29634 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL - 29634
r e BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: /y I SANITARY NO. APPLICATION SUBMITTAL DAri
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O ?R. NA •�� a t PPHN C091 RAC ,LIC NO: NIC CONTR(II.p'
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"""TL'CT'EN GINCER: .. 1.1 NO. ADDR
CONTACT: PHONE: BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial)`• BLDG 'ELECT PLUMB MECH
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE.
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
'�a,Z with Scotto0700omDiAti.a.3m,he Businessand Professions Code,rend my license is - . . r
O O PENMO'ISSUANCE RESIDENTIAL,,
Uin full force and effect. I ,I
License class Uwq - - ❑SFDWL _ '[I KITCHEN RE-PIPI,
N<L Dam Conmaor APPLIANCIS-RESIDI?NHAI. ❑ADDITION ❑PLUMBING RE-PIPP.
ARCHITECTS DECLARATION PANELS ❑MULT.UNIT ❑STRUCTURAL
Z p[ri 2 I umleneand my plans shall be used as ppblic recoNs MODIFICATION
pml- Licensed UP T02IN AMPS - El INTERIOR ❑CHIMNEY,REPAIR
rr 1Licensed Professional s. - 301-I0g1AMPS IMPROVEMENT
a •1
OWNER-BUILDER DECLARATION OVER IgA1 AMPS 0 BATH REMODEUREPAI 0LIUON
yy 6 I hereby (Sectffirm that I am exempt from the Comment Cas License Lew for the a� �--
pe30.0 followingtemoa.(Sutton]onstru Businessand Professions Cash:Any city or county 'SIGNS F.LT:CTRICAI. g",LO G�m !
Which requires o permit to construct,aha,inspreve,demolish,or repair any stmnurt G
y.a7 mit he it,tensed p,ulsorequiree thovisioso me Commatniunicense a"'oChtemem SPECIAL Cl RCUIT/MISC.
that he is licensed puauannnthe provisions of Ne Conwemrs License Low(Chepmr9
p0 (commencing with Section]OW)of Division 3 ofthe Business and Professions Code)or TEMP.MI?TF.R OR POLE INST - COMMERCIAL:
dy M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of - [I NEW BLDG/ADDITION [I DEMOLITION
Permit XON Smoon 7031.5 by any applicant far a subjects the applicant to a civil penalty of POWER DEVICES. [)TENANT FOOD SERVICE
4F. nor mora then Eve hundred doll...($50% IMPROVIiMP,NT -
d0
E] Los mearrnfthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC' - -'
will do the work,and the sloomme is not branded midbe ed fnr.le(Seo.7044,Business El OTHER
and Professions Code:The Contractors License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTU :,S
progeny who builds or improves thereon,and who does such work himself or duough his own employees,provided that such improvements ate not intended or offered for NEW RESIDENTIAL ELECT SQ ET
sale.If,however,the building or improveamet is sold within nae year of completion,the. - SQ.IT.FLOOR AREA $/SQ.FT.
_ owner-Milder will have the burden of proving that he did oat build or impmve for
AC]51.as owner of the property,am co exclusively contracting with licensed mentum to _ TOGA
nsuuct the project(Sar.70th,Business and Professions Code:)The Contractor's Li. -
QTY. PLUMBING PERMIT ^ air
cense Lew Jxs not upplyao an owner of prnpen who builds or improves thereon,anA �• PEE p,
who umin c prnjectx withacnntrnnhr )licensed p....ra othe Companums - 7�
Lice ,uw. PERMIT ISSUANCE ✓fit' 190"
!..
