29895 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUII.DINC.-EI.ECIRIGL PERMIT NO,
BUILDING DIVISION APPLICATIOWERMIT PLUMBING-MECHANICAL 29895 Q 8
• BUILDINGPROJEC9 5
I'IDENTIFICATION L J V J V
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
e647 cs a Ass 746AWe&IEAb
, O NER'SN E: PHONE: CONTkfCTUR'S NAME: 1,A';1X64LIEN
NIC COople
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CHITS /ENGIN
UC NO:
BESS
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ALT: PHONE: BUILDING PERMIT INFO
��7Q—/W c Q Consultant Fees Pald by Applicant(Initial) BII�pc� ELECT PLUMB MECH
/ e/[/ ELI ' ❑ ❑ ❑
NZ LICENSED CONTRACTOR'S DECfANAI'ION QTY ELECTRIC PERMIT FtE JOB DESCRIPTION
I hereby affirm dw I am Iicensal under pruvixinnn of Clwper 9(tonmcmeing
{v�{vaZ with section 7lXIB)ot DiviWon3afmheB 'ne.cndt e..ime Cnoodeoir hoyjice.ie, - RESIDENTIAL
F�� fullfaceenl eet _ �r Z ( PERMIT ISSUANCE
�F.UZ�
Lice Lc.e— ❑SFDW_ ❑KITCHEN'REMODEL
N<U Umc�Coo'D.L APPLIANCES-RESIDFIlT1AL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS UELI.A _ ❑MULTI-UNIT ❑STRUCfURAI.
Z O VJ'Z I undcrwnml my p omit shall be used,.forks resurrect PANELS MODIFICATION
OZJp UPTOMAMIS ❑INMR10R E]CHIMNEY REPAIR
Q��; banal PmfcssiowW 201-IIXk'1AMPS IMPROVEMENT
'
OWNER-HUILOER DECLARATION OVER I"AMPS El BATH REMODFLAEPAIR El DEMOLITION
o w 6 I thereby infirm am exempt 1 aexempt from the Convactm's License Law for the
3 L U following retxw.(Section 9031.5.Business and Professions Code:Any city car county SIGNS ELECTRICAL OOTHER
iL which requires a pmmit to cansmart.•alter,improv[,demdish,a repair any.rrucome
1=C primm its its one:,also requires the applicant for such Permit to file a upad statement SPECIAL CIRCUIT/M ISC.
twt die licrnsd pmutnt mo tic provision of de Contracuc's l,icenw 1aw(Chapter9 i
z.. rc ingwit Sccuon 1— afI .faliuon3Buslwt,dRofcssiauodc
C )u TEMP.METER OR POLE INST. ('OMMF-
NCIAL'
a a ohnhen eaemM ibctefmm ud the basic for the allege)c ion,imn Any vidwiun of ❑NEW BLDGIADDITION C)DFh10LITION
Section]03 13 by any yglw of fa a Person subjects the eplicant us.civil finally of Pn 'ER DEVICP_S
H ommore than Eve hunhed dollaa(351gp. s ❑TENANT ❑FOODSERVICE
TSCA ❑ 1,uawmerofneproperty,or my employees wit wages as their it sale contpenatif�
un, SiSW 1 LECTRIC IMPROO p�
�f_. willow the work,enJ lh xwclwe is not inmRYlCd oroRtrd for sale(Sa.]011,Bmiass - ❑OTHER O
W and Pmf.imo Cale:The Cvm or'x been law mkret not algly to uowns of ( O WITCH FIXTURES
6 a^
property,who b drus or Imp wv thrrnn,and who doe such wort himself or through _
his own employees.Provided that wch impnn'emtnn as not mendid m nlTertd for NEW RES IAL L SQ IT
sale If.however,tie hod" g orimpovcornt is saw ithinar year ofcanpletinn,etc -� SQ.FF.FLUOR AREA fasQ,UP,
own
a-builder will have be huden of proving that he did not horrid or improve for pur- -
pose of ole.). I �-
1,ori owner or the Property,am exclusively contracting wit Ilttto end constructors to TOTAL:
comwct the project(Sec.7044.Businns ad Prds lioru Ctsfe:)The ContronNx Li-- OCTe law does wtvpply m an ow.M Pmperty who buids or impavn thereon.and QTY PLUMBING PERMIT FEE �p5r
whoo
con .cuch fortaproject,withtcontmcmbs)lieu pununnuotM Cooucewe SOC u
Liana law. PERMIT ISSUANCE
❑ Ino exempt under Sec. ,B&PC nor time<wn
LBR-DAIN&Vi -WATER F
Prcr be U // ON
WORKER'S COMPENSATION DF,CLANATION BACK FLOW PROTECT.DEVICE
I IMcby affirm order peonity ofperptryarol the folbwing dcaLuviom: O(/
❑I have and will maintain a CenificvtofCunscni mwlf-inwm for Wotkcr',n Cnmpcm DRAINS-FLOOR,ROOK.AREA.CONE.
