29556APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
Ruu.DING PROIPH II1F, FICATIDA 1 295561
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PHONE
S CONK MDR'S NAME:
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LIC NO:
NIC
❑
CONTROL
wRC DiCTnR G EIiR: LIC NO, ADDRESS:
CONE
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BUILDING PERMIT INFO
❑ Consultant Feu Paid by Appllrant (Initial)
I hcmby cell Uw I ant lian.dl under pwvixiom of Chaper 9 (cwnmcrcing v
ZpZ wiN Swtlmo N00)of UiviniooJofste Busircu and Pwfcaioru Cak. cert vliccnscu
Fes, ty in full face aril effect. D
Q V Lic'ewe Clea
rn 6 a �1e--�!�Cmu.clur
C LEI'S Pit; III I N
Op Z. I rdmwlit ry pWu shilleuwtl eti pudic rtcatls
pQ� LicePrnf¢.xmal
-+bdOWNER-BUILDER DECLARATION
411'' 1 bertby nlinn Ihv I gem exempt from the Contractor's License law for the
x 31 V f011owmg recon. (Section 70313, Business end Rofcuian. Code: Any city ce county
YI Y- whicb o mrce a earn w eumtmot, titer. intern w coolikh. a ro,ir any somemre
prig to ib ioacince..Iw tcgahes net Vplicma fa such permit to Ok. signed ruct,ni
} than he is liCVoaJ puwun m do pmvi.ionnofthe CortltstclNs license law(Cbgvtr9
CC CO (contmeoaing with Stxwn I000)sf Division ant the Mmes, mO protections Cost or
a l4 that he u caemp Rerefrom and Ibc suis fa the alleged exemption. Any violation of
xg, Section ]0313 by troy applicam for a permltsubjcgs the upplicmt to a civil p otity of
F Z Y ver mote than f vc hutdred kticel (S"))
pI, as owner of the prvpmy,wmY cmploycce wiN wege.a+that wk amts "'tion,
well do Ne work, calthehe Corcinnot, Lica trMfcrtdfor sale(,Ser.)Bid,Buenas
3 mil P ty, wh or� Code: The os Contractor', ar's Licenx Iww does not apply to no near of
property, who build. ori th latch end wh rm, each work him oro tni for
his own employes, built i cd Nat rah impt k sold . ere on iruetlslnl a olfetwl for
We.IL howevwisebuEchahrtpmretant issoldwithinoa Yearofntmove for the
rT-builJcr will save the buten M povittg Uw he did rat build m improve for pm-
paa Mule.).
❑ q v owner of the (See.
, um exclusively Prof. ng with limmd cimlrW'tVre m
cenive u do n,. 'I' I in oral. aM P who bre lbl e:) Tic Cwurzta'a Li-
ne law Jos mR apply to m owar of pwpcny vce build. err itth,mvee Chicon, or's QTY.
who annacv.[m wch pmjats wish vamtmctor(.)liccm ipursusnuotlw Cnnvacuvs
Beene lay.
❑Lton cecmp urdtr 5¢. ,B&1'C for Ni. moan
Owner -I-
WORKER'S COMh1JSAfIUN DIiCLARATION
I hereby atm utlJtr anally of perjury nor of lie following dechmannon:
❑ IMve amt will nuinsnina CrniOcam MCmwnl In wlf-inwmfaWnkciaCnmpcn-
eeNn, as PmviJot for by Sewion 37M of its, Lamm Coate, for the pennon urc- M the
wart fa which this Perrin is honed,
E] I bave and will maintain Wakcr's Canlxn.wlion Insumnce, err requited by Section
3700 of de labor Cale, fa the nerfaretee Mthe work fa which thio peamn is awed.
ANly Works Compere tin lowmae ci rioT and Policy nurbur ore:
Came'. Policy No.:
CERTIFICATE. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibisonion rcN to a cvmpinW if Nc Permit u fon we hvx4ed Uollu.lS I W)
m Ion.)
1 certify that in Ne peffoomi Mthe work for which Nis permit m not id, I shut]
not eat any perm many mantles to as m become whjees m the W'Mcri ConsPcn
O Z tenon laws of Cslifmnme Dwc
Z O Applicant
.lam NOTICE TO APPLICANT, If, slice making this CeniGmM
ce Pemou fmor. yshould
�' become sublet to the, Worker's Canpcaation povinons of the labor Code, you mw
lLl fanhwiN comply with wch Provisions or this pmnit shall be trialed revoked.
