S 0337APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJECF [DEN'FIFIC'ATION
PERMIT NO.
S 0337
BUILDING AlS
sm
i'IIONE:
SANITARY NO.
AP/P/1LICA] ION SU13MI'ITAL DATE
O E 'SNAME:
CO ACI'[ fS NA '_ LICNO:
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BUIL HNG[[PERMIT INFO
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❑ Consullan(Fees Paid by Applicant (Initial)
BLDG _ IiLECI' _24 PLUMBMIi 11
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LICENSED CONTRACTORS DECLARATION
1 hereby affirm thin 1 am licensed under previsions if Chapter 9 (cmm�wncing
with Section70X)).fD,vi,iaa3oflhe Hasinessand Pmfessim,Cure, andmy limusent
L erase lass effect.
License Class Lio.k
Dom Comracun
QFY. ELECTRIC PERMIT FEE
COB DESCRIPTION
SFDWL ❑KITCHIiN REMODEL
❑ADDITION [j PLUMBING RE -PIPE
❑MULTI -UNIT [I STRUCTURAL
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
IMPROVEMENT ❑SWIMMING POOLS
PERMIT ISSUANCE.
APPLIANCES-RPSIDENTIAL
L
Fly
ZOsr�Z
OZ—,
ARCHITECPSDECLARATION
IundersmnJ my planshhall he usdas public records
PANELS
UP TO 20t1 AMPS
Llcen,od Professorial
201-1gOAMPS
a
413 O 6 V
OWNER -BUILDER DECLARATION
I hereby affirm that l 1. exempt from the Cssion, ors License c Law fnnhe
fallowing remora (Section ](UL4 Business and Professions Any city as county
El BATH REMODIiIJNF:PAIR ❑DIih1DL.UdDN
❑OTHER
OVER I(NNIAMPS
SIGNS ELfiCBICAI.
��pt.0 �
0�
}
demolish, or
which requires a e, also re nirewm, eller, improve, smacttor repair any slrucwrc
hayed salChapteen,
denhaillotmnee,ah..11. res the applicant for suchpennes License a e
Ihm he is licensed Pumuam m the provisions of the Concavities Licenu law (Chapter 9
SPHCIAI. CIRCUIT/MISC.
41 ..p0
ti Xn oG
—y
Qoral
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W�_
(commencing with Section 7000) (if Division 3 of the Busines. and Professions CNB) or
that he is count, therefrom and the basis for the alleged exemption. Any violation of
Sem¢ ]031.5 by any applicant for a permit ohimis the applicant to a civil penalty of
thaa five htmdruldollnrs Clow).
uvowncrofthe pukeny,or my employees with wages u.v dust ... lee rpen.,anno
I do the work, and the structure is not intended or offered for sale (Sm. ](W4. Havinas
and Professions Coe: The Contractors License Law dues not apply to an (,watt Y•
property who builds or improves thereon, and who docs such work himself or Ilmmgl
his own employees, provided that such improvements um nor intended or offered for
side. 11 however. rhe building or improvement is sold within ane year of completion. the
TEMP. MM- TR OR POLE INST.
COMMFNCIAI'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT El FOOD SERVICE
IMPROVEMENT'
-1 OTHER
POWER DEVICES
SWIMMING 11001, ELEC I' RIC
OUTLEI;S- WITCHES - FIXTURES
NEW RF'_S DE IIAL ELECfR SQ FT.
SQ. FT. FLOOR AREA
SISQ. FT.
-builder will have the burden of proving that he did nor build or improve far pur-
Fromowner
Free of sale.).
❑ 1, is owner of the y, exclusively amloachn,voi,so widCi,d Items mincrunovel
/
TAI" O
r, Ira
See. T I.i.-
project (See. ]Cann, Business and 1'nslcho hats Code:) The C
mamaeo . B
1
d pnmots of pmperty who builds (,rimpro e, thacmre
se Lawdoeor
QTY. /AB I ER T It PHI:
who contracts for such pnuJems with a comrunmCp) licensed pursuant to Me Commclors
such with the comononex
mLice�,qm Law.
&
V exempt under S. BP C far this
s,J IJ
PERMIT ISSUA isjSee
Owner Dare"
WONd :SCO ENSA'ron DECLARATION
1 hereby m tinder a1Rrer penehy of pry c juone of rho following Jwlvmlionr
ALTER -DRAIN - R(fiA)
VALIDATION
(7[ Q DO
BACK ROW I'N F .DEV[
DRAINS -FI.O ,R AR' ,GOND.S'
IN I have and will maintain. Ccoilicateof Consent owif-insure for Workers Cimpnr.
