL:
construe,Ne police,(Sec.700,Business and Professions Code:)The Cieductors Id-
se Law does not apply to an owner ofpmper,y who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who contracts for such pmjeets with a convacmr(.g licensed pursuant in the Contractor s
License Law.
El I arexemptunder Scc. ,B&PCfor,hixrtaxon PERMIT ISSUANCE
Owner
ALTER-DRAIN&VENT-WATER(EN
Doe VALUATIONWORKER'S COMPFNSgT1UN DIiChARA'TION BACK FLOW PROTECT.DEVICE r� t O
1 I hereby maim under penally of perjury one of the following declarations: J
L)Ihavoand will maintain aCenilicutenf Coreenl losclf-insurc for Wnrkcr'x Cmahn- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPIi CONS'INUCTION
arnica.as mmddcd for by Section 3]W of the Labor Code.for he performance mage
work for which thin permit is issued. FIXTURES-PER TRAP
�'1 have and will maintain Worker's Compensation,Insurance,as required by Section
of the lhabnr Cde,lot the pcRnmunce ofthe work for which this permit is issued. GAS-EA.SYSTE,N-I INCAOUTLE1'S OCC.GROUP APN
My wilCarrier:
[gp,cehsaulyty puce carrierold Nu.:nJt(nI5 X0001O'�
Cartier: (il.N'�.�1ATEO Policy No.: WORK R- GAS-EA.SYS'1'LM�OVER4 UA)
CEkTIPIC O OF SATION'IINN FROM WORKERS'
COMPENSATION INSURANCE GRF.ASFIINDUSTRL WASTE INTERCEPTOR
OThis section need not hecamplaed it the Cz.it Ix forms,hundred dollars($Ill,) BUILDING DIVISION FIEks
or IexsJ GRI:AS9'1'RAI' --
Icmifythininthepermannanceofld, ask for which Nis pemhit is issued,I shall PLANCHECK PEE
not employ any person in any manner sons o become subject.. he WorRan,Compen- SEWER-SANITARY-STORM EA.NOI FT. ENERGY FEE
Z sntivalaws OlCnlilla
'om .Data
Z O Applaud WATER HEADER WNEN'DELECTR GRAIN
it
G NOTICE TO APPLICANT:If,after making this CertiRca,of Exemption,you should WATER SYSTEMIFREATING
P'^ , became xam.,m,he Worker's Conhprnxaion pros Binns of the LoMr Cn le,you must SOILS E
fudhwith comply withsuch provisions or this formatshall be deemed revoked, WATI2R SERVICE
Q Q n
CONSTRUCTION LENDING AGENCY
r7. z NEW RISIDIiNTfAI.I'LMB. SQ.FF. PAID
rJ0 I herebywhich his
lhauhorelssued( ee30lending C.)agency for me Performance of Da tt ' tN
LL F he walk fur Which,his pacttit is issued(See.J09],Civ.CJ
O U Lender's Name
glI
Lenders Add, TOTAL.(y 1 certifyythin I have read,his application ond.uanhat the above information is BUI ARVEE
r.
Vt correct l agree to comply with all city and county ordinances and share laws releing t" QTY. MECHANICAL PERMIT FEE
UZ
r1- huildingenns0uchme,unit hcrebyvuthoriae repo,con tivesofihix uf"yocnler uprom SEISMIC
above-numahm ed pmpeny('in inspection pufrynn PERMIT ISSUANCE
(We)agree to ave indemnify and keep hamdess the City of Cupertino against ELECFRICFE, `s
liubil'nica,judgmen ants and expensesw Ich may in any way ncnue against said City g1.T1iR OR ADD TO MIiCH.
inconsequence, ego o thisp i, PLUMBING PEE. 1`
APPLICAN ,OF AN LY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,00p CFM)
SOU E .all ONS MEC HANICA[.FEE '
AIR HANDLING UNIT(OVER 10."CFM) CONSTRUCTION TAX
nawrc OfAloplitutdivaenoto EXHAUST HOOD(WNUCT)
HAZARDOUS MATERIALS DISCLOSURh HOUSING MITIGATION HE
Will meapplicant nr future building,vOtal.t,suns,or handle himadem,notarial HEATING UNIT CFO I0C.000 BTU)
he defined by the Cupertino Municipal Code,Chapter 4.12.and the Health and Safety
Code,Snctlon 25532(x)'! - HHATINGUNIT(OVER I01i BTU)
❑Yes El No
VENTILATION FAN(SINGLE RESID) PAID
Wilt the applicant or future building Occupant use equip acini or devices which Date Receipt g
emit hummnus air roniv„inants is defued by the Bay Area Air Quality Management
BOILUR-COMP(-3H1'OR I(XL000)BTU)
District? 4:
❑Yes ❑Nn BOILIiR-COMP(OVIiR IW,gO)BTU)
1 have mot W hamrdous materials AIR CONDITIONER ISSUANCE DATE
tryuimmenn under Chapter
Health n Safety Cods,.Sections 25505,25533:mJ 255]4.I undemanJ Na if,he NEW RESIDENTIAL MECH. SQ.FT.
ofthengdcesnents which nmoilly
ale matt ori of ismymsp,msibdificano"ify,he xoncy.m 3— � O /1
of,he requirements which mail be con pdonn issuance of a Cenilica"e of[kcupancy.
Ownuf in.Ihofiecdagen, Done 'TOTAL: ISSUED BY:
OFFICE