S 3290 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD PLUMBING
ME CTRlGA1• I FRp'T NO 3290
BUILDING DIVISION APPLICATIONIPERMIT PING PROJECT ICHANIFIC lV
BUIP.DINC.PROJECT IDI+NfIPICATION
BUILDING ADDRESS: ::NITARY NO. APPLICATION SUHMITTAL DATE
10080 Ewj% 1-,12-.-
OWNERS g
NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
jibi W A "0 N/C CONTROL it
RAcB,iTECT/ENGINEER: LIC NO � ADDRESS: ❑ 9 / 7
C�ACT PHONE: BUILDING PERMIT INFO
�! 1 O� �5Z_� V ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I nm licensed under provisions nl Chapter 9(cnnnnencing
OceZ with Smtion7W0)nf Division 3uf the Business anJ Professions Code,and my lkensc is RESIDENTIAL:
WOO PERMIT ISSUANCE
F•aI in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
Rua License Class
Lic.M APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE.PIPF
I.G0. Dam Commcnrz ❑MULTI-UNIT ❑STRUCTURAL
Dm
ARCHITECTS DECLARATION PANELS
F MODIFICATION
CZ4Z lundantmd my plans shallMused us Public remNs
OZ.-Z UI'T020NIAMPS C3 INTERIOR ❑CHIMNEY REPAIR
F4tcgq Licensed Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
gZ OWNER-BUILDER DECLARATION OVER I00IAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
at I hereby affirm that I am exempt from the Contractor's Livens,Law for the
iyS O L U following reamn.(Section 70315,Business and 1'mfessions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
m 3:,N which requires a permit to construct,alter,improve,demolish,or repair any somehow
`V,0 prinry its issuance,al-mquires the applicant 6rmehpenniuo Gleasignulsta¢meat SPECIALCLRCUIT/MISC.
;!(y that he is licensed pumnontto lheprolkions ofthe Contentoes License Law(Chapwrl)
SCC wommencing with Section 70kaBof Division3ofthe Businessund Professions Cale)or TEMP ME'I'ER OR POLE INST. COMMERCIAL:
q y m that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of a ❑NEW BLDGIADDD'ION [I DEMOLITION
IiX1 y Scotinn]B31.5 by any applicant to,is fruit subjects the applicant mucid pra ,of POWER DEVICES [I TENANT ❑FOOD SERVICE
t mote Non rive hundred dollars(S5110). IMPROVEMENT
Oas ownet of the property,or my maployces w iib wages as their sole compensation. SWIMMING POOLFLEC RIC DOTHER
will do the work,and the xmacrue is tet intended,,,offered formle(See.]W4.Business � A ^
mand Pmlclsioas Cade:The Cuntracm",license Law does not vpply v an owner of OUTLETS-swill I %TARES !n fY-.� J
propcny who Milds or improves thereon,end who docs such work himself ar Wough -
his own employees,provided that such improvements am am intended or,o@red fm NEW RESIDENTIAL IiLF.0 14.
sale.if,however,the building or improvement is sold wiNin one year ofeompletion,The SQ.Fri FLOOR AREA FT.
LSQ.
necbuilcam will have the burden of proving that he did not build or improve for pur-
ito.of vale.).
I,as owner of The Property,am exclusively contracting with licensed contractors to AL.
