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29394 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-F,LE(7fRICAL PERMIT NO. 29394 .a J9 3d Ju^ ^ w BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL L BUILDING PROJECT IDENT'IF'ICATION BUILDI GADDRESS: Ps ' SANITARY NO. APPLICATION SUBMITTAL DATI 1V�1 0 N 'S .NAME: r.. - `I' CO R CIY) NAME r LICNO: NIC CONTROL? siclioia AR 11xCTTNGINF.ER: \`J JLI NO: ADDR 1 i% i ❑ CONTACT: PHONE: - BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRACTORS R'S DECLARATION QTY ELECTRIC PERMIT FEE - 1hereby )of shatIam Ifthe Bounder provisionof Chaptere(commencing AL, DESCRIPTION ,�4'Z win Section]000)MDiviaion Sof rhe Business and Pmfessions Cohered mylicerse is RESIDENTIAL: aCp in full force and PERMIT ISSUANCE <UU License I Lic.p ❑SFDWL El KITCHEN REMODF:1. rF,)Z, Da Cmmdor APPLIANCES—RESIDENTIAL ❑ADDITION EI PLUMBING R&PIPE Z(.., no RC ECLARATION ❑MULTI-UNIT ❑STRUCTURAL O 1 ai xJ as public rtcoNs PANELS MODIFICATION O Z UPT020IAMPS �� ' ens - en []INTERIOR [I CHIMNEY REPAIR Q ^ 201-1000AMPS IMPROVEMENT Oat I for BUILDER m the CmuION OVER I(WAMPS ❑BATH REMODEUREPAIR 0 DEMOLITION Its affirm that 11. exempt from the Contmcmo License law for the 0OTHER 3 a V following son.(Swoon Jconstruct,alunax and Professions Code:Any city stcaunre SIGN$ELECITtICAL Y74 O which requites n permit re quires time,improve,tuition demolish,or repair any structure priorm its ismance,also requires be 0pplicum fnr such perminn til...igneJ nammem SPECIAL CIRCUITIMISC, Ila V_ vW1� that he is licensed atomml m Cheprovi,onsufthe Contmnor's License law(Chapter9 COO (commencing with Smimn]000)of Uivisian 3ofthe Businns and Prvfessiuns Caie)or TEMP.METER OR POI-E INSE COMMERCIAL: CL c C ones he is exempt therefrom end she basis far Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION e ob Section 7011.5 byany applicant fora permatabjecos theapplicans me civil penalty of POWER DEVICES ta ❑TENANT ❑FOOD SERVICE O01,as than Five hundred dollarsycirpl. IMPROVEMENT ❑Icoffic era(No property remyo,intended with wages astheir(Sec. 044.8 sineson. SWIMMING POOL ELECTRIC C^ wdl do the work,and the fracture is not intended or offered Tressle(Sec.7044.Business ❑OTHER a3 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES property who builds or improves thereon,and who does such work hin pelf m through his own employees,provided that such improvements ax not intended or offered for NEW RESIDENTIAL ELECIR SQ FT. sale.IL however,the building or improvement is sold within one year of completion,the SQ.Ire.FLOOR AREA $/SG Fr. mer-builder will have the burden of proving that he did not build or improve for put, P pose of xle.) 0 1,as owner of Ne property,am exclusively contracting with licensed contractors to TOTAL: construct the project(See 7044,Business end Profession CsAa:)The Cuntmcmex Li- cense MAR law does not apply to an owner of property who builds or improves therenn,and QTY. PLUMBING PERMIT FEE who contour s for such projects with a eantracmr(s)licensed pursuant to the Contractor's - Licensclaw. zPERMIT ISSUANCE O lan,exempt underSee. ,B&PCfor this reason , CITY Lill- GUrehIIN) Owner Date ALTER—DRAIN&VENT—WATER(EA) VALUATION WORKF.R'SCOMPP,NSATION DECLARATION BACK FLOWPROTECT DEVICE I hcrchy affirm under penalty of perjury one of the fallowing declarations: ❑I have and will maintain a Cerafictae ofConsenrto self insum for