29659' APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO - ,'i.. '• '.
BUILDING DIVISION APPLICATIOWPERMIT
'11 - BUILDING: ELECTRICAL
PLUMBING - MECHANICAL
PERMIT NO.
1
29659
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1 BUILDING PROJECT IDENTIF'ICAT'ION
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BUILDINGADDRESS:
FEE
SANITARYNO, o- -
APPLICATIONSUBMITI'ALDATI
/O -AL D£R OR 009 , X27.
ELECTRIC di
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OWNER'SNAME: PHONE:
CON 'IRACTOR'S NAME:O4T1iRO0771S LIC NO: [�
s FC /4L( GJyOP1Y'
N/C
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CONIROL#
4CIITIECr /RNGINEER: - - LIC NO:
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ADDRESS _11V ZSLQ4..�G"Q. C%�P1La
CIS
CONTACT '• - PHONE:
sectjmt 7031.5 by any nppheam fm a permit mbjwl, the ttpplicmn in a civil hooky ref
tat more than five hundred dollars (S500).
1, as nwnerof the property or my employees with wages as their,me compensation,
will do the work, and the strucmru is net intanded or offered fur Selo (Sec. oA4, Itusinesx
BUILDING PERMIT INFO
'
❑ Consultant Fees Pail by Applicant (Itiilinq
BLUC ^ LE PLUS MECH
LNG MITIGAI "ION FiiE
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F,LL—
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hereby aUirm Ihm 1 am licenutl under provision, of Chapin, 9 (commencing
with Seuinn]OINO of Uivision3efthe Rosiness and Professions Cale, xnd my license lx
in full three and effwi. �7 - i• 4Q'�jy
Liccnu Class !J Lic. p ( A J
Dam Cnmmclm
ARCHITECTS DECLARATION
1 undemanit .,,]..,,bull Reused a, public rums,
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FEE
SEISMIC FHE
Licensed Rnlessiowl -'
OWNER BUILDER DECLARATION
ELECTRIC di
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1 hereby offum that 1 am exempt from the Contractor's License Law for the.
following reason. (Son ion 7031.5. Hu,incss and 11 ficAions Cede: Any pity or county
'which
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requires o permit to construct, alter, improve, demolish, or repair any .arvcmrc
,nor m its issuance, also inquires the applicant for such permit m file a signed statement
Ihal h¢ I, lleenmd pursuant la the awi,ion,or the Comotelo., Liveno, Law (Chapin 9
fccmmencingwith Section]UOB)'of Division 3 of the Business and Profession, Code)nr
,bat he is eacmpt therefmm and the basis harder alleged esemptimv Any violation of
.
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sectjmt 7031.5 by any nppheam fm a permit mbjwl, the ttpplicmn in a civil hooky ref
tat more than five hundred dollars (S500).
1, as nwnerof the property or my employees with wages as their,me compensation,
will do the work, and the strucmru is net intanded or offered fur Selo (Sec. oA4, Itusinesx
a3
end Professions Cale: The Comtnciors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himselfur through
LNG MITIGAI "ION FiiE
his own ompinywa, IT vid,d but such improvemmnts am not imendnd or oRercd for
sale. If, however, the building or improvement is sold within one year of completion, the
er- buildrr, will have the burden of proving that he did nor build or improve for par-
-
pose or sole.). '
L un exd Pommeling cantmmors m
ronswn the project Business and Code:)cTheetl
the Project (S 7e , B
Business and Code:) Ilse Contractors Li
rtywhosedporimpro thereon ,and
cents Luwdm,r apply to an ny who bus
p
Q'1'y,
such
who contracts for such projects with acontracmr( v) Iicenud pursuant to Contractor's
ajectsownenntraca the
License Low.
'A,
❑ Tom exempuunder Sec. . B & P C far,low reaum
ner Date
1 WORKER'S COMPENSATI ON DECLARATION
T hereby affirm under penally m one of me dwloms
id Cm immic or Workers
❑ of COnunt Cousin-
t
nation, as provided for by Section J]00 of the Labor Code, for the pvrtormoncc of the
as pro ide for by Se Lion 3700
ce of th_
r Code, for the performance
;kA which this permit is issued.
3
Q]'f has a and will maintain Workers Compensation Insurance. as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
_
My WorkersGnnpcmtionlppunmcen,,oar and Policy ny�bw not
Carrier. S7tiTf i%!/'MQ PolicyNo.:�T /O/ 69
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPHNSA'I'ION INSURANCE
(This version need not be completed ifthe permit is far one hundred dollars ($100)
orles.s.)
Icrady'limotheperf nice it he work for which ibis pernnh is hooed,I skull
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not employ any person in any manner m es to become suhjwl to the Workers' Compero
,anion Laws of California. Daie
Applicant
1
NOTICE TO APPLICANT: If. after making this Cenificam of Exemption, you should)
become subject n the Workers Compenxation Proswima of the Lobar Cade, you must
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forthwith wmply with such on,kors or this pertnh'shol l be deems] cooked.
CONS" 1 RUCTION LENDING AGENCY,
. Ihemhyuffnn Phut there is aamstnutinn lcnding agency for tlm PCd ounnee of
the work for which this an nit is issued (Sce Noel Cie C.)
