S 0346FILL IN INFORMATION WITHIN RED LINES -
CITY
APPIACATIONMERMIT
R11IIBBl:Lttl
CONTACT:
BALL POINT PEN ONLY
BUILDING - BLECIT
% C!
❑ Consultant Fees Paid by Applicant (Initial)
�aZ
Y OO
RUb
:Z,
LICENSED LON IKAU t UK S UhLCABA ZION
embyrm that 1 am mme
1 h.Ifi licensed under provisions of Chapter 9 (concing
wimScedon]IUOpdDivisionyettheBasinessandl'ndesuoasCode,andmylicenseis
Lfull liercp and eR �+
icense Clans �n I.w.N f%�/�J/
Date % a qel� 'S� Cursmtr�j-- �� -
Q y , ELECTRIC PERMIT
_
PHRMIT ISSUANCE
APPLIANCES - RESIDENTIAL
n Q a
y gF
ARCHITECTS DECLARATION
1 understand my plans shall he usedas public records
PANELS
[I STRUCTURAL
U1111) 200 AM I'S
3 t: W
'ie fa
Y W Q
L U
!(�
'y
Licensed Pmfessimnol
OWNER -BUILDER DECLARATION'
I hereby affirm that 1 am exempt from the Contractors License law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve. dumolivh, or repair any stranort,
prior to its issuance, mse requires the applicant for such permit to file it signed statement
that he is licensed punuaouo The provisions of the Contractors License Law (Chapter 9
201-10(XIAMPS
OVER IWU AMPS
SIGNS ELECTRICAL.
SPECI AL CIRCO I1'/M ISC.
TEMR METER OR POLE INST.
q0
yy yy
(commencing wim Satiation 7000) of Division 3 of the haziness and Professions Code)or
that he is exempt therefrom and me b®is for me alleged exemption. Any violation of
se m4,
call
=QO
al
Section 7031.5 by any applicantfor a permit subjects the appliarm to it civil Knotty of
not none than five handl'al dollars ($500).
❑ Las owner ofthc pmpi or my employees with wages as Their sole compensation,
willclothe work. andthehtructure isnel intendedorortettvl forsale(Sec.II04. Business
and Professions Code: The Comeacmrx Littasc Law des not apply to an owner of
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWI 'I CHBS-FIXTURES
L 3..
property who builds or improves thereon, and who dues such work himself or through
his own nnployee.s, provided that .such imprrvctnenas are not intended or offered far
NI?W RESIDEN'FIAT, BLECTR
rovecm is stilt] within one year of completion, the
sole. If, however, the building or impm
ownerrbui der will have The burden of proving that he did not build or iintoner for pur-
ITA,
pru of sale.). '
EJ 1, as owner of the property, am "elusively contracting with licensed comm cher, to
construct the project (Sec. 70PI4, Husi n"a and Professions Code) The Contentions Li
tense Law does not apply m an owner of property who hm1U. or improves merenn, and
QTY. PLUMBINGPERMIT
whit convects for Such projects with u cnntmetor(s) licensed pursuonno the Contractor's
PERMIT ISSUANCE
License Law.
I am exempt under Sec. . B at L' C for this reason
AU[ ER -DRAIN At VENT- WATER (EA)
Owner Date
WOR KIiR'S COM 1'P.NSATION DECLARATION
BACK FLOW PRUFECI. DEVICE
1 hereby affirm under penalty of perjury one of The following Jalamtiam:
❑ I have and will maintain a Cenifiame of Cotown,to self -insure for Workers Connived-
DRAINS- FLUOR, ROUE AREA, COND.
cation, as providW for by Section 3700 of the Labor Code, for the performance of the
work Iia. which This permit is issued
FIXI'U RES - PER TRAP
❑ I toward will maintain Worker's Conepmarilion hourance, as required by Section
3700 of the Labor Code, fortheperfarnranceofmc work forwhich This permit is issued
GAS-EA.SYSTEM-I INC.60UTI.ETS
My Workers fampen rt Tax umnce r r and Policy rte bar
Carrier. f7As ?:rll ePolicy Nn.: /3�'�y/f-4L
-
GAS- EA. SYSTEM.OVER 4 H;A)
GRUASUINDUS" 1'111. WAS1'Ii INTERCEPTOR
CERTIFICATE OF E.XEMIsHON FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
('Ibissatimnnead nMbecompleted irtheperoeir i. formichmaloold.11am($100)
orlesx.)