nrmwm Ne project(See.704q Business and Professions Code:)The Commove,Li-
nse Law does nut apply m an owner of property who builds or improves thereon,and QTY. P, G PERMIT FEE _
who contracts for such projects with a conlracmrl licensed pursuant to Ne Commctors
license Low. PERM . ANCE
1 am exempt under See .R&P C for this reason
AUMM-DR ENT- A) VALUATION
Owner -� � Dom � '
WO R'S COMPENSATION DECLARATION BACK FLOW P ICE O T
I hereby affirm under penalty of perjury one of me fullmving declarations: 1.1
I haveaM will maintain aCmifcmeof Consenuoself-insum for Workers Compete DRAINS-FLOOR,ROIF.A OND. STORIES TYPGCONSTRUCTIOt
mamas provided for by Section 37M of the Labor Cale,far the performance of the
737
ork for which this permit is issued FIXTURES-PER TRAP
I have and will nomemin Workers Compensation Insurance,as required by Section
00of the Labor Code,for Ne peifonnanccol'Ne work for whichad., mit ix issued, GAS-EA.SYS'TCM-L INC.4 OU'FLLTS OCC.GROUP APN
y Workers Conlpmestion Insurance carrier and Policy number are.umc Policy N,,: GAS-b?n.SYSTEM-OVER 4(EACERTIFICATE OF lIX17M[MON FROM WORKERS' G EA RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BU RING DIVISION FEES S
(This cairn need not he completed i flhe permit is borrow hamhed 6.11 0,Hall Ii TRAP Q PLANC ? ' � r
Q
nr tete.) J
I codify that in the performance ofthe work for which this pemrit i,issued,I shall >R_SANITARY-.'TOR .201
ort employ any person in any manner ar ar to Mromc mhjm m the Workers'Compete ENLRGY FTiE Z O
,Z soli,,.Laws of California.Date TER H. E /ELECTR GRADING PER
O Applicant NOTICE TO APPLICANT. I'
If,after making this Certificate of Exemption,you should WATER SYSTEMn RE IN
V) SOILS FIfE
Mornsh compo the Workers Compensation Provisions of themeed Labor Cale,you must
ai ti
forthwith comply with such provisions or this permit shall MdecTned revoked. RI. BE SERVICIi q O
I � z CONSTRUCTION LENDING AGENCY NEW RESID: R. .FT. I
Dae Recent tM
rt
I hoffi
erebyml thmthere isxamstruction lendin6 agency lnhpoman
e erfce of
{US.- Ne work for which this permit is issued(Sec 30G.Civ.C.)
O Lender's Name TOTAL:
U I.endees Addne,s GILDING FEE
'{yrs I cer ify that I have read this application and state that the above information is
al
fir U`) correct.l agree to comply with all city and coumyrrdinances and state laws relating to QTY. MECHANICAL PERMIT F SENMiCIVE D
U building cousimetion.and hereby authodue representatives of this city to enter upon The
above-mentioned Property for inspection pugrrnes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,indemnify and keep harmless the City of Culsrino against
liabilities.judgmem.costs and expenses which may in wry way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the sigumpli of in
APPLICA TU S ND. N f1 .L COMPLY WITH ALL NON-POINT AIR HANDLING UNI'f(TO 10.0H)CF1,11) MECHANICALFF.E
SDURCI3 RL "I S.
� 4A AIR HANDLING UNIT(OVER I(1,00(I CIT1) CONSTRUCTION TAX
Afwwre nliconVCont ter 7 Dam
EXHAUST MUSING MITIGA'L'ION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous Tmamrial HHATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Calc,Section 35532(a)7 HEAPING UNIT(OVER 101,0x1 BTU)
❑Yes YNn VENTILATION FAN(SINGLE RfSIU) PAID
/� Date Receipt a
Will the applicant ur forum buildingoecupam use equipment,,,devices which BOILER-COME 11HP OR 1(11,0IITU)
it hmurdous air contaminants as defined by the Bay Area Air Quality Management x1 TOTAL:
otria? BOILER-COMP(OVER 10.00 BTU)
❑Yes No
I have read the meridian materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUA CE DATE
forma Health&Safety Code,Sections 25505,M533 and 25534.I undersand that if the NEW RESIDENTIAL MECH. SQ.FC
building does not currently have a tenant,that it is my responsibility to notify the occupant 1/
.fine requirements which must he met prior,,,issuance of a Certificate of Occupancy. ?1
Owner rr authorized agent Date TOTAL ISSUED BY: �L
OFFICE