S3235 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELECIRIGM. PFRMITNO
BUILDING DIVISION APPLICATIONIPERMIT PLUAmING MECILINICAI, S 3235
BUIhDINII PROJF,CT IDFNI IFICAI'ION
BUILDING ADDRESS: SANITARY NO. APPLICAI'IONSUBMIFFALUAI'E
AR-WE E �-
NER'SNAME: Fjj PIIUNIi: CONTRACTOR'S NAME: (•,, LIC NO: 77
, S'A NIC C(1NTROLa
ARCHITECT/IdxGINIiIiIi: LIC O'. AU RISS: I 1'1'� ' LI,IP12D uL ❑
ILIA
CONTACT: PHONE,: BUILDING PERMI'I'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLEM11 MECH
D ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARAnON QTY. ELECTRIC PERMIT FEE
I beach,off,.tMtl am f d undia,roviaon,al Chapter 9 Brommarcm, JOB DESCRIPTION
=Z wnh} t ]OUOprfDt is I nth lion e u u f e«lo vnd ply tic eix RESIDENTIAL:
LL:00 PERMII ISSUANCE
z 4'F nfull f ce and el "S J 2n] ❑SFDW'h ❑KITCHEN REMODEL
4UU Lce se , :: _ Ie N Lt 61--� 7 f(/"�-`�— APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
D:ne coot L 'tilt 4lriX • ACRCf
Foy ARCHI CECI"S DECLARATION PANELS ❑M1fULTI-UNIT ❑STRUCTURAL
.ZONZ I understand my plans shall be used as Lattice records
UI'TO AM1fl'S
MODIFIG'IION
OZ—O CI INTERIOR El CHIMNEY REPAIR
Licensed Pode.ecional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER D17 N.ARAHONOVUZ 000AMPS BATH ItIiYIODlil.lkl?PAIR UI?MOLCCION
5 uc I hereby affirmthat l m exempt p1 f theC trace L 1 for the
ICO R'U SIGNS ELECTRICAL ❑OTHER c , 4F_AT6
It WwaF Thi g (Section] 5 B . JI Nuristan,Cod a Any aunty
u.yhih requires permitconstruct.'ll pr d I'.h repair any structureell& e <
.F n'0 p o I t I. y Ih , tt p 'G la 6 d:I Iement SPECIAL CIRCUI I/MISE ��III e"A
Ixf r�at, (bathe is licensed pn the Pworsions oftheContractors I 1 (Cbvpin9
1�+1�0�0 (a,mmcnang wnh Sen on]IXMI)of 11 vision} (Ihe Ruvnese and Pmfesi ons Coda or '1I"M1'METER OR POLE INST COMMERCIAL:
W 'hal he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
applicant t
_IL 113 1 S by any is armit objects applicant m c
a ivil Innahy of POWER DEVICES
nu'more than Five hundred call... ❑TENANT ❑FOODSERVICE.
W Section]
L5.,Z} 1 VIiMENT
5=Q ❑I,avowmmik,dlepmparreme is nor
meadvil ithsvnges aa'hci(See 044.B sines. SWIMMING POOL ELECTRIC HER
LW tui ll Bothe work,andthe she Cons 0otit¢ndalorawo des, s�la(Sec.]0of(,wall if
LLI�� 'td V t 'Code 11 C t' t 1 1' J : t apply t ncr of OU'I LETS SWITCHES FIXTURES
I ta"3— p upeny vsho build,,,, p theorist.and hit does such walk harwil it IhrouEb
t his own employees.pr Jed that such impromVirients are notintended B d for NEW FEMDENTIAL 1'11 CFR SQ FL
sale.If,however the building or improvement is sold winners ycvrofeempiclon,the SQ.Ff.FLOOR AREA S/SQ.FT.
ovinerbatilder will have(lie burden of proving that he did not bolder improve for or.
Post,of,-R.)
O 1,as ouaer of Ihe property,am exclusively emaraeting with m
licensed enmemr,to IOTA[,:
consumer
the Pori(Sec.]M4,Business and Professions CMc:)'Me Contractor's Li-
seLawdoesnotapplycallownerofpropenywhobuildsorimprovesthereon.and QTY. PLUMBING PERMIT FEE
wl mntnats kasuch projects with,It reseal)licensed Furslumm(he Cnmrncrall"
Liecnse Law. PERMIT ISSUANCE
E)I an exempt under Sec. .B&P C far This reams
ALTER-DRAIN&V17NT-\4'ATER(EA) VALUATION
Owns Late
. WORKER'S COM PLN ijor,or DECLARATION BACK PLOW PROTIiCI'.DEVICE 2 ^�
I hand%affirm unJer pvnalry te ofCon one of the fNhwlng de rker's a' J J
❑Ihave:ro will for
lection Certificate of Common self-insureher Ciumper.Ile DRAINS-Iq,00R.ROOEAREA.COND. STORIES TYPE CONSTRUCTION
smirk,:w provided for by$welters 3]Ial of Ihe Labor Gula,fur the perfnrnnance of the
work fav ad
Ibis penal'iv-1,v. i'I%TI]RES-PL'R TRA('
have and will maintain he performance
Co ce ofthion rk foranle.
