S 3226 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLRC'I RILL lits 11'I'NO
BUILDING DIVISION APPIACATION/PERNIIT PLUMBING-MECHANIC L 3226
BUILDING PROJECT IDESI'IFIG'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICATIU'7N SUpBMI'I'f9AL DAT
_AOLOW ' 'SN Mfi. PHONE: CONI'RACI'OR'S NAME: (J LIC NO.
,S NIC CONTROL#
ARCHITI-C '/LNGINF.ER; LIC NO: ADDRFSS,'7Liii(J to IU I%V R1/ ❑
CON'I'nCT: PHDN1a HUILUING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
O - Q1 a ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PFAMIT FETE
with them,Wfir o nm[;at,licensed nada pm,iu n,or Cd,mr 9(ema deadng JOB DESCRIPTION
IMr7 ff lint
�QO Sof the xusinese and ProfdssionsCWaand my licenmk PERMIT ISSUANCE: RESIDENTIAL'
Fes_ in
full Unsaid
Class
anJ f/' / ❑SPDWL ❑KIT CHEN R1iMODliI.
aUzV Liccns,Clans Conn APPLIANCES-RLSIDEN'I'IAI. ❑ADDITION El PLUMBING RH-PIPE
�Qtu Dam Cantmnnr
a D. ARCI{ITF,CrSDECI ❑MULTI-UNIT El STRUCTURAL
zcyz lun"eefund my plans shall be need as pn mmrfad, PANELS MODIFICATION
Oz4—a UP'102WAMPS El INTERIOR El CHIMNEY REPAIR
FNfW Licensed Prof-amid 201-IIX1nAMPS IMPROVEMENT (]SWIMMING POOLS
QI,z; Oat I ran rmnnpI3R m theA ontrim a' OVER HXX)AMPS ❑BATH RHAODE1jREPAIR [I DEMOLL J rrl ry
[�C C or I hereby affirm mat nm exentpl from the Cnn,racmrs License Law for the
senx i 13
U following reason.(Section 7031 s,Business and Professions Code:Any city or county SIGNS ELECTRICALEjlTrlI1E/Rk�(1�I b�
which m"riax a Penni, ,,mnstfun,.Iota improve,den ol,sh,m repair may omomoe
F"u•��' prion,,its isstramcc akorewirex the applicant for permit o file a signed.mte,ae , SPECIAL CIRCU I'UMISC. O 4:SA-L4_osJ6R�
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9
W�00 (commdnein6 with Scctinn 9,XNI1 of Divi.i.13tithe Rashness and l'rda..ions Cale)nr TEMP.METER OR POLE INS'L COMMERCIAL:
a E eC ma hu is exempt therefrom un"Inc hois for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
,u_N Section1.11.5 by any applicant for a permit wbject%the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
.I mum than fisc hundred dollars(851X).
y Z Y IMPROVEMENT
i=C ❑ Lothe owner k.and pn,ryactur is of intended ed roomed
f rsaei(tol(See
contpcnaaiom, SWIMMING POOL IiLECTRIC
and Pr the f,.Coffe saunum is not License Lae does I.,apply to ad Business �O.TH�rR
13 m and 1'oy his ha Caf.,irhdmp Contractor's License Law crus not apply to if owner of OU'1'LP.TS—$WITGE{ES_PI%TITRES J/
property who builds or imp t e thelium,and who low such work himself of through
his awn employeese provided that such nen,o mdna arc net intended or offered for NEW RESIUIiYTIAI.ELF:CIR SQ FT.
sole.l[however,the M1uilding nr impr.venmm is eolJ within one Ycar of contplerinq lb, gQ.IT.FLOOR AREA S/SQ.Irl'.
crnuilder will have the burden of proving that he did not build of improve for pur-
pose of vlcj.
E] 1,ns owner of the propety,ant exclusively co..Imm ng with deemed c auded rs.Its
"TOTAL:
.named,he pn,ive,(See.91chf.Bnsincas and Professions CmIv)TW Cot amselo s LI-
cenmLaw dot notapply toanowner of propcoy who builds or improves thereon,and Q'rY. PLUMBUNG PERMIT FEE
won aontmns),much projects wins.atmmnndsl licensed pmfora It,the Commoor's
Liferaw 1.Vs. PERMIT ISSUANCE
Cl 1 am exempt under Soc. .B&P C for this reason
Owner Dec A Uf13R—DRAIN&VENT—WATER HCO VALUATION
�
WORKER'S COMPENSATION DECLARATION RACK FLOW PROI ECT,DEVICE
I herehynfinar tinder penalty of Ecrjmy one of the fol low ng deolnntions: s fJ
7Ihuve.nlwllmainuinaCertifarwACnnma lomlGinsurefrWnder's Compcn- DRAINS-FLOOR,ROOF.AREA.COND.
