S 3268 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY •
CITY OF CUPERTINO RUILDIN;-ELECTRICAL. PlItIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBNG-MECHANICAL �J 3268
BUILDING PROJI?CT IDENTIF'ICATIUN
BUILDING ADDRESS: �� �� e0) SANIFARY NO. APPLICATION SUBMITTAL DATE'
OWN N hIT �- /( a_L N PHU h. 1{WJ$`$C..f��ORR'SNA ,.+,_n// �� 1�.fxy'r��/'J��] NIC CONTRUI.p
ARCHITEC'EIIIEENNNGINEER: /��a i LIC NO: AUp /W 1 /4&re O `�/ lam^^r
CONTACT. ,Ptd/rONE: / BUILDING PERMIT INTO
eL Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
dy0000 '
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LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby intimi that 1 ran licensed under provisions of chapter v(commencing JOB DESCRIPTION
DYZ with Section]1X0)of J ft a emacs and Pokesioa me.ane my license is RESIDENTIAL:
WOO ys ^� l� /' PERMITISSUANCE
F�.. mfull forces -1 STOAT, ❑KRCHIiN REMODEL
�UV I.rem,Class APPLIANCF'_S-RESIDENTIAL ❑ADDITION O PLUMBINGRE,PIPE
v a a Dme contrecmrLI
ARCHITECPS DECLAR ION [I MULTI-UNIT ❑STRUCTURAL.
Zpr7/sZ [rude smndnry Plans shell W rood aspubllcfcerads PANELS MODIFICATION
UPT0200AMPS
O Z,.p ❑INTERIOR ❑SWCHIMNEY
NGREPAIR
POOL
Licensed Nofessional IDI-IgOAMPS BATH R IMPROVEMENT [I DEMOLITION SWIMMING POOLS
SYS; OWNER-BUILDER DECLARATION OVER 11X10AMPS [:J BATH REMODEf/REPAIR ❑DEMOLITION
S C W Q I hereby affirm that 1 am exempt from the Contractor's Ca License Law for the
XaX06U following reawn.IScdion'lol LS.Business and Fiofessinm Code:Any city or emumY SIGNS ELECTRICAL ❑OTHER
W 3 C,y which requires it permit to construct,aheq improve,demolish,or repair any swmum
OQ prior to itsissuance,also rectal res the applicant for such permit m tile a signed statement SPECIAL CHUG IT/MISC.
s�}'( Na he is licensed pumuanuo ihepmviointr f the Contractor's License Law(Ch.111,9'IW
�1�00 (commencing with Section B)ofDivision Jofthe Businessand PrET
Professions Code)., TEMP.MER OR POLE INST. COMMERCIAL'
I y e C that he is exempt merchant and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section 7031.5 by any applicant for a ryrmnsubjece,the applicant to a civil Penalty of POWER DEVICES
r r�
not than five hundred dollars l33W). []TENANT Cl FOOD SERVICE,
h Z_} IMPROVEMENT
^�- Q I,as owner of the propenR nr my enrployeea with wager us thtir...renmpenmriun, SWIMMING POOLE
will do the work,and thesbvetare is not intended or offered l'orsale(Sec.0H44,Hmaineaa ❑OTHIiR
Wm pod Pmfecsioa Calc:The Comancon's License law des not apply to an owner of OUTLETS-SWIl'CHES U
progeny who builds or improves Neter,and who does such work hlmsclL of through
his own employees,provided mariner improvements arc not intended or offered fin NEW RESIDENTIAL,ELHCTR
sale.IL howev,the building or improvement is sold within one year of completion,the
SQ.FT.I7LOOR A REA $ISQ.IT.
wntr-builder will have the burden of proving that he did not build or improve for pur,
puss of su1c.).
I,a owner of the property,am exclusively contracting with licensed comments er IO A
cam uct the project(Sec.7044,Business and Professions Cedep The c-camo as Li-
ase Luwdoes not apply to ua owrerot pnspeny,who builds or impnrvestherco.,and QTY, PLUMBING PERMIT FEF. /(\\
who contacts for such projects with a contremods)licensed pursuant o the Cnntmemr's D
License Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&V IiN'I'-WATER(EA) TI
Owner Dam
WZIU
WOR KER:S COly al IT TI in DECLARATION HACK PLOW PROTECT.DEVICE JUL
N (hereby vff nn tender pcnuby nfperjury tine of the folhnving Jcdnradonc
ehave prowled main mi na37am of the Latin,
for Workers Comp em DRAINS-FLOOR.Rp)I',AREA,COND. p.¢TOklps TYPECONST CIION
.I semen, r provided for mi Section,kcr 3]e,)of the Labor Gds,for the performance of the B
work for which this permit is issued. FIX'T'URES-PCk l'RAI'
�{fhave and will monmin Worker's Campeactime Insurance,as reqcti
uired by Seon
�7lmrT+Ae latraC de, the peffunnunceoftheworkforodichthn>pemmisj'ssevil GAS-IiA.SYS TEM-I INC.4 OUTLETS OCC GROUP APN
My WodcWWyy99I n I r c :ted Policy"ft ?/
Carriee�lll I,niky No.:IC(_ ,/ GAS-EA.SYS'I EM.OVER 4(17A)
CERTIFICATE OF F.XEM ION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE IM'ERCEPfOR
IIl11LDING OIVISI(IN FLES
(This section neat not re,completed it the permit is Intone hundred dollars(E H0) GREASii TkAl'
or IessJ PLANCIIIiCK PER.