h his pens by Session
. t of the Lather Care,for peRnmana of toe work Ga which this Lennie is issued GAS-G.S1'SI'E:xl-I INC.q OV1'LG:TS OCC.GROUP AI'N
My Workjy'y'tf-'op�g'rq I vurancc t Policy n m h r �$
Carries:[ ISCl11 rnEey Na.:dJ��k fly IQLfI GAS-k;A.SYSFEM.OVr,R4(E
CERI'IPICAI.OF EXENIPI'[ON FROM WORKERS' OHEASPIINUUSTRL\ TE INHiN
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Ibis section need nn'becnntpleted if the wroutisforanchnndral doEars($1110) CREASE TRAP J - --
orless) PLA CHECK FEE
Icertifythal imhc verformance.f Ne work farwhichlhis permi,is i.vsued,Ishan SHWER-SANITARY-S'1 1 iA.
not employ any Personany manner so as to become subject m the Workeri Comfe n- .Y I'hE
Oz smion Lnws of California.Unlc WATER HEAIER W/V EN"7 .V 'k GRADING IEE
z 2 Applicant
..y f/1 NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you chnuld � WATER SYS')EM?RIIATING
F ? havure subject to the Workers Compensation provisions at the Labor Cole,you must SOILS THE
{a forthwith comply with such parswans or this pem,il shall be deemed revoked. WATER SERVICE
Q
Z)O CONSIe is a eio LENDING AGENCY NEW RIiSID1iNTIAIJ'LMB. SQ.Pil ('AID Dane Receipts
1ne¢byaRrm thathereIi issued(Scr,30 len ding agency for the performance of
LL I'+ he work for which'his psmnit is issued(Sec.JRI].Civ.C.1
ULeader's Nmnc TOTAL:
A-1 Lender's Address
r TO'TA
y 1 certify that 1 have read this application and state that the above information is BUILDING P"
Com. h correct.I agree to comply with all city and county ordinances sad .It laws oilman,la QTY. MECHANICAL PERMIT FEE
Uz building construction.and hereby authorize representatives of this city I(,enter upon the SEISMIC '
alunemandened property I'or in,gac'tinn purpoves. PERMIT ISSUANCE
(We)agreem save,indemnity and keep hannlc%s the City of Cupertino.,most EI,P,CT ( FT
liabilltax.judgments.c Is ande swhich may in any way accrue against sail City ALTER ON ADD TO MECH. PLUM1IBIN FEE
nsegncnce oR ami of lh'Femti
APPLICAN'P U S' DS N ,I.CCl LY WITH AL1.NONPOINTAllt HANDLING GNI'1'(TD IU.01a1 CFM)
_ MI'CHA At,FRE
SOURCE '1'I
AIR HANDLING UNIT(OVER Ift000CFM) CONS]RUC ION TAX
Si a A p muMConv, ' Dom EXIIAUSI'HOOD OVIDUCT) HOUSING MITIGAI ION FEE
HAZARDOIJS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle haeardous material HEATING ON]'1'(TO 100,N10 HTLB
as iterated by the Cupertino Municipal Code.Chapter 9.12.and Ne Health and Safety
0cle,Secliun 25532(:0? HEATING UNIT(OVER 100,003 BTU)
0Vcx E]No VI?NTILAIIONI.'AN(SINGLI?RIiSID1 PAID
Dae Receipt a
• BOILER-COMP((IIP(lR 1(p,
Will Ihe applicant or future huddin,t o cupanl use equipment or devices which
emit haIXlfl BTU)
eunr
dous air ntamnat
iav as defined by the Bay Arca Air Quality Man'gcment TOTAL
Duane,I BOILER-COMP(OVER too.00011I'U)
❑Ye.s El No
I have wait the hauNnus materials requirements under Chapter 6.95 o('bc Cub- AIR CONDI HONER ISSDANGIi DATE
funic HCJO,&Sakty Coda.Sections 25505,2v,93 and 2.5534.1 undershmd that it the NEW RIiSIDENI At.MECH. SQ.FI'
building doss net cummly have a tenant,that's is my msrymsihilily Io maty the ieculxml
of Js,requirement's which nun be me'prions Issuance of a Cenifirme of(kculunay.
Owneror rathodarl ugnn Date TOTAL: ISSUED IIP:
OFFICE