S 3240 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL OINT PEN ONLY
CITY OF CUPERTINO ntnLDmc- .d lRIC'AL I'E RNO 3240
BUILDING DI VISION APPLICATIONIPERMIT PL11Mnmc-n1HC11AN1cA1.
BUILDING PROJECT IVINTIVICATION
BUILDING ADDRESS.. SANITARY NO. APPLICATION SUBMI'TT'AL DAT f:
OW BR'S AMI:: PHO E: Cc NI'RACfOR'S NAME: .IC No
e Q - NIC CONTROL#
SRe layx
s ARCHITECT/ENGINBEN: LIC NO: ADDRESSo V O ❑
I .1-714
e
CONTACT: PHONE: BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME MECH
oa ❑ ❑ 19 ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby alarm Nm I am licensed under movLdons of Chapter 9(cmnmeneNg J013 DESCRIPTION
MW rXOzO with Smfion7INlosdDivisior3nl'Ihe Businessanl Prorcxslonscade.and my licensees L:RESIDENTIAPERMIT ISSUANCE
FF��F in full farce and cll'ect. �y'T I ]�/: ❑SIUWI. El KITCHEN kEMODEI.
N6W Datente— Clontrac0-1 J -1 APPLIANCCS-kl!SIDEN'flAl. ❑ADDITION [I PLUMBING RE-PIPIT
ARCIIITELTS DECLARATION ❑MUI.TI-UNIT ❑STRUCTURAL
F.O w PANELS
y O N 7,. I undern:utd mY plans sh:Jl he used as public records MODIFICATION
OZ�O IJP TO 2tN)AMI'S ❑IN['PRIOR ❑CIIIMNF:Y REPAIR
F��YI Licensed Professional 20141000AMPS IMPROVEMENT SWIMMING POOLS
G �-4 OWNIiR-H1111.DF.R DF.CLAHA'fION PjkBR 0 'O
�' Q I hereby affirm that 1 am exempt from Ne Contractors License law for the OVER 1000 AMPS ❑ AHE RF1.10D1G'LtJRF,PRI feIk DIiMO.[TION
D.O d-) following....(Section 7131 5,Bnsimess and Professions Cade:Any city orcounty SIGNS ELECTRICAL OTHER _yam L
LLO Ha which requires a permit to construct,alter,improve,demolish,or repair any structure vyw II
rn.] prior to its lssmume,ale requires the applicant forsmch permit to flea signed statement SPECIAL Cl RCIJ I'T/M ISG
rte} Etat he is lientsed pursuunun thapmvisione of Nc Cnntrnctnr's Liwnsc Law
Ch is 9
�ap0 (commencing withSeclinn]IXNpol Division hl We Business and l'ndesdso Code)., 'I FIVE.MEI ER OR POLE INST. COMMERCIAL:
a that he is eo m n therefor.add the hasis for the alleged caemptioa.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicam for a permit subjects the afflicanfto a civil Penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
do
tLad d thinfvehundor dollars($5W). IMPROVEMENT
S6 1,as covamol le Propeny,ormy employees with w.,,tetheirs"Ic ammpenselion, SWIMMING 1'001,ELECTRICg..0 will do the work,and lhend
truare is not intended or offered for.sale(See 7144,nosiness
❑OTHER
5C and Prnfrtrsinos Cade:no Contractors License Law dnev not apply Io an"wall of OUTLETS-SWI TCHES-FIVI'1JRHS 00
property who builds or improver Ihercan,and who does such work himself or through
his own employees,providM that such improvements am not intended or od for NEW RESIDENTIAL ELECTR ET ,
.
ale.If,howlver,the buildingar improvement is sold withm,heyemofcompinffereion,the SQ.FT.FLOOR AREA SISQ.IT.
