S 3168 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..PT,ECI- ICAL PER rr ND.
BUILDING DIVISION APPLICATION/PERAIIT PLUMBING.MECHANICAL 3168
BUILDING PROJECT IDF,N'1'IF'ICAI'ION
IIUILDINGADDRESS: SANIT'ARVNI AI'PLICAI'IONSU[iktlTTAI.VAI'p.
�
OWNER'S o/NAMIi. 1'IIONIi: r CONTHACfI)R'S NAME: LIC NO.
C(INfROI.a
A ( J
• gNCHIIiCT/IiNGIN1iER LIC NO: ADDRESS. ❑
CONTACT': 1-110NIT BUILDING PERMIT INFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT I'LUmB MECH
LICENSED COMfRACTOk:S DECLARATION QTY ELECTRIC PERMIT FEE
1 nereny arhrtll alit b am licensed aNer pmvi,mn,nrenapter y commencing JOB DESCRIPTION
Z with Smion]IXpl of Uivisinn3nl thellu.,ines,and Pnslesaions Cede.aN my licemei, RFSIDENTIAL:
,00 PERMIT'ISSUANCE.
FEWin full term ani,cBat. ❑SI�DWL ❑KI'fC111iN HL'MODLI.
a U F License Clan Lie.p
Q U AI'I'LIANCIiS-RESIOIiN'I'IAL ❑AUDIT'[ON ❑PLUMBING RI}PIPIT
H Z W Dam Contractor
H G tL ARCIiITLCI'S DECLARATION ❑MULTI-UNIT ❑STRUM URAL
PANELS MODIFICATION
p Z in
zoinz I undetsmnd my plans shall h used a%public recoNs UP TO 204 AMPS
[I INTERIOR ❑CHIMN17YREPAIR
F�~II Licensed Pmressiowl ](H-IgX)AMPS IMPROVEMENT I]SWIMMING POOLS
OWNER-BERLDER DECLARATION
a '4 OVER❑o0AMP$ El BATH RfiMOUli1JREPAIR DEMOLITION
%OwQ I hereby ulfnn Nal I arta exempt trona the Corinidars Lineae Law fir Oho ❑OITEH
3,F Ibllnwing mnnon.(Section)U11.5,liusincss:uul Vndissipns COulc:Any c'ny lar con^tY SIGNS ELECTRICAL �]
yoo Q which requires a Permit m coldral,alter,improve,drulOi,b,or repair any vtruclum �X
I_-EE-pJ poor to issuance.also requires lheappficam far such pernolw Rle.,ignedstaement SPECIAL CIRCUIT/M ISC.
M7that he its licensed pursuant m the provisions Of the Contractors license Law(Chapnn9
lay.0 pO (commencing with Section 7")of Division J of the Business and Professions Cidc)m TI'.MP.MISTER OR POLE INST. COMMERCIAL:
M 0.c C that he is exmnpt therefrom and the hasis for the alleged exmnption.Any violation of ❑NEW BLDG/ADDITION ❑Ill?MOLITION
k m W Seetlon 9011.5 by may applicant fur a pennit snhjeets the applicant to a civil penalty of PDWER DEVICES ❑'I'hNANT [:]FOOD SERVICE
W^N notmnrethanlivehundmldollam 15510).
�Z6 [,as owner of the norm Ioces with wines as thcirsole cont lain, SWIMMINGP(IULI!L1IGTRIC IMI'ROVIih11iN'1'
Q props. c Yogi Y a Pepsi ❑O'I'LIER
F will domefir,,..,and thes a Course
inExemse Law
do for sal ioploy mm o limitless
and Oy.hiob Cite:The Coil airs ..it w law Jas not apply to a i Owner of OUTLETS-SWITCHIS-IBX'fUR
his o ny who e,mes,or improves therein,and who does such work deedhimor or through
his own employeese provide)That such impris sold w thin not intended or affered for NEW RGSIVF.NTIAL Ii1.liC1'H SO 1' SQ IT.1'L(IUR AREA S/SQ.IrI'.