❑ a axe t rade . ,B&PC fort ismason s7
ALTER-DRAIN&VENT-WATER IEA). - (YAfJUAT10N
WORK ER'S'CONITION D[CLA 1to
0 BACK Is1,OW PROTECT'.DEVICE , /FV
T hereby inform under penalty nl'pejury one of theta owing declarations: - -
1 have and will maintain o Certificate of Consent mse1G t'
❑ mforthe Worker's Compere DRAINS-FhOOR,NOOP,AREA,COND. STORIES TYPE CONSTRUCTION
work
r provided for mi Section PILO of the Labor GNe,for the Performance of the
work for which this nmetit is i orkJ. FIXTURES-PER TRAP
❑ I have and or Code. on Workers Compensation work
who h rtyuirtd by Section ,
MyWftheLCo Cnsatinthsuranci cancer fthe and
forthrwa:spermit is issued GAS-1iA.SYSTP,M IINC.40UTLF:TS OCG GROUP AVN
Ce Workers Compensation Insurance carrierroli Policy Weather are: GAS SEA.SYSTEM-OVER4 GZA)'
Carnec Policy No:
CERTIPICATEOFFSNI[ON EXEMPTIONMOMWORKERS' - -
COMPENSA'T'IONINSURANCC GRF.ASPJINDUSTRL WASTE INTERCEPTOR
(1 hlssemion need not he completed if the permit is fir hundred dollars($I W) BUILDING DIVISION FP.ES
GREASG
orlv..) - - - 'TIiAP
- PLANCHECK I:EE
I cerifythea intheperfnnnancc.fthewmisfnvehicbthispennit is issued.)shall soSEWER-SANITARY-.9ORMEA.2(p IR. -
not employ any person in any manner sm e1 m become subject er'u the WorkCompere ENERGY FEE
O Z sotto.Lows of Califomia.Dam WATER HEATER WIVENT/F.LECTR
Z O Applicant GRADING FEE
h
NOTICE 10 APPLICANT Ifs often nuking This Certificate of Fourftimn,you should WATER SYSTEM/TNI?ArTNG
abecome subject to the Worker's Compensation previsions a]the Labor Code.you must SOILS FEE
Pi Q forthwith comply with such provisions or this a mildiall be deemed ecradid. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDEN'HAL PLMB. SQ.ET. PAID
L) O 1hereby.affirmotor there is a rnnvuucom lending agency far the pebormace of - t Date RemE,re
w ?. the work for which this permit is iswed(See.3097,Civ.C.) Vr
Q FF'"'L) Imulm's Nana TO L:
Lenders AdJmss TOTAL:
1 certify that 1 have mad this application and state that the above information is BUILDING FEE
4V) comm.I ugreetocnmplywithell ciryandommotmiromeesand ,are hovionlatingsn QTY MECHANICAL PERMIT FEE 56 1
U building nos.dmdion,unJ hereby authnriru represcntmivcs of this cirymenmr upon the SEISMIC FEE
above.metnioned property for inspection purposes. PERMITISSUANCE
(Wm agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiabilitim,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MUCH,
in consequence of the granting of this permit - PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALi,NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) -
SOURCE REGULATIONS. '^ MECHANICAL FEE }
AIR HANDLING UNIT(OVER 10,0110 CFM) CONSTRUCTION TAX
Signammof Applicant/Comracmr Dam EXHAUST HOOD(W/DUCI)
-HA9ARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hatandous material HEATING Gist m100.010 BTU)
asdefined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety - - . 11Code,Sminn 355" ? HEATING UNIT(OVER I00,000 BTU)
❑Yes C]No VENTILATION FAN(SINGLE RESID) PAID
Date HeceiptM
Will the alieoni ter future building use n ase equipment of devices which
mil
ehavvJoaaaiir rmmouJnontsmde0ned6,hytheBayAreuAirQu�lityMonage'tricot' '" BOILER-COMP(311PON OgWO gTlI) '
TOTAL:
District? - BOILER-COMP(OVCH IW.00p BTU)
- Ldoe�a
Fl No •
ad the hmardous mammals to uimmems under Chapter 6.95 of the Cali- AIR CONDITIONER ,
y _ ISSUANCE DATE,
Safety,Code,Sections 45511.5,25539 and 335.4.1 understand that if the NEWRESIDENTIALMECH. SQ.PT. -
nten t base.tenant,Nal it is my respnsibility m notify the micuparscou which must he met poorto issuance of o Certificate of Occupancy.itted agent - Dam - � TOTAL: t ISSUED BY.
OFFICE