SEWER -SANITARY -STORM EA. 200 Pf.
Iccnifythat in thcperfnmunecofthe workforwbi,h mispennit is issued, Is1Tn11
not employ any person in any mer m annas m become subject to the Workers' Compen-
WAIHR HEATER WNENTlELECTlt
Oz
O
n lion Laws of Caifamia. Date
oil
y
q yNOTE
a;
�
Q
NOTICE TO APPLICANT: If, ager peaking This Certificate of Exemption, you should
become subject tome Wnrri Compensation senor Qa.c of the Labor Care. you mu.T
forthwith ea Provisions or this permit shall rte deemed revoked.
hwith comply with such
CONSTRUC'OONLENDING AGENCY s
WATER Sys TEM/BIiAi'INC,
WATER SERVICE
NEW HE51OBM1'IAh PLMB. SQ. FI'.
V O
Lt.0
O ULenders
W
thi That there isuad(Sea.on leading agency far porformaneenl'
work
the work for which this permit is issued (Sea. 309]. Civ. C.)
Name
Lendc Address
-
TOTAL
Icertify thea I bout rent this upplicnTinn not store thea the aM1nve information is
On
L) Z
conrU. l agree to comply with all city and county ordinances ant] amts laws relmingm
huiidingconswction, and hereby aumnrirc representatives ofthisciey teenier upon the
QTY. MECHANICAL PERMIT
PERMIT ISSUANCE.
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
AT:]ER OR ADDI'O MUCH,
liabilities. judgments, costs and expenses which may in any way accme against said City
in mequence of the gnml'mg of this permit.
AIR HANDLING UNIT (TO 10.00 CPM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE. REGULATIONS. '
AIR HANDLING UNIT (OVER 10,000 CFM)
-2� 17%
/i_ !-t_.___,._� XZ -2
Signature of Applicam/Contractor 'fiet,
EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
ITHAI [NO ON] r (TO 100,000 BTU)
Will The applicanl or future building tweepatn store or handle Itarnrdous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(:)]
HF,A'1'I NG UNIT (OVER IDBOTOM BTU)
❑Yes ❑No
VIiNfI1,AT10N PAN (SINGIJ? It I151U)
0011 the applicant or future building occupant use equipment or devices which
emit h ra mus air contaminants as defined by The Bay Area Air Quality Management
BOLI ER -COMP (3HP OR I W O(XI B'TU)
BfALER-COMP (OVER 1(0.(X1(1 BTI)
District]
0Yes E] No
Alit CONDITIONER
I have read the Tromso., materials requirements under Chapter 6.95 of me Cul,.
NEW RISIDEM'IAL MECH. SQ. ET.
tori. Health & Safety Gale. Sections 25505, 25533 and 23534.1 understand Thai if the
building dos nee currently have a tenant that it is my retpmu,b,fity to unify the acupent
of me mquirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or mina isJ agent Date
TOTAL
FEE
PE51T NO, 0346
NI'IARY NO. APPLICCAlIOOONNN SSUUBBBM:['['A[
N/C CONROL#
BUILDING PERMIT INFO
11LDG{`LEC{.'' PLUMB MUCH
El It ❑ ❑
JOB I)ESCRIPTION
RESIDENTIAL:
O SFDWL
❑ KI' I'CHEN REMODEL
❑ ADD] T]ON
❑ PLUMBING RIi PIPE
❑MUT:I'I-UNIT
[I STRUCTURAL
MODIFICATION
❑IN'IHRIOR
❑ Cl IIMNEY REPAIR
IMPROVEMENT
SWIMMING POOLS
0 BATH RENO EIJREPAIR
EIDEMOLITION
❑OTHER
COMMERCIAL:
El NEW BLDG/ADDITION ❑DEMOLITION
❑ I'ENAN'I' ❑ FOOD SERVICE
IMPROVEMEN
❑ G'lHI:R
1 _5z VALUATION
STORIES
BUILDING DIVISION PERS
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS ITH
PAID
Dom Receipt.
TO'T'AL:
BUILDING EEE
FEE
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGAJ ION FEE
PAID
Date Receipt#
DAFE
$/SQ. FT.