29752APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT.PEN ONLY
CITY OF CUPERTINO RUILDING- ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT CATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
"
BUILDING ADDRESS: I I
19110 Stevens Creek Blvd. The Roasted Coffee Bean
SANITARYNO.
APPLICATION SUBMITTAL DATE.
oc '�
oenant 7Jared Carlson L
CON'1'RACbORISNAMH: LICNG:
P Con Construction 49041
N/C
CONI'ROI.a
Z
A HITLLT /ENGINLER: _ LIC NO'.
- 'ProCon Construction 490413
AD li 4
�� §2 DeMille Dr. Si 95117
CONTACT: PHONE:
Tim Healey 247 -1444 .'
❑ Consultant Fees raid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG uME Ec
LICENSED CONTRACTOR'S DECLARAI ION
I hereby aW= Not I am licensed uMer pmvisions of Chapter 9 (comrneacing
with Section ](Hil) of Division J ofthe Business and Professions Cadc, unit my license is
In full lbrce and ffed.
License Class -A 90T�o�T QQ Ide,p e}asa B
Date — Cry._./— Convacmr
QTY.
ELECTRIC PERMIT
FEE
JOB DE$C ION
RESIDENTIAL,
❑SFDWL El KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
❑INFERIOR,. .�t f --. ❑CH IMNEY REPAIR
IMPROVEMENT
❑ RA R OD IIREPAIR O DEMOLITION
§ a 1
OOTI J ��ss((.��
°�s7p�
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCI If1'ECT;S U:: +E'Q On
I understand my plans shall be usW as public records
PANELS
UPT0200AMPS
-
'] Licensed Profosvinual
J Oat I am exempt r m the Coe ION
d
C 1 hereby affirm that 1 am exempt from the Commctors License Law for the
following reason. (Section 70315. Business and Professions Code: Any city or coumy
W requires. permit m coroarm, elm,, improve, demolish, .,repair any structure
prior in its issuance, also requires the applicant such permit to file a signed stmemem
that he is licensed pursuant to the provisions of the Coulneter'n Licnse law (Chapter 9
(commencing with Section 7 000) of Division 3 of the Business and Professions Code) or
C that he is exempt therefrom and the basis for interdiction exemption. Any violation of
- Section 7011.5 by any applicant for a permit subjects the applicant o civil penalty of
e not more Nan five hundred dollars (8500).
0 Las owner of the properly, or my employees with wages as their sale compensation,
will do the work, unit the amdure is not imended or offered far sole (Sec. 7014, Business
3 and Professions Code: The Contractor's License Low does not apply to an owner of
- property who builds or improve., thereon, and who does such work himulf or through
his own employees, provided that such improvent are not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that Ire did not build or improve for pur-
pose clinic).
s vs owner of the Sm. 7 di. B exclusively Cmfessiong with license) wntrocmcs m
consumer the project (Sec. ]014. Rosiness and Pm(cssinns CNeJ The Contmc,ors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) I lecused pursuant no the Cora ucmis
License Low,
0 I am exempt under Sec. B & P C borthis reason
201- 1000AMPS - -
OVER 1000 AME'S
SIGNS ELECTRICAL
SPECIAL CHIC, &USCI
eIi .4I
'TEMP. METEROINST.
u1V
NF:W BLDG /ADDRJON 0 DEMOLITION
,WBL [I FOOD SERVICE
IMPROVEMENT
0 OTHER
POWER DEVICES.
-
SWIMMING POOL ELF I
OUTLETS -SW I'I CHES -FI RHS
NIiW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOI ARBA
S/S FT.
(
It
QTY, PLUMBING PERMIT
FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT' - WATER GA)
Owner Date
VALUAI ION
WORKER'S COMPENSATION DECLARATION
1 thereby affirm under Certificate of e pe jury oneofmmrollowingdurker's o
ttaor, as and will fee SuCedlftcamof Consent ull'eno ,Port Workers Compem-
Ron, as provided for by Seaton 3700 of the Iada Code for the perfonnance of N<
work for which this permit is soned
1 have and will maintain Worker's Compensation Insurance, as required by Section
W of Ne LahorCNe, for the perforancc of the work for which this permit is issued.
