S 3234 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 Lgp1Cv1T NO, 3234
BIIII,DING DIVISION APPLICATION/PERMIT PLUMBING-3IECDANICAI.
BUILDING PItOJEC'I'InKSTUFICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI plAI.DATE
OWN 'S NAME PH NG CONTRACT'OR'S �
NAMIi: LIC NO:
C � � NIC CONTROL#
TIEff-
;AR CHI IECTIENGINEER: I.IC bill'. ADDRESS: MAkOi cG ❑
1`41AUMAJUAL
CON'T'ACT. PHONE: ILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG HLECIPLUMB 1,11,01
R �0 510 9`7 O1 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. F,LELI'RIC PERMIT FEE
1 hereby affirm lhm I am license under provisions of Chapter y be canting JOB DESCRIPTION
ClyZ with Scction7nagofi)i,i,ion3nnhc Bm,i.,,,.n,iProfc,,innu C.de,undmyliccnscl+ RESIDENTIAL:
♦x10 0m PERNU IF ISSUANCE
fulllbrontef I C ❑spam. ❑KUCHENRHMODEL
WGSUP License Clas.. _ Cj1n Ma d APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE PIPE
ARCHITECTS UECLARAI'ION prr�.a,rPANELS ❑MULTI-UNIT ❑S'TRUCURAI.
zpyZ I understand my plans shall he uscdes public records M(ll3llolCATION
0 Z.-0 UP 10200AMPS El IN] El CHIMNEY REPAIR
Licensed l4ofcselonal 201-I010AMPS IMPROVEMENT E]SWIMMING POOLS
AYE.] OWNER-BUILDER DECLARATION OVIiR I(NOAMI'S ❑BATH RUMODEURITAIR ❑DIiMOLITI N
6 I hereby door that I am exenfa from the Comma p's License Law for tilt n 9
k 06 U following reason.(Section 7031.5.Business and Prafecdons Code:Any city or county SIGNS ELECTRICAL ❑OPIER �k'TV—Q Q�
W 3 w y which ra �ss a nerr d In lonamel,mice Improve,dcinoYa,,or repair nor 9mianra � '�"� •(b /{Ou't6
prinnn its issuance,also requires the uppllaml forsuah fiction to fle a signed amtcnhem SPEFJ4IQ1PC1JFDMISC,
that he is licensed pursuant to the pravisionsofthe Cnmrocmrs License Uw(Chaparl
yap (commencing with Section 7000)Of Division 3 U(fie Bnsines,and Professions Code)or TC 3A FI'ERO i1NS1'. COMMERCIAL:
y q o y that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NIiW NLDG/ADDI'T'ION ❑UIih10LITION
ad..w Sectinn]031.5 by any applicant for a permit mIjecrs the npplieum ,,d civil penalty of Ml EVICH.. ❑TENANT ❑FOOD SERVICE
L. not tnne In five IQ laid dollar,($50o). IMPROVEMHN'1'
q=6 I,us nwnerof the norm In ces wish wo res as theirsnle tom lion, S INC til ' 41C
62' prnlre Y YnnP Y 6 cense
H. will dothe work.and lhcPare,we is oat o andedcroffered for sake(See7BM,Bmsdnce, O 1:R
W 3 m and Professions Code:The Contractor's License law does not apply e,an owner of O 1 LEIS-SWII'C111S-FIX'
propcny who builds or improves thereon,and who does such work himself m Ihnntgh
his own employees,provided that.such hoproverb nts aro not intended tar offered tLr k1iSIDEN'I'IAI.I?LECIk '.
6ale.It.M1nWOVu,the building,,inprnvul..an[lssnd wllhlnnoe,carol completion,the ^ ti 11XXIOARIIA SISQ'FI'
wneotatildcr will have the burden ofproving that he did not build or i,nprnve far par- 7 S
aa nf,m.)
. 'tocols
❑1,a owner of the property,am exclusively contracting with littnud mntmmors m
anOa rrei the project(Sic.71144,Bminw'a and loon oiuns Coda,The Contmcmrs I...