.cation, as providd for by Section 37M of the Labor Code, for the performance nl't hu
ES
TYPE CO. S'I'I1UC'I'ION
work for which this permit is issued.
FIXTURES- TRAP
-11 have and will maintain Workers Compensation Insurance, as required by Section
3700ofthe Labor Goa. fnrrhe performanceaflhe work fn -which lhispenni, is isx-1
GAS - EA. SYSTE C.40 S
OCC, GROUP
APN
My Worker's Compensation Insurance carrier and Policy number are:
Carticc Policy No.:
GAS - EA. SYSTEM OVER -Al
CERTIFICATE OF EXEMITION FROM WORKERS'
COMPENSATION INSURANCE
GNHASFJINDUSTRL WASTE ING HR IPI'DN
BUILDING DIVISION FEES
(This section need not he completed if Ne permit is fortune hundred dollars (S ah
or less.)
I GREASE 9'RAP
PLANCHECK hill
O z
z Q
I minify that in the pedurincot, ofthe work for which this Permit is issued, I shall
not employ y person in any manner so as mite me'objecr1. the Wnrmoccommit
xatioa L li Err Date ,
APPlican
SEWER - SANI'T'ARY - S'T'ORM F.A.200 Fr.
ENERGY FEa Q
Wn'1'ER IIIiATEk WNENT/ELF:CfR
GRADIN E
NfYfICE'f0 P CAN'T': e, afar makmg t , rti,m al of LamPtia d you should
become subject no the Wnrtrrs Cnmpensalion (,f the labor Coe, nun
WATER SYSI'EMOREATING
soIe.
as--
>
Lki
aQ
L) 0
r
44 F
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provisions you
forthwith comply with such provisions or this Feint shall be, decreed revakd.
CONS'FNUCTION LENDING AGENCY
rat (here is a cm etractinn lending agency for the pe rforncom of
I hereby.f fim th
the work for which this Permit is issued (Sm.3097. Civ. C.)
Lenders Names�
WATER SERVICE
PAID Dale Recei l#
P
NEW RESIDENTIAL PLMB. SQ, ET.
TOTAL:
Lenders Address
OTAIZ24
M
BUILDING FEE r V
hcenify,Bin 1 have mad this application and stale that the above information is
IZI
Uz
correct. l agree to comply with all city and county ordinances and state laws relining to
hadiingconstruciion, and herehyamisrm mpmsenmlivesofrhiscity menmrapin the
above mentioned property for inspection purposes,
(We) agree to save, indemnify and keep hamdess dPo City of Cupertino against
QTY. MECHANICAL PERMIT FEE
r 70
SEISMIC FEE JJ
PERMIT ISSUANCE - D
ELECTRIC 1: O
Iiabilities,judgmeals. costs and expenses which may in any way accent, against said City
in const a cute (,f the grmning nf,his permit.
ALTER OR ADD TO MECH.
PLUMBIN
AIR HANDLING UNIT (TO [QUO CFM)
FEE
0 70
ICAMIND RSTAN AND W LL COMPLY WITH ALL NON -POINT
SOUR BREL ,L IONS �'/ q'�
10,000MECOAL
AIR HANDLING UNIT (OVER IO,w CFM)
CONS ICTION TAX
. ugn.t re of pp icanV mr Dae
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCC P
HOUAfNG MITIGATION FEE
HEATING UNIT (TO 100,000, BTU)
•Will
the applicant or future building commanl.aore or handle hmuNnuv material
u.v defnd by the Cuperino Monter' Coe, Chapter 912. and the Health and Sal'cly
Code, Section 25532(,)7
1 [EATING ON[ T (OVER I1X1,00013'TU)
❑Yes o
Will the applicunl nr future Building aacupant use equipment or devi0e5 which
I hazardous air conmmiaams as fued by the Bay Area Air Quality Management
PAthis)
Date Rccci,t# (7
0
VEN`IL,V ION PAN (SINGLE RIi51D1 �j C
BOILER- CONIP(311P OR 100,00X) RTU)
BOILER- COMP (OVER I W,OfO B'T'U)
>aia7 4/
❑Yes
AIR CONDI III ONER
I have read the Ismumos materials requirements under Chapter 6.95 of the Cal i-
NOV L. N TE
NEW RES I DENT IAL MECH. SQ. ET.
Lima. Heidth & Safety Calc, Section, 25505, 2553.1 and 25534. 1 understand thin if IIm
baldingdocsnnt ready u • len I Iitl.cmy respnmihil'dy to nosily the occupant
LO �
ire whit mu. c n to issuance nl u Cenif cif fkcepanc
,hm-Dale'OTA
Y:Ovatrar
ISSUE D
OFFICE