.arm.as provided for by Section JIM of the Labor Codd,for the perminam ce of the S I DRIES TY IF CONSTRUCT K
work far which this pennit is issued. I FIXTURES-PER TRAP
❑I have and will maintain Workers Contpenxvtiun Insurance,as quimd by Section
37M ofthe Labor Cale.for the perfommred of work for which this permit is issued. GAS-EA.SYSTEM4 INC.J OUTLETS OCC.GROUP APN
My Wud.a' p r and Policy nn
a ut gqyynnr�'gEI, yp.osiS's`.. y {�
Carries � �KkA L[7N TePolie No.:� ��.OfJO U2 is GAS-EA.SYSTF,M-UVF,R#(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASEIINDUSTRL WASTE:INTERCEPTOR
($1110) GREASE TRAP BUILDING DIVISION ITES
Curia scnion ncN not be completed 11 mepomti,is lirzoac hundmJ dollars
or less.) 1'LANCII[CK FEE
Icertioiling inure Ndfornimed title work for whichtis,wrod,is issued,Ishall SEWER-SANITARY-STORM EA.2001'T..
not employ any ,air in aayntwumr unto he e, �f to the Workerv'Compen- ENERGY FEE
O Z .wti.a laws of Calif..iu.D lc i - l e`-aY WATER HEATER W/VESTMLECTR
Z O nppR,am..Y�'�: 4Iojeo f !l GRADIN.FEE
=
NOTICE 10 APPLICAN'E If,u11e,naming this Cenificac of Exemption,you should WATER SYSI'HM,rTRHATING
a , become subject t.the Wmkels Compensation provisions of the Labor Cale,you mussSOILS T:.
CkL forthwith comply with such provisions ur this Penni,shall he,d,,ard revoked. WATER SERVICE
aQ
=1z CONSTRUCTION LENDING AGENCY NEW RFSIDI3NTIALPLMN. SQ I PAID
I hdry ileo rmmnnherciesued LS-
lendingagency!oohs prrfnrm:mm of ate Rcociptp
� � the work lin whicM1 this permi,is issued lSe,.3W),Civ.CJ JAN
C U lenders Name TOTAL
lenders Address 'IOT .-
1 I denily Lha,1 have mud this applicator.and fate t rai the above information Ic BUILDING FEF.
lin ommu.l ugme(noun y with all city and d... oN,mnccs anJ stat laws mlaingm QTY. MECHANICAL PERMIT y
U z mildin6eonfmaion.and hereby authorize represenmti.o ofihis city tneneruponmc
almvo-mmationed property for inspection purposes. PERMIT ISSUANCE IL
(we)agree,.sacro,indemnify and keep hamduss the City of Cuperim,ngaim, ELECTRIC FEE \F
liabilhics,ju"grnd .utsst, x me"hichnteyinanyadcrocagamstsaid Ci,y
ACTlilt OIX AOD T(t MP.CH.
in nsvyuen' the intof this u. a PLUMBING F[(V
A" N STA SAND\" f.( WITH ALL NON-POINT
Sol, AIR HANDLING UNIT(TO 10.000CPM)
SOIL .EGL' ONSMF.CIIANIC, PEE
AIR HANDLING UNIT(OVER I0.000CFM) NAX
atCONST IO
s ignure ofA plicandCo nor V U."d F,XI MUST HOOD fW/DUC'1) HOUSING 1'1'IC TION PEE
HAZARDOUS MAI ERIALS DISCLOSURE',
Will the applicant or future building occupant store or handle ha.ammus material HEATING UNIT(TO 100.000 RTU)
as defined by the Cupertino Man, axle,Chapter 9.12,:rod the ILalth and Safety
Code.Section 255321.1^ HEA'1'1NG UNIT(OVER 1!X1,001 B'FU)
0 Ya PAID
VEN'IlLAT1ON PAN(SINGLIi RFSID)
y'
Will the or!naa building occupant use equipment of deviceswhich
Dat, Receipt#
emit hmadous me condo e byhe Bay Are..Air Quality Maagdment BOILER-COMP fJHI'OR I00,000 BLUE
District? O
Yes tiBOIhIR-CDMP(OVER IIXI,IxI1 RIUl
ma�
I have maJ the our Noun oe m ircn¢ms under Chu Icr fi,95 root the Call- AIR C(1NDITIONER
p ISSl1ANCC UATIi
li,mia Ilvelth&Safety C to SecIl. 25597 uad 255711 undersandohm tithe NEW RESIDENTIAL MECH. SQ.ET. Q - '�huildingJceam cu havesit ismy msponsibili, ton afy ' _ 20 �I�eof the raquircmcn , mrMt sofa Cgaufi ryJEc
Owner nr amhmtzeJ alien, Date TOTAL: ISSUED BY:
OFFICE