29543 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAI. - FERMI T NO.
BUILDING DIVISION APPLICATION/PFRMIT - PLUMBING-MECHANICAL. 29543
BUILDING PROJEC P IDENTIFICATION
UILDING ADDRESS'. /J . Qh,•��j SANITARY NO. APPLICATION SUBMITTAL DATE
N t 'S NAMIt. %LG 1j5 NE.- 363••00 CO - 'NAME: LL �O / /�� � �V
•NIC CONTROL%
ARCIHTECUHNGINEE LIC NO: ]LESS:- ❑ '
Z De C e
CONTACT: - / PHONE: t-aa� BUILDING PERMIT INFO
6'e C .le•Z55a3363 1(rk:onsultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SIRED
❑ '❑ ❑
Lrm that
DCONnHd orderSDECar,.1 CON QTY ELECTRIC PERMIT FEE
I hereby affirm mat 1 lam licensed Be ander provisions of chapter 9(anmmenphtg JOE DESCRIPTION
OmZ with Section
ull reand effect.
Jofine Business and Professions Cale.anJ mylicenseis i /
X00 in , PIiRMIT ISSUANCE 3� eJ RESIDENTIAL:
Nul fenseClass effect. TTS WI. D KITCHEN REMODEL
-UW License Class Conor APPLIANCES-RE.SIDENI'[AL
tF�i Dam Cnmrunus DUITION ❑PLUMBING RE-PIPP.
ARCHITECT'S DECLARATION - DMULTLUNIT TTSTRUCfURAI.
z O '6 1 undersand my plans shall be used as prude accords PANELS
yMODIFICATION
OZ-, UPT020(AMPS El INTERIOR ❑CHIMNEY REPAIR
f=�F'u1 Licensed Professional - - 201-IgRAMPS - IMPROVEMENT
OWNER-BUILDER DECLARATION
a� OVER 1000 AMPS D BATH REMODEVREPAIR EI DEMOLITION
WW WQ I hereby.(Firm that am exempt from the Contractors License Law for the
pe,3dO whichfullossinguires..(Semon]ommBusinessamive,dela ti Code'.Anydry oramnty SIGNS ELECTRICAL ❑0'THER
W Ce which require.n permit re tunswet,abaq improve,demolish, fi repair any atucmm
W r,n.] bathe sfiveranee,vlsotaluirestheepplicuntfae Comenccons nLiOm Law(Chapter
SPECIAL CIRCUIT/MISC.
F, M thmheircia xod pSWiourthepmviOxmn3 ofte Business
nd Proe Lames Cos
ter9
� 00 (cntrtmencing with Sretion](100)of Divisionl of the Nosiness end Professions Cnde)or TEMP.METER OR POLE INST COMMERCIAL; ,
d p,m pC that he is exempt therel'rme and the basis fell the.11c,d exempoem.Any viol,nion of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLX7 4N•Q Sect 701 LS bynnyapphearanfar a permit subjects the applicanno a civil penahy of POWER DEVICES []TENANT ❑FOOD SERVICE
han
of more tfive hundred date. S500). IMPROVEMENT
-
D1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
I-es will do the work,and the swre ctuis not intended reoffered holstic(See.]Oi6,Business DOTHER
3 m and Professions Gale:The Contractors License Law does not apply to an owner of OUTLHI'S-SWITCHES-FIXTURES 1 3
property who builds or improves thereon,and who does such work himttlf or through
his own employees,Provided shat such improvements am not intended or offered fur NEW ItESI1lENT1 'ELEC`I'R - SQ pr.
sale.If,howevun the building or intproventent is sold within one yenrefcompletion,the SQ.FT.FI ARBA VSQ.FT.
