29019APPLICANT TO FILL IN INFORMATION WITHIN RED LINES, USE BALL POINT PEN ONLY
CITY OF CUPERTINO h BUILDING-ELECTB
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHA
&_4m:1C_ $,V99.
la:mom
t
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000 of Division 3oflh. Business and Professions Code. and my Hearst, is
in full force and effect.
License Class Lic.N
ARCHITEGYS DECLARATION
I understand my plans shall be used as public records
IONTR CTOR'S NAME: LIC NO:
%cY-'5c .'.
+e1V% . $7916
,DDRESS:
l4so 3ew(Iitr. [�+.
SA Ad
0i
❑ Consultant Fees Paid by Applicant (Initial)
TTY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES —kE.MU1?NTIAI. '
PANELS
UPT0200AMPS
d - OWNER -BUILDER DECLARATION
yy N 1 hereby affirm that 1 am exempt from the Court License Law for the
>(a d V following reason. (Section 703 1.5, Business and Professions Coot. Any city or county
tF O which requims a permit ,, con, roct, aher, improve, dcntnlish m repair any structure
poor to its issuance, also requires the applicant for such Permit o file a signed smrtment
} that he is licensed pursuant o the provisions of the Convector's License Law (Chapter 9
�p0 (commencing with Section Wild of Division 3.1 the Business and Pmfeaslons Cnhe) or
d n C that he is exempt thetefmm and !be basis for the alleged exemption. Any vwimun of
Section 7031,5 by any applicantfor a permit subjects the applicant to a civil penalty of
p, not more than rive hundred dollars S51Np.
Sp ❑ Lo the work, the propructur intended
wimwrdf r (Sec.
compensation.
will Jothework, and the strucumis not intendednr offered far sale(Sea o it Business
0. and Professions Cole: The C esmarena,here's License w Law Joel nut apply to un owner of
progeny who Ayers, or improves thereon, and who due a such work e himself or through
his own owe employers. t h, provided that such mens is told o are not inmates m offercJ for
sola1Lhowever.thebuilding oran or proving
Isantswithinone yea mf improve for
,soownsculturilder will have are buNen of proving that he did not buil) or improve for put,
1 of s owns
0' 1, as owner of the Sce.7popery. , n exclusively Proficcontracting with licensed enmmcma i-
construe the project (Sec. o an Business and ry who bei Cale:) The Cs themor's nd
who contacts
law does not apply toad owner of property who builds or improves metean, and QTy,
whonse Lawa for such projects with a ennOuctoRs) licensed pursuant to the Contractors
License Ince. ,
O'I;am exempt under Sec. ,e&PCfor this revson
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent in self -inure for Workers Compen-
sation, as provided lin by Sa:Jon 37a) of the Lnlwr Cale, for the performance of the
work for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 ofthe Labor Gale, To Lha performnam from work rot which this permit is iv mad.
My WinkerIns�ylpee Round Policy number are:
Carrier:{'/Ti'C -(r4IV olicy Nu: 11
CER' nicxi E OF EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE
(Thi, section need rot he amalleard if Ne permit is farone humlred cellars ($IIID)
or led.)
I certify our in the Kd oo comm ufthe work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers' Conqun-
'0 %. saloon Laws or California Data
Z 0 Applicant
NOTICE TO APPIACANE If, after making the. Cen;fcam of 1ixcaution, you should
F^ ; became subject to the Worker's Compensation mAsion, of the Lahr Code, you must
{all forthwith comply with such provisions or this Permit shall b<deemed Mended
.
Q
CONS'IBIJCTION LENDING AGENCY
U 0 (hereby affirm that there is a construction lending agency for the performance of
wo F the work foe which this permit is isaual (Sea 3097, Cls, CJ
0 U Lenders Name
Lenders Address
0. 1 certify that 1 have read this application and state that the ebove.infnrmatiun is
U) corect.I agree to comply with all city and county ordinances and state lawn (eluting to QTY.
o UZ building contraction, and hereby gumodzs represenmses ofthis city to enter upon the
above-mentioned primary for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accede against said City
In consequence of the granting of this fammit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade, Chapter 9. 12, and the Health and Safety
Coda Section 25532(u)? '
0 ye, ❑ No
Will the applicant or future building am pant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
El Yes ON. r
I have read the hazardous trtalerials requirements under Chapter 6 95 of the Cali -
forma Heeled & Safety Cade. Sections 25505, 8533 and 25534, 1 understand mat if me
building does not currently have a tenant, mad it is my nexpersibility to daily the occupant
of the requirements which mu.t be met prior to issuance of a Cenifcam of Occupancy.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'1'13MI'. METER (3R POLE INST, -
POWER DEVICES
SWIMMING POOL ELECTRIC
QUTLETS— SWITCHES — FIXTURES
SQ PT.
PERMIT ISSUAN
ALTER—IRA VENT— "RCCA)
BACK FLOW PROTECT DEV(
FIXTURES — I% TRAP
GAS—EA.SYSTEh- INC.40U T
GAS—EA. SYSTEM-OVE CEAs
GREASF/INDUS'1'RL WASTE IN'1 1?['TOR
GREASETRAP
SEWER—SANI'T'ARY—STORM EA. 200 FT.
WATER HEATER WNENT/ELEC'I'R
WATER SVSTEMC REATING
WATER SERVICE
NEW RISIDRN''IAL PI.MB. SQ, PC
MECHANICAL PERMIT
PERMIT' ISSUANCE
ALTER OR ADD'TO MECH.
AIR HANDLING UNIT LTO 10.000 CPM)
AIR HANDLING UNIT (OVER 10,000 CFM)
TMHAUST HOOD (W/DUCT)
HEATING UNIT GO 1011.0(x) BTU)
HEATING UNIT' (OVER 100,0) RTU)
VENTILATION PAN (SINGLE. RESID)
BOILER =COMP CHIP OR 100.Om BTU)
BOILER—COMP (OVER 100.0001311J)
NEW RESIDENTIAL MECH.
OFFICE
SQ. IT.
M
7E
29019
I�
RESIDENTIAL
C SFDWL
❑KITCHEN REMODEL
❑ADDITION
❑PLUMBING RE -PIPE
LJ MULTI -UNIT
CSTRUCFURAL
SOILS FEF. is
MODIFICATION
11 INTERIOR
11 CHIMNEY REPAIR
IMPROVEMENT
0 BATH REMODEUREPAIR 0 DEMOLITION
OOTHER
COMMERCIAL:
0 NEW. BLDG/ADDITION
TENANT
IMPROVEMENT
OOTHF,R
SQPC FLOOR AREA
i
FEE NO 221995
t. (�Y VF'fa u...
STORIES
0 DEMOLITION
0 FOOD SERVICE
I .0 / ,
TYPF.0
ENERGY FEE
GRADING FEE 74
SOILS FEF. is
PAID
tc Rxeiptp
TOTAL:
BUILDIN4UE J
FEE
SEISMIC FE -E
IdXCTRIC FEE
_a
PLUMBING FEE
MECHANICAL FEE �1
CONSTRUCTION TA
HOUSING MITIGATION 'E
PAID
Date Receip
TO L:
ISSUANCE DATE.