S 3289APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - Mf:CHANICAL
BUILDING PROJECT IDENTIFICATION
PEI�ITNO. 3 2 8 9
`v
BUILDING ADDRESS.
054,:) Deoda--c1- Dnve �e��u CA- a�i4
SANITARY N0.
APPLICATION SUBMI']']At, DATE
OWNER'S NAME I • PHONE
W✓l (0 fi VCht3-U37�
CONTRACTOR'S NAME LICNO'.
mei /iatllC�e�
NIC
❑
covrRul.N
AHCfII'TECTIIINGINI31?H: LIC NO:
ADDRESS:
CON'1'ACC PHONE:
❑ Consultant Fees Paid Iry Applicant (Initial)
BUILDING PERMIT'INFO
BLUE ?LIiCf PLUMB MECfI
❑ ❑ ❑
LICENSED CONI'RACE R'S DFCI,ARAT ION
I beery athan that I am Econ. n trade,pm,kiona of chapter 9 (Ornament,
wrhScale. 7(XX))al Uivi,inn doll he liu,ioc,, I Prol... ion, Code. are On, l iccnse,,
infulllineanddTca.
DateClass Lic. N
O:uc Conu'uclor
Q'TY ELECTRIC PERMIT FEI;
JO D . CRn TION
Rle TI
' wh ❑ KITCHFLUMBIN RF PIPE
❑ADDITION ❑PLUMNING KE -PIP(?
❑MULTI -UNIT ❑NTRUCTURAI,
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMHHT (] SWIMMING POOLS
❑HATH REMODEIJItEPA1R ❑DI'sMQ1.ITIQN
❑ OTHER
PERMH ISSUANCE
AI'I'LIANCES-RESIUUN'I'IAL
ARCHITECTS DECLARATION
I unJcaumJ my plan.,b,dl lv: uscd a, public records
PANELS
UI'TO 200 AMPS
Licensed Prof ..innal
OWNERBUILDERDECLARATION
1 hereby affirm that 1 am exempt from the Contract,,,', License Law for the
following mason. (Section 7031.5, BL3,incx, and 11 O, ion, Calc: Any city ser creamy
which renins apeman m,oroom, alter, improve, Jetmlish, or repair any sauaure
prior m it, i.,..ancc. ahnrcgmire,fica,plicantfor such pennh to E de a aigned swlcnu7m
Nut he Is licensed pamoate m the pmvieionv of the C,,m... Our', License law (Chapter 9
(commencing with Section 20XXp of Doi.iar 3ofthe Bmirii and Pm(eoions Codr)o,
that he is exempt the chem and the brat. for the :Jleged —option, Any violation of
Section 7031.5 hyany applicant for alarrio mbjeav the applicant a civil penalryuf
m than Fve hundred dollar, ($500).
❑1. aro owner of the property. or my employees with wages as their safe compensation.
will do the work, and the structure is not mended or offend I', nolo( Sec. 2044, 11
racr's Loensc Lnw Jots nut apply it, a til'
and Profcs,in is C'alc:'1'he Co., m
pmpcny who Wild—, improves Ibemon, and woo drcs such work himvd! ser through
Itis own cr,pWycc,, providal than Intl intpnwanenI are not imendcd nr ofl'eal I'mr
sale. IL however. the buiWingor improvement is wild waturoic yearof completion,
e -builder will have the burden or proving that he did not built or impmvc for par -
Jose of staled.
Ej 1, as owner of the property am exclusively butra ring with licensed cmnmaon m
nmsnuct the anice, (S,O.2194, Businos and Pmfe„loos Ced,) the C..mmmer's Li-
mLaw does not apply to an owner ofprnpcny who builds or impmvc, mcrton. and
who comrade for,ach pmjml, with a emtmctugs) licensed punmunt to the Contractnr'x
License Low.
❑ I am exempt under Sec 1 B h P C for this reason
201-10(MAMPS
OVER ]III
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TIIM P. MI?TER OR POLE I NS' T,
MMFR 1 I: y
❑ NEW BLDG/ADD '10Poo MOLI' N
[-1 TENANT ❑FOODSERVICE
IMPROVEM17NT
❑OTHIiH
N)WER DEVICES
SWIMM INC, IY IOL ELECT
OU'H-E'1'S-SWI'TCHIS-F
NEW RESIDEN'I'IAl. 1?Lli...lt Q FI'.
SU. FT. FLOOR AREA 9SQ. IT.
0
nD
UTI
'I'OTA I,.