My Workers Compensation Insurance curlier and Policy�ta}�bSLare:
Canicc Policy N., `�1AU,10_ /�fj
ER FE %EMI'TIONIBOM WORKERS'
COMPENSATION INSURANCE
auction need not beannpleted It the proof, is barium hundred dollars DIIXI
or less)
I certify that in the performance of the work for which this permit is issued, l shall
no, employ any person In any ricamermns m become subject the Workers'Con,en-
uon Taws of California . Data
Applicant
BACK FLOW PROTECT. DEVICE
DIL41Nti- F100R, ROOF,AREA, COND,
STORIES
_
'
TYPE CONS'rRUCf10N
LJC
FIXTURES -PER TRAP
GAS -EA, SYSTI3M -1 INC.4OUTLETS
�^
��
OCC. GROUP
APN
GAS - BA. SYSTEM OVER 4( EA)
GREASMNDUSTRL WASTE. INTERCEPTOR
BULL V ION [Tills
GREASE TRAP
PLANCHECK FEE
ca
'IiWE SANITARY -STORM f?A. 2(b FT.
-
/�
ENERGY FEE
O.
WATER HEATER W/VENT/ELECI'R
GRADING i
NOTICE TO APPLICANT. IL uRer making Nis Certifcem of Exemption, you should
become subject to the Worker's Compensation pmvisions of,hc Lahr Cude, you must
foMwith comply withsuch,unwWonsonhis permit shall be deemed invoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is is sued (Rcu. 3097,1 CJ
Lenders Name COE1Efar �.a
WATER SYSTF.MfI'REA'1'ING
SOIL$ FEB
WATER SERVICE
PAID
Date Receip
NEW RESIDENTIAL PLMU SQ. R.
TOTAL.:
}tai
Lendeh Address
I certify ,h I h, av tpJaati nestle ,h �e above infonnmion is
rtecn l agree m@m}' , rg (r('unry(�sls� c y�i 1Qdoting ¢t
heilding c. con Afi`3t,w ,. Mo £%�racen. as of ,h or y.up,cr uportmo
chose- mentioned ®'nti' 7ie:pccz,2,2poses.
(We) agree m save, indr nnify and krep harmless We City of Cupertino again,,
habilities, judgments. costs and expenses which may in any way aceme against said City
in consequence of the granting of this permit.
APPLE "c"BN�ERSTANDS NO WILL COMPLY WITH ALL NON -POINT
SOURCE R �GU T IS.
C,✓I
J /'
p
`
BUILDING FEE
_r
Q TY. MECHANICAL PERjCFM)
FEG
SEISMIC FEE
t
VERMIT ISSUANCE
ELECTRIC FEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT(TO 10,000
MECIIANICAI. EEE
AIR HANDLING UNIT (OVER 10,
CONSTRUCTION TAX
Signature o Applim Contractor Date
I/.,AZARDOU ATERIALS DISCLOSURE
Will rhea Ikan,a, future building ,ecupani Mmoor handle humNoua mnrerial
as defined by the Colombia Municipal Cale, Counter 9.12, and the Health and Safety
Cade, Section 25532m)?
El Yes 40 No
Will the applicant or Pomrt building xcupttnl use equipment or devices which
full hazardous air contaminants., defined by the Boy Are. Air Quality Manogcmem
District?
❑ Yes
I have read the hmadous materials p
requirements an under . 1 tar r.ta d that if the
foci.gdoes &Safety Cade, Saunas 25505. iss5JJand255)4.I understand
building does liens which bust uhmtpicar ticmynsofeClrtiycaramifythmecup.m
junifyd,hutasnal
f the requirements which taus, he tact p,imrois4uance ofe Certificate of Occupancy.
EXHAUST HOOD(WOUCT)
HOUSING MITIGATION FEE
HEATING UNITCf01()U,000 BTU)
HEATING UNIT (OVER IW,"BTU)
PAID
Date Rveript g
VENTILATION PAN (SINGLE RE SID)
BOILER-COMP OHP OR IOU,O(NI BTU)
.q
100,00s) HOLLER- COMP(OVER 100,00s) BTU)
AIR CONDITIONER
ISSUANCE DATI7
�� //��'(►./p/5��1 /-�
`;t�', ✓_ Fes'•
ISSUHD BY
s.
NEW RESIDENTIAL MCCH. SQ. FT.
Ownerorauthonzcdogem�Dam
-
OFFICE v.