Lenders Name
Lender's Address
I really thin 1 have read thi, application and ,lam that me .Mme information is
correct. l agree to comply with all city and county ordinances uW state laws relating to
buildingconuruction, and hereby aumnriee« prexentmivesafthis city mentor upon the
a me-rucnthomrd property for inspection Purp we'. 'H
QTY.
OVT agree to save, indenmify and keep harmless the City of Cupti ino against
ham lilies, judgments, costs and expenses which may in any way accme against said City
in comequence of the grunting of this permit.
•
APPLI NT UNDF.RSTANDS,AND WILL COMPLY WITH ALL NON -POINT
.OUT 'E R�EG�ULAATIOON�S�/^'
New/ • I'f/�^ � �� /J 'Z.G'
V HAZARDOUS MATERIALS DISCLOSURE
Will the epplicunt nr foram building ocapanr store or M1andle harardnus ma rdfit
as deliaed by the Cupenino Maricipal Code, Chapmr 9.12, and the Health and Safety
ell, 25532 (0)7 -
❑Yes ON.
Will One applicant or future building occupant use equipment or devices which
emil barsrdnus air contaminants as defined by the Bay Area Air Quality Management
. 1 Disuricli
Fl Yes ON. -
1 have IT the hvardmi, mmenals requirement rmder Chhpmr 6.95 of the Cali.
mania Health & Safety Code, Sinuous 25505.2553] and 25534.1 understand that if the
building does not currently haven meant, that it is my responsibility, to notify the accupanl
of the requimmems which must be nnei prior to ismance, of a Cenificam of Occupancy.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
PANELS `
UP TO 200 AMPS
FEE
TEMP METERDR .INST.
POWHRDEVi (-
-
SWIMMINGP I.ii IC Af
oU'ri_ETS -SWI - IX' ES
NEW RESIDENTIAL HLEC R SQ Fr.
TOTAL
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT - WATER GZA)-
HACK FLOW PROTECT. DEVICE.
DRAINS `FLOOR. ROOF, AREA, COND�. —�
FIXTURF,S- PERTRAP . l/'
GAS -EA. SYSTEM -I INC.4OUTLEfS
GAS - B. SYS'IEM OVER 4 LEA)
GREASETRAP r
SEWER - SANITARY -STORM EA. 200I7.'•
WATER DEALER WNHNT/F.I.ECI'R
WATER SYS'DEIG BEATING
WATHE SERVICE +
NEW RESIDENTIAL PLMB. SQ, PT.
TOTAL
MECHANICAL. PERMIT
PERMIT
ALTER OR ADD TO MFC L
AIR HANDLING UNIT GO 10,000 CFM)
AIR HANDLING UNIT' (OVER 10,000 CFM)
EXIIAUS'r GOOD(W /DUCT)
HEATING UNITUG 100.000 BTU)
HEAPING UNIT' (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100.000 BTU)
BOILER -COMP (OVER 100,11011 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. icl
OFFICE
COMMERCIAL:
❑NEW BLDG /AUDITION ❑DEMOLITION
❑TENANT ❑FOOD SERVICE
.-IMPROVEMENT
❑OTHER.
LIurrhliry0
FEE ^
STORIES TYPE
FEES
PLANCHECK FEE.
ENERGY FEE
GRADING FEE
SOILS THE
PAID
ate Re tp
0 S17DWL ' ❑ KITCHEN REMODEL
❑ADDITION ' ',� PLUMBING RE-PIPE
❑MULTI -UNIT ❑S'TRUC'TURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
ATH REMODFUREPAIR ❑ DEMOLITION
OUTLIER. '
-
'
f
TEMP METERDR .INST.
POWHRDEVi (-
-
SWIMMINGP I.ii IC Af
oU'ri_ETS -SWI - IX' ES
NEW RESIDENTIAL HLEC R SQ Fr.
TOTAL
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT - WATER GZA)-
HACK FLOW PROTECT. DEVICE.
DRAINS `FLOOR. ROOF, AREA, COND�. —�
FIXTURF,S- PERTRAP . l/'
GAS -EA. SYSTEM -I INC.4OUTLEfS
GAS - B. SYS'IEM OVER 4 LEA)
GREASETRAP r
SEWER - SANITARY -STORM EA. 200I7.'•
WATER DEALER WNHNT/F.I.ECI'R
WATER SYS'DEIG BEATING
WATHE SERVICE +
NEW RESIDENTIAL PLMB. SQ, PT.
TOTAL
MECHANICAL. PERMIT
PERMIT
ALTER OR ADD TO MFC L
AIR HANDLING UNIT GO 10,000 CFM)
AIR HANDLING UNIT' (OVER 10,000 CFM)
EXIIAUS'r GOOD(W /DUCT)
HEATING UNITUG 100.000 BTU)
HEAPING UNIT' (OVER 100.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100.000 BTU)
BOILER -COMP (OVER 100,11011 BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH. SQ. icl
OFFICE
COMMERCIAL:
❑NEW BLDG /AUDITION ❑DEMOLITION
❑TENANT ❑FOOD SERVICE
.-IMPROVEMENT
❑OTHER.
LIurrhliry0
FEE ^
STORIES TYPE
FEES
PLANCHECK FEE.
ENERGY FEE
GRADING FEE
SOILS THE
PAID
ate Re tp
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TOTAL:
BUILDING THE O
f
FEE
SEISMIC FHE
Q
ELECTRIC di
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MECH [CAL 1'EE
CON y RUCTION TAX
IIOU.
LNG MITIGAI "ION FiiE
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