Worker's Compen- DRAINS—FLOOR,ROOIr.AREA,COND. STORIES TYPE CONSTRUCTION saoion,as provided for by Section 37M of the Labor Code,for the performance of the work for which this permit is issued. FIXTURIS—PER TRAP 0 1 have and will maintain Worker's Compensation Insurance,as required by Section ' 37M of the Latter Code,for t he performance of the work for which this permit i s issued, GAS—HA,SYSTEM-I INC.40UTLET'S OCC.GROUP APN My Worker's Compensation lnsumnce PolicyCarrier: carticrPolicy number are: GAS—EA.SYSTEM OVER 4(EA) FROM CERTIFICATE OF COMPENSATION NFROM WORKERS' COMPENSATION INSURANCE GRFASf%INDUSTRL WASTE INTERCEPTOR (This section need not be completed ifthe permit is hour hundred doliws IS[an) BUILDING DIVISION FEES or loss.) GREASE TRAP PLANCHECK FEE I certify thm in the performance ofthe work for which this permit is issued,I%hell SEWER—SANITARY—STORM EA.2W FT. not employ any person in any manner so as m th become subject to e Workers'Compen- ENERGY FEE O,Z anion lawsof Califom it.Date WATER HEATER WNHNT/ELECfR �2�,d Z O Applicant GRADING FEE Lie) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMRRHATING a ' benne subjea5m the Wmker's Compensmino provisions of the labor Code,you..it - SOILS FEE Lit forthwith comply withsuch pvokinns nr dtis pvtor shall he deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FIt PAID L) Thereby affirmthavhero is iconstmetion lending agency for the perfnmunce of Date Receipt W. r+ the work lot which this permit is issued(Sec.3(197.Civ.C) p 2 Lenders Name TOTAL: WLenders Address - TOTAL: 1 certify that 1 have read this application and state that the above information is BUILDING ITE roe7II correct.l agree to comply with all city and county ordinances and state laws timing to QTY. MECHANICAL PERMIT FEE G G building connmcoion,and hereby authorize representatives of this city to enter upon the SEISMIC FEE above-mealmord property,for inspection purposes. PERMIT ISSUANCE (We)agree 1.saveam ,indemnify and keep hdeas the City of Cupertino against ELECTRIC FEE Iiabilaies,judgmema,cosh son expenses which may in any way accrue against said City ALTER OR ADD TO MECH. mconsequenceof thegr Ing of this permit. PLUMBING FEE APPLICANT ON SAN COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) SOURCERP MECHANICAL FEE AIR HANDLING ON]P(OVER 10,0)0 CFM) CONSTRUCTION TAX Si m o..me.. ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE AZARDOUS MATERIALS DISCLOSURE Wi11th applicant or fmure building mcupant start rr handle humNnus meterinl HEATING UNIT(TO 110,000 BTU) as defined by the Cupenina Municipal Calc,Chapter 9.12,and the Health and Safety Cade,Section 25532600? HEATING UNIT(OVER 100,000 BTU) O Yea ON. VENTILATION PAN(SINGLE RESID) PAID Dam Receies whichptN Will the applicant prem,u building occupantAo. it Quality or anagement BOILER—COMPQHPOR IW,000BTU) ^ emit hamNats air cnn0tminunts as delined by the Be,y Area Air Quality Management TOTAL: /D Dist e@ DYca ONn BOILER—COMP(OVER 100,000 BTU) I have reed the Ins z..dm o., aterials reqmun uireents der Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE hand Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,Fr. buildin6 Jxws nm currently hove a tenun6 that it is my resrymsibility to notify the occupant " of the rcyuimments which must be met prior m issuance of a Certificate of Occupancy. I Owner nr amhorized agent Uma TOTAL:F ISSUED BY: OFFICE