se Law does nouB,ply lu me ownernl'property what hnilds or intpn,ve,(hemmn,not QTY PLUMBING PERMIT PEP:
who contracts for such pmomts with u contract s)Ecmued pursuant to the Cnmractor's
License Uw. PERMIT ISSUANCE
❑I tan exempt under Sm. .B&PC for the moon
ACfER-DRAIN&VENT-WA'I'IiR(EA) VALUATION
Owner Data
WORKER'S COMPHN5ATION DECLARATION BACK FLOW PROfHCT.DEVICE
. Ihereby u0mtunder penalynfperjuryoneofHefollowing declam.tions: /8 DD
❑I have and will maintain a Certificate ofConsem u,sef-inmrc for Worker's Cnmpem DRAINS-FLOOR.ROOF,AS HA,GOND, STORIES TYPH CONSTRUCTION
salon,as provided for by Section 3910 of the Labor Code for the performance of the
wad for which this,until is issued. FI X URES-PER'rRAP
Fl I have and will muimuio Worker's Cumpenmtiun Inxnrance,as recluned by Seetiun
3700nfthe Labs Cee,iia the performance of the work lin which this permit is issued. GAS-EA.SYS'IIiM-I INCAOU'1'LETS OCC GROAT' APPS
My Worker'xs fy Iry� rand Party nu 3`fa�l✓b
Cartier. #4 ,It 62Z Policy No, 0001 Q2 F3 GAS-EA.SYSTFM-OVER4fEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' G REASPJINDUS'IRL WASTE IN'I'ERCF.PTOR
COMP17NSA'I'ION INSURANCE =BUILDING DIVISION FEES
-
('I'his Iludinnred not becoo,lu(edid theperom is locust hunJrcddnllars I$POPE GREASETRAP
or less.) PLANCHECK FEE
I certify that in the peAommncc ofthe work for which this permit is issued,l shall SEWER-SANI'T'ARY-STORM E.A.2W f'f.
not employ any Snoo in any manner so as to Mone subject to the Workers Contain. ENERGY FEE
O z ,tion Laws of Cmilioma.Date WATER HHATO R WIVI?NTBI.,C'1'R
y 2 Appllnmt GRADING FEE
G7NOTICE'TO APPLICANT:If.alter making this Cenillcam of Exemption,yet should WATER SYSTIiIAO REN'ING SOUS TLE
a ; beeane subject to the Workers Comparemion Provisions of the Uh,r Code.you must
LkI fnnhwith comply with tach prnvisians nr this permit shall he JemneJ revoked. ' WRI ER SERVICE
]
CD La
z CONSTRUCTION LENDING AGENCY NEW Ii F.SIDI3N'fIAI.PLMB. SQ.PI', PAID D Itecaill#
L) 0 IherebyaHirm lhanhere issued( e,30 len Jing agmmy dnnbc perfnm,dnw of
the work Por which this pcnnit is issued(Sec.3W7,Civ.CJ
❑+ [-. TO'T'AL:
Lander',Name
U
LLeaender'n Address TO BUILDING FEE�.t 1 ccnify thppli
at I have rend this acation.and stare that the drove infonnmimn Is
L to enreal.1 agree m comply with all city unit county ad nances and alnla lawn rebfng to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby autbonae represcalativesofthis city lmenternpon the SEISMIC FEE
above-nentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(we)agree to save,indemnify and keep hamrlcss the City of Cupenine against ELECTRIC FEE
habil Plies,judgments,costs and expenses which may in any way uecme against slid City ALI'HE OR ADD 10 M ECH.
ne hscqucnce n- M."'
PLUMIIINf,PEE
APPLICANT . 11. 'OMI'LY WITfi ALL NON-POINT AIR HANDLING UNIT(TO IO,IIINICPM)SOURCER ".A MLCHANICALFEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
P-11
urs nl plicnnl .nnmr,im Date HXI MUST HOOD f WIDUCT) HOUSING MITIGATION FER
I IAZARDOUS MA'I'HRIALS DISCLOSURE
Will theopplimnn or forum building hweupant,loree,haadla ha...husnmreddl H HATING UNIT T 0100.000 BTU)
as defined by the Cupertino Municipal Cee,Chel,pc 9.12,and the Health and Safety
Cafe,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ( VIN'I I LATION I-AN IS]NO LE RINI U) PAID
Delta Neceipl#
Will We applicum or future building occupant use eyuipmem or devices which
snit hazardous air cnntamina I dewed by Ne Bay Area Air Quality Management ROILL'R-COMP(JHPOR 100."BTU) TOTAL:
District?
El Ves No R I HOILER-COMP IGyBW 01x1 if FU)
O
Ilhave read to h:rnardons Prairies haquirpmmoP under Chapter 6.95 of the Cali Alit CONDITIONER `,,•s ISSUANCE IJAPIi
fnmia Ilwlth&Safety Code,Sections 255115.25533 and 25534.1 understand that tribe NEW RfSIDENIIAL MECU. SQ.FT. ! `— ,�.
00
buildingdnesnomu tlyha tenant,that it is my responsibility u,notify a,ocglp�
of the requires' �Al h�Iyhe e 'or to iseuanccofaCertiycmep{Oa(u��t6(,�1-Y.
Owner, nr eJ dgcm//- / LnDale TOTAL] ISSUIiD 13 Y: I x�•-
OFFICE