ovine,however,lM1e building oun nap t rn, she did Gal b iyear 01 improve i cr-hullJcrtwill huvcthchunlcnufPnrvingthmhcJidnmbuilalorinapmvcLnPur-
P�,.enrxme.). rarnl
❑I,as owner of the property,tan exclusively contracting with licensed contractors to
met the project(Sec.9044,Business and Pmfe,sions Cwlu:)The Contractors Li
me law does nm apply to an owner of property who builds or improves themon.and QTY. PLUMBING PERMIT FEE
who contracts fir such projects with a caricaturist licensed pursuant o the Conwood%
License Lt.. WWNHNJdB.H=
'r ISSUANCE OE] I am exempt under Sec. .13 A P C fir this reasn
-DRAIN h VONT-WATBn(EA) VALUATION
VWORK- COMI'IiN,j.,al LIE me folk I'llN IL(lW PH(YI'ECT.UIiVICI?1 herebyill in i under penaltyof perjury one of the fn%uming da ker's m❑IM1avc and will mtinminaCcrtifc:ecu(CnnxnunsclGimum forWarkcrsCimpen- S-f1WR.H(1O1�,ARIiA.GOND. gpORD�S TYPECONSTRUCI'ION
cation,m..wiJed for by Section 1]1X)ofte Labor CNe,for the Acro m i of thewnrk for which this permit is issued. H6S-PER TRAP1 have land will Inaimuin Worker's Co..l'usalami Insur:mce,as required by Section
191XIo1'the Labor CNe.frthe v,li..... 1c ftbu work for which this perm,,ix issued. EA.SYSTEM-I INC.4 OUTLETS I OCCGROGP APN
My Worker's Comen,ation Inmmuee artier and Policy mother arc:Cartier: Policy No.: ITA.SYSTEM-OVIwR 4(EA)CERTI KATE OP EXEM TION FROM WORKERS' IVINDUSTRI.WASTE INTERCEP ORCOMPENSATION INSURANCEIIUILUING DIVISION RB5(Thi,w,ionnad not be eomplered ifthe pennil is forone hundred dollars 1511X11ETRAI' I'LANCHECK hilior less,
Ioyay,b:n...in perfinnanccnl workwlt Nispcnnniswcwcd,Lslo- -SANITARY-S'IXIRM 8A.21X1Irl'.nal employunY person in onYuumarxo us to M1ecomesubject m thinWorkcr,iCwnpmt- IiNBRGV I ?liZ saion Lawsof California.Ilene BEAT WNWNHNJdB.HCTR GRAVING PER.
ZO Applicant
NOTICE TO APPLICANT:IL after nuking this Certificate of Exemption,you should WATER SYSTENUTREA'1'ING SOILS FEE
1'^ ^ hrome subject m the Workers Cimla:nnaion provisions of the Labor Cute,you must
total comply withwch pnwoinn<nr Its permit shall be famed revoked. WATER SERV ICE
Q AIU
� Z CONSTRUCHONLENDINGAGENCy NI?W RIitiIUENTIAh I'LMII. SQ PI'. Il. c RtO
U O 1 hereby ani rot that is a consvvnron Penning agency or he Panbmaame of
� (-' the work for which Ihl,pennil is ..ucd(Scc.1097.Civ,C.1
OLcnder,Name
U 1<nders AJJres, T( AL.
PWi 1 study that 1 have rad this application and state that the above information is HULLOING 'ih
,F". LG arfaer.Ia,,.to comply with all dsyand county ordimrce%iml,wtc laws retail.,III QTY. MECHANICAL PERMIT PEE S1iI5Mlc
U Z buildings norlion,cud hcmby antiluill rcinelcnancel of tb'o,ayu true-upon the
abovo-nwntinned Pmpany for I2vpection pmposos. PI1RMH ISSUANCE ELECTRIC Il 7
(We).gree in,tvc,indemnify and kap hamJn,the Cuy of Cupertino agoing
Iiabilities.judgnnents,costs and expenses which may in anywaynceme against stiJCoy ATTER OR ADD TO MECH. PIDM1IBING .FII
in consequence i1 The granting if this"not
APPLICANTUNDER
STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITTO I1.0(10CFM) MECHANICAL IN
ii
S URCE REGULATIONS.
AIR HANDLING UNI'I'(OVER 10,000 CFM) CGNS'TRUCITON'AX
Signature o APplic i/ n Dmc EXIIAl1S'1'IIOOD(W/Ill1C'lT HOUSING MI'fIGA'OON LYE
IIAZA r OUS MAITiR1AL5 DISCLOSURIi
Will the applicant Or future building Occupant stem it handle ha menus material HEATING UNIT(PO I00.000 ITT By
a defined by the Cupertino Municipal Cade,Chapter q.12,and the Health and Safety HEATING UNIT(OVER 101.001 BTU)
Cade,Section 25512(1)'
C3 Yes -1 No VE N1'ILA I'ION FAN ISI NGLE RESIDI PAID Dam knxiptN
cNanWillthea,l'uant or l umm huilningnin,upamu,c cquipincnt or devices which BOILER-COMP(31IPUR Births)It I IH
mit hmaius air enntaminls as defined by the tiny Area Air Quality Managenunt '1(),
ryo
Dium"? BOB, -COMP(OVERI d,000BTU)
E3 yes E3 No
AIR CONDIT TONER ISSUANCE DA'I'S
Ili Jhacvd materials y re t J Chapter rthethan
Ch- ///
fomuH'lll Ni SafetyCN Section,255(15 2581 12551) Iunderstandirt Ithc NEW NESIDIiNTIgI.M1f EG,II, SV.I'1. / /
manto,f t ay lr It , lhtl: y :P bnfil flythc y. (—
nfNercquinnunswhthmuslM.out prone nxautu faC it -t Rl�auP'wy. /
Ownermtuthomedagent Date TDTAL: ISSUED BY: •••-/f__
OFFICE