ownumbridder will have the brassard Proving dem he did me build or improve for par-
Pose of sale.). ,A
❑ I,a nl dee PntpertY,n wdusivelY cnnanrting with Ilwnsul nmtrmrors to
rtw rad heespmjwt(Seo.7144,Ba,awls and Profession'Co.., h.Cn ootars L-
muse".does fiotupply 1.anownerofpmpeny who builds or impraves llmcamn,and QTY. PLUMBING PERMIT
whoenrnrams fursuchprojects with amour do(r)licensed pursuant"+the Contractors
License Law. PI7RMIT ISSUANCE
1 am exempt under Sec. .B&P C f ar his reason
ALICE-DRAIN&VENT-WADiR OUG VALUATION
Owaer Dale
WORKERS COMPENSATION DIiCLARATION BACK FLOW I RCUECT.DEVICE �� ^ G ly
Ihcrebyaffam order parelOof perjutyore-1'the following declinations: / o /
❑Ihavc anA will maintain uCcnificamof Consenunself-insure for Wnrkcr's Cumpen- DRAINS-FLOOR,ROOF,AREA.GOND, STORMS TYPECONSTRUCI'ION
scion,as provided far by Section 374 of the Labor Cade,for the performance of the
work far which this Permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workmi Compensation Insurance,as required by Section
3700of line l't n'C"de,fnrtheperl'"rnenceofthework A)rwhiehthls Perntitisissued. GAS-EA.SYSTEM-1 INC.4 OU'I'LEI'S OCC.GROUP APN
My Werke . YRlpyf yy JqAI pp «eurlermid Policy�uipllej u(q,�,, a
Cartier. KIyI1Q8/b Policy No: 'IKn-IOIOIC GAS-EA.SYSTEM OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFANDUSTNL WASTE INI'IiHCEPI'OR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(Miso,mian aced nm be co.ii,doediff,,,cnnil is f rmuchindemdolla,($100) GREASETRAP
or less.) PLANCHECK IIB
Immify Nm in lhcperfonnancradian work far which this pantie is issued,]shall SEWER-SANITARY-S'IOIiM nploy IIA,2110 PI.
Bol atiny person in tiny manner m so as becnnle sah)eel to the Wokcrs'Compm- ENERGY PEE
O z smon Laws of Cnheriona.Date WATER DENIERWNENf/ELECTR GRADING FEE
z 0 Applicant
ti NOTICE'11)APPLICANT.IL after making this Certificate of Exemption, should WATER SYNI'IN- eCREATING
PnN-t hemire added land Workers Cnntpcmamon prowetin,"f thm
e Labor Cnde,you on SOILS FEB
W forthwith 1,with such provieluns arias Permit dnll he deemed revoked. WATER SERVICE
Q
CONSTRUCTION isaON LENDING AGENCY f NEW RESIUIiN'1'IAI.PLMN. SQ.Irl'. PAID
'7O Date Receiptp
1 hereby ch bi that is aed Vice.construction0 lending l a6ency for the Performance of
the work for which this permit is issued Vice.3097,Civ.CJ
fL U Lenders Name OTAL'
C.7 Ixnders AJJress TOTAL:
Lkl I certify Nut I have read this application trod sem that the.have inlisnnmiun is li 1. FEE Ll IM
hmromt.latest m comp],with all city and loamy online ces and sem laws mlodmg ur QTY. MECI IANICAL PERMIT
U 2 building construction,and hereby amhnrim m1m,cnmdves ofthiscily to emeru"Ohe SEISMIC FEF.
F-t above-mentioned p.,n,for inspection purposes.
(We)agree to save.fidemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE. gaff# lull
liabilities,Fdgmmdv,c :m and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. IPL
M2!ZX
PLUMBING RTE
ADNO, LY WITH ALL NON-POINT AIR HANDLING Uhl10,000 CFM)
MIiCHANICAI.PFJ?
AIR HANDLING UNIT(OVENIQ(NNCPM) UCTIONTAXSi aruof , tsCmn Date EXHAUST HOOD(WIDUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
W III the applicant or foam building occupant smrc or handle hamrdous andmial I[EATING UNIT TO I00,000111'U)
as defined by the Cupertino Munielpel Code,Chapter m.12,and the IIeNh and Safety
Code,Section 25532m)p HEATING 11N11'(OVER 100,000 B I'U)
E]Yes ]Nn VENTILATION FAN(SINGLE Rp_SID) PAID
Dore Receipt x
Will the applicant or furore building occupant use equipment or devices which
emu hasnrdnux air contaminants as Defined by the l3ay Area Air Quality Management BOILER-COME I3BPOR I0Bt11NIHJV) TO L:
District'!
❑Yes ❑No BOILER-COMP(OVER I(NI,IXNI In'Dp
AIR CONDITIONER
I haveHealth
mud the acidulous STs i...neutron requirements under .I mol homy of the Cali- ISSUANCE DATE
foredo gdoes&aSafetyct
Crile.Sections 25505.25533 and 25534.1 ur nifin std Nal Late NEW RESIDENTIAL MECH. SQ.IT. ^(
building Dons nm currcndy hmeelenan6 that it is my tnrymsibilitymnotify the ocsvpam A
of the requirements which must he met prior to issuance of a Cmificgte of kcu /�1 Jy!p
�Ii-
Owner or umhnrimJ.gem Dam IOTA)^ ISS ED BY:
OFFICE