QTY. PLUMBING PERMIT FEI:
PERMIT' ISSUANCE,
ALI'UR- DRAIN & VENT -WATER (EA)
Z
_
Net
WORKER'S .altyof rB ON DECLARATION
1 hereby penalty of perjuryorteoftheiroar, f.. W kee,C..:
andwal maiirm ntain in.ore for Worker's Compere-
I]Ihave uu, WllDna.nulneC...037meol Go Lobo, Cod
Anion, a, pmvidcd I... by Sm... J2fM1 til Nc IaMu Cala for Ihe 1xRnnnunec of he
work forwhich till,permit i, orker
37 1has und Lawill n e. for Wurkcrn taneo hew work,h hi%pertlby S,11 11
which
3700 My Wifthe l�oTCrde.fnnhepedammneer and Polk liawhichthispermiti. issued,
Myler: ,Cantpenaminn Insurance cnrtierand1'No,: mmmhcr um:
Cnrricr: Poficy Na.:
CERTIFICATE OF E%EMFfION FROM WORKERS'
C0I I'ENSAGON INSURANCE
(lTis uetionnttJ not rte completed if the pemrit is for one handrail Jolla(51(X))
nr le"')I'hANCI
I certify that in the pstfrmanceorthe work tin which this varmt is issued, Ismail
not employ any peso in any minerso as to became wbject On the W'n k,,, ComMn-
satins Law, of Calinnea. Doc
Applicant
PACK FLOW PNQI'I?CI'. DEVICE
;
UItAINS - FLOOR, RUOP,ARBA. COND.
vtnglp5 'TYPEC'IINS'I'INC'I(IN
FI%TURF"_S-1'F;R TRAP
GAS -IiA.SYS '1'EM- I INC, 40UTL1!T.
OCC GROUP APN
GAS -13A. SYS I'1?M-f IVLR J (BA
GRI?ASIYINDLjSr,Z. WAST' TIINCEPIfIR
BUILDING DIVISION FEES
GREASETRAP
HICK Fl?IC
SEWER - SANG' -STORM EA. 200 FT.
FAERGY FEE
WATER III? R WNIiNT/HLECI'R
GRADING PEE
N(JIICE TO APPLICAN, 11, after making this COO Vicom of lixeniptian, yet should
become subject to the Worker's Compensation provisions of the Luber Code, you must
RrlInvuh comply withs.cb pon,monsonhis pemrit shall he deemed rr,ok,d.
CONSTRUCTION LENDING AGENCY
I herchy affirm l he Thee is aanutroctiun lending agency for the l,,I mace'l
the work Iia which thio permit is issued (Sec. 3092 Civ. C.)
Lcni Name
WA'I'Elf S'TEM/IAIIA'IINC.
W iR SERVICE
SOILS FEL'
PAID
Dam Rariptp
iiNEW RCSIUENNIAL I'LMH. SQ, HE
'TUTA
TOTAL
Leaders Address
L:
BUILDING FEE
1 henify that I have read this application and nme that he above information is
ma, l agmc in comply with all city and conmyordinerrns and Aare laws refill", "I
building nmatmction, and hereby authorize npmsenatives oohiv city n, corer uryn the
aMrve-menlimed pmpeny for inspection pnrpuse,.
(WO) agree to saw, indennily and keep harmless the City of Cupcnino against
liahilities.judgracmts, costs and Oxpcn,c, whicb may in any way accmc against said City
tscyucnce if gnome” of mi, pcmnln
API`LICANT' UNDERSTANDS AND WILL COMPLY WITH ALE. NON-1.OLNT
SO KCIRFGU1 54LATIONS.
C I—� _a
Q"1'Y. MECHANICAL PERMIT' EE
SEISMIC FEE
ELECTRIC PEE
PERMfr ISSUANCE?
Ald HR OR ADD T) MITCH.
PLUMBING FEE
AIR HANDLING UNIT TO 10.000 C)
MECHANICAL FEE
AIR HANDLING UNIT (OVER XX)CPM)
)
CONSTRUCTION TAX
i,nualo, 61ApNiamdCnt mete. V m
HA%ARDOUS MAdFRIAIS DISCLOSURE
Willlbc:Iapncmt or fmun:holdin,ucuupad vom m anndlc ha'rardous naredaf
as defined by the Cupertino .Municipal Code. Chapter 9.12, and the Health and Safety
Coda Scainn 25612(a0'/HEATING
L] YO,
Will the upplinuu m tonne building occupant use cyuipnmm nraleNwince
x mit buxarJoua air comamimm�s m ddincd by the Huy Arm Air Quality Ma..nagenmm
Diana'! /
E] Ye" t^i/
I Intro mad the hvuNouv mweiulc to under Colt 6 95o the Coli-
reyut ar
Ratio Health h Safety Code, Section, 25505.25533 and 25534. I understand Ihm if the
buildingdue inlet ndyhavxaenol. hunt isn.,,aibil ily leli fy it, occupant
oft -ny ire nownicn mu.be ama pilot to i.auanery mpora eennga ....
etpp y
/ / G
E%HAUSI' 11000(WA) )
14OUSING MITIGATION GdE
HFAPINC, UNI 'I'('I 1.0)111ID
UNIT )VER I W,(XX0 B U)
Or
PAID nc Beery, D; -
e
\'ENfILAI' N'PAN (SINGLE RF_SIU)
Boll. 5K- CONIP IJHI' OR 100.000 NTD)
TOl'AI:
BO .ER-COMI'(OVER 1040X1 B'I'U)
ISSUANCE DATE
ISSUED BY:
AIR CON D TIIGNIiH
NEW RF,SI DENTIAI, MITCH. SQ. IT.
'TOTAL:
. wnum.ud agem Orae
OFFICE