leenifythtt in thelixiomrunceofrhe workforwhiahthia permit nivaed,Lthall SEWER-SANITARY-STORM IiA.210 IT.
not employ any person in any manner so as to become arbiter to the Workeri Comlwn- ENERGY FEE
z ,Z surto.laws of Cilima ie Date WATER BENNER WNENP/ELECTR
O Applicant GRADING FEE
IA NOTICH1'0 APPLICANT:If,after nuking this Certificate of Exemption,you should WATER SYSTEMOREATING
a ; become subject to the Worker's Compensation pmvisinn.e el the Labor Code.you must SOILS FEE
(71 ti Forthwith comply with such pmsisionsmr this permit shall M deemed revoked. WATER SERVICE
as CONSTRUCTION LENDING AGENCY NEW kESIUIiN('IAL PLMH. SQ. PAID
Z:) z Receipt»
I hereby alRrm Na chem is a construction lending agency Ibr the performance of
L) tll� he work for which this perosit use..ed(Sec.3097.Civ,C.)
0 1<ndds Name
re 'romkl:
W Lanacr's Address
'TOTAL:
1 cenify that 1 have mad this application and state un 'he above information is BUILDING
r
r)&I commit.I agree m comply with all ciry and county ordinames and stem Law,relating In QTY. MECHANICAL PERMIT FEE
Z bakingcomwmiourand hereby aumorim repmwarnie.a.f9discityeenmr upon the SEISMIC FEE
above-mentioned property for inspection pugwses. PERMIT ISSUANCE �/�
(We)agree to save,indemnify and k� less the City of Cupertino against s 'I V ELECTRIC NEIi
liabilitics.judgmems.costs and expenses ichor any wey accrue against said City ALTER OR ADD TO MIiCH.
utast mf rhe Rooming of this it. PLUMBING FEE
coan n)
NT UNDERSTANDS I W OMPLY WIT14 ALL NO DINT AIR HANDLING UNIT(TO IH,(XX)CFM) MECHANICAL ITTE
5 RCHI EGULATIONS.
7 . AIR HANDLING UNIT(OVER IB.UUBCFM) CONS'IRUCTIONTAX
Signemm of Apph. nnDem EXHAUST HOOD(W/DUCT) HOUSING NO I'IGAT[ON PEE
HAZARDOUS eb MATERIALS DISCLOSURE
Will Ne applicanrorfawm building«supero smmmhanJlc hassrdouz metrial HEAPING UNIT GTO 100.000 H'I'U) LTJ
us def and by,the Cupet in,,Municipal Code,Chapter 9.12,and the health and Safety
Cafr,Section235J21a)? ,,,,�yyyy THAI ING U N I'f(OVER 100,000 BTU)
❑Yes /, VENTILATION FAN(SINGLE RFSID) PAID11 Date Receipt»
Will the applicant or future building rscupam use equipment or devices whish
01 emit hmardous air conuminp(rrsa defined by the Bay Ams Air Quality Mmugemem
BOILER-COMY(3HP OR IW,(XO BTU(
Distrrcf! I/�� TOTAL:
❑Yes ❑Nn BOILER-COMP(OVER IW.g10 BTU)
AIR CONDITIONER
I have mad the Intersects materials rageimmem under Chapter 6.95 of the Cali- ISSUANCE DATE _
forms Health&Safety Cale,Sections 2551Jf 5533 and 25534,1 understand that if me NEW RESIDENTIAI,MECH. SQ.FC 2-
is
brume not cunneadyh.vea/en.1. (�smy rexgmsibilitymnotify the wcupam C- /
of the ii air tncnu which mal h4ua d r to rsmarrc of v Ccnifcate�(y^./yP�/�n�cLY�L
Own uthn sed agent -,ILD tS e TOTA.: Z c ISSUED BY:
OFFICE