ovarebuilder will have the harden of proving that he did not build or improve for pur- T\Yh,
pose of role.). q v—
❑
I.as owner of the property,am exclusively contracting with licensed untraema to TOTAL: / ` `J
mnstmat the project(Sec.7 W,Businessland Professions CsdcU The Contrnnors Li-
cense law dors nm applymmowner orpmpeny who uratic or unproven rococo,.and QTY. PLUM FERMI .PGE v\ ��l \1 �Q �r
who contacts for such projects with a crntrrctood licensed pursuant Contractors ll....VV
ense
0 lamlxenpXr Sec. j 20f-
_,B k PC for his reason PERMIT ISSUANCE - '
Iflwner pate ALTER-DRAIN&VENT-WATER(EA) VALUATION
W CER'. OMPiit:AI N DECLARATION BACK FLOW PROTECT.DEVICE
Iherebya8 ,made enalty of perju one of the following dcclaradone V yL�C�
D l have and will maionin uCeniBwte of ConxentmsdGlnsure for Workers Cnmpen- DRAINS-FLOOR,ROOF AREA,COND, STORIES TYPE CONST RUCTION
cation,as provided for by Section 3700 of the Labor Cale,for the performance of the
work for which this permit is issued. FIXTURES-E'ER TRAP g
❑ 1 have and will maintain Worker's Compensation Insurance,lax required by$mina
3700of,he Labor Cede,fortheperfomtnnceaftnewark farwhich thicpernit is issued. GAS-FA.SYSTEM-1 INC.4 OUTLETS -'OCQGROUP APN
My Worker's Compensation Insurance carrier and Policy nrmher are'.
Caere,: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE - GREASIIINDUSTRL WASTE INTERCEPTOR'
Mesectinnneednotberompaued if0epermilisforunehuMreddollars($Ifq) BUILDING DIVISION PEPS I -
or lair)I GREASETRAP PLANCHECK FEE "'i
cenify that in the pem
tfonnnncfthe work for which this pemtit isissued,
..apin-l SEWER-SANITARY-STORM G. FT 200 �+
not employ any petsan in any mun,ter so m-to became suhjut m the Wurkvrs'Cnmpen ENERGY 17EE
at-11
Z .firm Laws al Culilbmia.Dale
Q - WATER HEATER WNIiNT/ELCCI'It
Z Applicant GRADING FILL'
Vj NOTICE. APPLICANT.If,agmaking ing this CendOeate of Exemption,you should WATER SYSTIiM/IREAq'ING
a foams sudjbjectyi the Worker's Compensation Permit
shal of the Labor Code yen must SOILS FEIi
� forthwith comply with such provisions or this shell he dumeJ revoked. WpT1iR SERVICii
0.
0 CONSTRUCHONLFaVDINGAGENCY NEW RESIDENTIALPLMB, SQ.FC PAID
U
U O (hereby nffimtteat mere isaconstruction lending agency for the Performance of Date Race iptY
Dn F~'t the work for which this permit is Issued(See.3(00].Civ.C)
_ Lendels Name TOTALLUkI Under's Address TOTAL: /
P4 I urn fy that I have read this application and state that the above information is BUILDING FEE inq r�
h correct.l agree to comply wish all city and county ordinances and state laws relating to QTY. MECHANICALPERMIT FEE
U z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE O
alwswunemiened pmpeay for inspection proposes. I PER MIT ISSUANCE
(We)agree in save,indemnify and keep harmless the City of Cu amim against q�y ELE(LRIC FEE O
habil itics,judgments,cots anti expenses which may in any way accrue against said City ALTER OR ADD TO M ECI I. afY UMBUM BING FEE e/D
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'L(TO 10.000 CPM)
SOURCE REGULATIONS. MECHANICAL.FEE 0
AIR HANDLING UNIT(OVER 10,660 CFM) CONSTRUCTION'TAX
Signature of ApplicamiCommaor Date f EXHAUST HOOD(WMUCII (LOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocmtpmn store or handle hazardous material HEATING UNIT(10 00,1100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(m)? HEATING UNIT(OVER 100,Bllf1 BTU)
D Yes DNc VENTILATION PAN(SING LE RES I D) PAID
v Data Receipt
Will the vpplicam lar fuwre building sruuprm use cyuirynem or dcviccv which BOILER OR IW,fAU BTU)
Distr n:' O
emit hazanduus air contaminants as defined by the Bay Area Air Quality Ma o,conot g 'TOTAL: I23t$';
❑Yes Disk, BOILER-COMP(OVP.R 100,000 BTU)
I have read the httznNous matedako nos under Chapter 9.95of the Cull- AIR CONDITIONER A
yuiremc p ISSUANCE DATE
maria Health&Safety Code.Sections 25505,25533 and 25516.1 accentuation tion Bthe NEW RESIDENTIAL MECH, SQ.Fn
building does not curemty hate a tenant,that it is my responsibility m nmify me tceepon
of the requimntetns which ours,be stet prior,,isswmce of a Coni ricrac of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY. �✓"_ sem'
OFFICE