Q
] Z CONSTRUCTION LENDING AGENCY
V O I herehy affirm Net mere is a aonnmction lerdlog ageruy for the frrfm mee of
the work for which this panda is issuad (Ses. 3(IY], Civ. C.)
Israll Norte
V Racer's AdN , .
yI cutify Not I hzve toad this.wiicnion erd . Nat Ute above o imution in
Uy rnnat l egnc no cmy+lY with ell dry coat rnuntY miimrcn erd smtc Ivwe «laming m QTY
Z budaingcateunatkn.aro hereby anwri.e repre.eatativeeMNnnty memtrnpat we
above-menuotd property fa hr aloaiion putpo ex,
(We)trgmc lo me, intlemnily land keep hvrleav the City of Cupenim a sumo
Iiabilwn,llWgmeoss, co W, mal expenses which any, in any vey atvue nicest and City
in casxequence of to grenning of Nis Pemmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
J SOURCE REGULsiJIONS.
/ HAZARDOUS MATERIALS DISCLOSURE
Vol One epplic.m or future builNr, oc"Mat stere orhvdlc b.vnluu mistrial
ss Aefloi by the Cupcninu Municipal Oslo, Chshtcr 9.13, mal Be HuIN cert Safety
Cods. Satin 25532(.)?
❑Ye: FI No
Wit] the.pplieem a f inure building occupant use equipment a devisen which
mit lwuudnm dr anmmimunB m &&.mai by the Hay A. Air Qurmly Memgemem
DiNnal
[j Y. No
I have recd Nc ha>mdtus matarials rtyu'ventws otdw Chvf.tr 6 q MsheCal i-
ftrnia Itenth & Safety CWa Semiunx 25505, 25533 mal 21514, 1 mloursand IMI if the
buikiing atm m cone'tly hire v remora. dna in is my newonsib iry to notifyto ocufmn
of the requitrnmss which non M trcl print m i.cttunce ref. Cent ficnte of Ocupwcy.
Owner or erAmend agent Dela
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCULI MISC.
TEMP. METER OR POLE IN5M
POWER DEVICES
OUT,U TS - SWITCHES - FIXI V RFS
NEW RESIDENTIAL ELEM SQFT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER( )
BACK FLOW PROTECT'. D WC
DRAINS - FLOOR POOR C
FTKT UREC - PER TRAP
GAS - E.A. SYti fEM.I INC. 4 OlJTLt5SV, lar
GAS - E.A. SYSTEM OVER J (EA)
GRIASEINDU.STRI. WASTE INTCRCET'OR
GREASE TRAP
SEWER -SANITARY -STORM EA, 2200 ff.
WATER NEATER WNENDE.ECTR
WATER SYSTENI/fREATING
WATER SERVICE
NEW RESIDENTIAL PCMB. SQ. FT
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MLCH.
AIR HANDLING UNE" LTO 10,000 CIM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD (WMUC )
HPATING UNIT (TO 110,010 BTU)
GRATING UNIT (OVER 100.000 BTU)
VINTILAGON FAN (SINGLE RESID)
BOILER -COMP UHP OR 10(1,000 BTU)
BOILER - COMP (OVER 100.0)) BTU)
AIR CONDITIONER
NEW RESIDENTIAL MECH, SQ. PT.
OFFI
FEE
1 B DESCRIPTION _
RESIDENTIAL
❑SFDWI, ❑ KRCHFN REMODEL.
DMON ElPLUMBING RI PIPE
MULThUNff ❑STRUCTURAL
MODIFICATION
❑ INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEL a E 4AI� Cl DEMOLITION
El OTHER
MAY 2.9 1OO_
COMMERCIAL,
❑NEWBLDGIADDITION ❑DEMOLITION
❑TENANT -vt LfII IOFOOD SERVICE
IMPROVEMENT
❑ OTHER
FEE
SQ. FT FLUOR AREA LSQ. h -L
-)'ba it�
VALUATION
770:F ?
STORIES TYPE CONSTRUCTION
(ICC. GROUP AM
BUILDING DI .ION FEIS
PLANCHECK FEE
ENERGY FEE e f
GRADING FEE
SOILS FEE
PAID
D N><ip Y
BUILDING FI
FEE SEISMIC FEE
ETECIRIC FE
CONSIRUCIION TAX\
HOUSING MITIGATION FEE
PAID
Date Receipt 0
ISSUANCE DATE
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