svioa u povidM for by Section 37M of the labor Cale,for the perforrnwmce of the STORIES TYNECONSTRUCTION
wale for which this permit is ixwd. FIXTURES-PER TRAP
0 1 Nie wd wBl m,imain Worwins Carmen.ation Inaurwe,as readied!by Section
37Wofthe tado,Condo.lie the p<ifomiweoftlic work far which tis perp mis issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
MyW Gunn and Policy umber Z GAS-EA.SYSTEM,DVER 4IEA)
Ce s policy rR0
IPICCOMPEA�l 17 I ETONIPT I NIRA OR F.RS'
COMPENSATION color ATION INSURANCE GRPASF/INDUST'RLalASTE INTERCEPTOR
(Thisrmion nerd rot ht contplcmd if Ihapcmtit is Brar hundred Dollars(g TUI) BUILDING DIVISION FEES
m�.) GREASETRAP PLANCHECK FEE •'� LIC
Iccnify that inlfc perfarmuemdtt work fmwhith to lcrmim ii imucd.],"It SEWER-
nosho y eery perm.in any manor sec ex to beca.suhjmmno Workcn'ComPcn- SANITARY-5"IORM1I GA.3(p FT. ENERGY IEE
O z avian laws of Cadifoo,m.Due WATER HEATER WNENT/E1ECHt
z O Appfirvu GRADING FEE
rn NOTICE TO APPLICANT:If,eller outing this CerdG m of E,mmptiaq you should WATER SYSTFlA/IREATING
1^ — become subject to the Wmrrl ere,Compensation pmviomon of robe Lahr Cud[.you most SOILS FEE
fonhwit comply with'aoch Mvivons or this permit stall to Ueentd resulted, WATER SERVICE
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL NAB. SQ.FE PAID
U 0 hereby uffimnhet tart ieaco.,nwmiun kd'mg agcrcyfortk(Marrunce of Vie Reeeip♦
Or. Be wvct for which his permit in issued(Sari.3W7,Cis,C.) _
Lrndcls Nano TOTAL:
V Itafc(s AJdrexc TOTAL:
I certify that I have read this alfidication umd some that to those information is - B •FEE r.
rn moat 1,gree m comply with ell cayend...nmyoommwnax mdstaa luwn mlvingm QTY MECHANICAL PERM IT FEE
U z building construction.ted hertbY,ulturia rtprtxcwdve M tis sitymrn1,upon the SuMMIC FEE
above mcnlicrerd ItnMcnY rte inxpcclioo puryora.
IWOsgosa to rove.indemnify anal tali haodcssthc City of CuPcnint egrira PERMIT ISSUANCE ELECTRIC
l iabiloies,judgm oris,costs anal sapensa whwh may in any way accrue,guvt aid City'
in mnsecii M the graming of this permit. ALTER OR ADD TO MECH. PLUMBING FE
APPLICiIKU UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 101"CFM)
SOUR R GUTATIONS. MECHANICAL FE
AIR HANDLING UNIT(OVER 10.000 CFM)
CONSTRUCTO'TAX
I Sig? eaf Applicanuo(Convecmar j6tc EXHAUST FOOD(WNUCO HOUSING MITI ON FEE
HAZARDOUS MATERIALS DSCLOSURE
I Will the aMbetht or future building ocrripant msec or handle hudnus material HEATING UNIT TO In),"BTIH
its defined by in,Cupcdno Municipal Code.Ch,ptn 9,12 oral the Henth ad Safny _
Code.Sectio 25538x1? / I(EATING UNH(OVER I W."BTU)
C]Yea �Q
VEN9l IATION FAN(SINGLE RES ID) PAID
Will the Dam Receipt a
air ccomntafmua Willing by the Bit,
Air
Micateepeh BOILER-COMP UHP OR I WADI BTU(
tilt haradtus air conlomivnts as dcMN by the H,Y Arte Air Quality Mwgemrnt TOTAL
Dmonn tC)Yes BOILER-COMP(OVER[W,000 BTU)
I hese mad tk lumdome nm 0,matml ms oda Chapter 6.95 of do Cali- AIR CONDITIONER ISSUA DA
f madth&Sunny Cale,Sections 2596,25533 and 25534.1 udenwnd that if the NEW RESIDENTIAL MECH. SQ.FT
idi doermswernly buveatrnant.that int is myon prtnitilim mtify ltr uccuptnt
f � heeYnl/rJ�w�hit iou be mel poor m ux.,.,.� f e J/O�j�mcy
I, Oxee'.11 l IAagent a
(s/C� Igoe TOTAL: - ISSUED BY:
OFFICE