29015APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - KLEC'MUCAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL
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BUILDING PRROJJECP� IDENTIFICATION
BUILDIt."L\ 11 Y 11 U• g%�S v �^`�-C" �l�ll C
Climb Moll -rAw ff
I hereby affirm Net 1 am licensed under N.As. of ChWar 9 (comnewing
Opo with Se,.7111811 of Divinicn 3 oftle Bueineu and ProfeasinnsCNc,mW my licens, Ix
F�� in full face and cRmL
Q VVZ Uc. Class Lie. N
NQ 6 Due Contractor
gF.. A�RCHI;ECTS DECLARATION
ZOI%Z'�^)PIe�.I ha�bc usW upuWic lnasLr.
Inz�_ f 1 le_i
❑ Consultant Foes Paid by Applicant (Initlnl)
I OWNER -BUILDER DECLARATION
I hereby affirm thin I am excmpt front the Cmtiractes Licunxe Law for the
following oraso0 (Smiw 7031.5, Busi. uW Pcofasiom Cade: Any city «county
which na, irt. N Permit to cenaw,l alter, orprove, demolish, «refmin tiny stntecon,
prior to its issuance, also rtyuira dte eppliraott for such permit to file a tigncd sutement
Nal he is IicenxM purxunnua the Pn vitticos of IS, Commnnc, c Lecnre law (Chapter 9
(commencing with Section 7(Mq) of Division 3 of Be Business aotd Profadoro Cni or
Nat he u esento derefran and the basis for the Nkged eMvogim. Any violation of
Sstioo 70315 by any applictnt for a Permit subject, the applicant to a Civil petty Of
not mor, dun five No,irad dollen ($500).
I, en owner of the PregsenY, Cir my enytlnyen with wags as their salt mmpematien.
writ dothesoon;, amithe she Coneun«i Li, "w clo for We(Sec. 7 an Business
and Pmfcasiaa Cade: The n anncmr's License Law dnea nn apply to 1f raver of
loo,varryhis Own wdto.odds a ionpmvcs thncan, a, who dno sue. text hlntxclr m Nmugh
his own employees, booth nl Ont such impmveold hi not immWcf «placrN f«
sale If. however•thebuildingrmntpmv,trcnt is Baldwithin orcyouofamWle for ur-
owrer�bu0der will Msc tie bmdcn o(pmving t� he did rut bulM m impmsx f« pe-
p 1, u owner of the Nopcny. ant exclusivelynestatvfassiong with nrensed entowna"a l-
a U tha WojcsY (sse. 71W6, Business std Pmfasi ban Codc:) TIe Conuan no- Li-
cem Law dace nm apply m en owner of prtTons the builds or imposer thmmn, e, Ql'Y.
who contra,u f«such laojecl witha sv«oanv(s) Ih,n1N pmsttam to the ContractoYt
M Icono law,
n exetrytt ud4r Sea .BAPCf«this rtaam
Oww Dat,
WORKERS COMPENSATION DECIARATION
I hetehy after under penalty of pagio, ane of the yellowing dccNwionz,
❑ 1 lmvcand will nwintaina Ccnif muf conwmto relGlnsw, fnr Wwk,rs Campco-
salon, as po.ihd for by Section 37M of the labor Codc, for the ledetr a of de
vosk for which Nin pcmut u icaucd.
1 ha a e, will mwntain W'«tc'e Compna.flon Insurance, as reyuir by Section
3700 of tle, Laherc Coda, f« Nc pt rro.re of the work fa which Nit pcmut is ioced.
My Wojm's
Cartier wcarrier vd Policy n
Nw:uaayFMoPolicy
/ CERTIFlCATEOPEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sachem heal not ba cmrolnal if the pertnit is f« ore No'ca I dollua (SI W)
m less.)
I carry that in the perfermuoe, oftlte work f« wheh this perrut is iwcsL 1 shall
not ertytloy tiny pante in any mnnner—to m become uN en to the Warkcna Cont
O Z ut'mn laws of Calihnnie. Doa
Z Q Applictint .
NOTICE TO APPLICANT: If, after inking this Ceniftcste a Exemption. >vai shouts
Fxhems,, subject to the Worker'. Com,ranuicn larwaisms of the Lahti Cedc, you must
W f«Nwith comply with such prnvidncis or this crnut shall, dcemcd rcve8nl,
aQ
= Z CONSTRUC110NLPNDING Ag agency
U ,for, by which thator, isentl(Sec.30 [ending agency lm the ped'esomarce of
thcwotg for which thlspcmtit in lnsuW (Sec. 309). Civ. C.)
C) U LaLndrch's Nurre
n'1 A
1 certify tify
Net 1 here read this applicuiem and sutc that the above son collation is
V�1 cv�Llegrcetoamnmly with alldrymd sunmyadinti«ea, nate (center
QTY,
U buildingeemonarl lnnit Itoehyw,fite, ct,coas. tivn of Nis city men¢r unto the
above -in e) .,ce ptofe va far i rrat is ,[kaT, l
(We)agoceto lave" at sr Jyandkeep yinan Ile City of Cupertino agaiw
ine)itien,j,gmcntse eroOsgran and,Mpcma which may in any way acme againss said City
nscyuence of the granting of this pcmtit.
APPLICANT UNDERSTANAND WILL COMPLYWITH ALL NON -POINT
SOL'ftC alE( I
it
Sig�fAmIre3m/Comructor Due
HAZARWUSMA Alam". OS URE
Will the epCuIsnt a future building kecupant stator mocihatatUe hawt h ac marmot
Craft def S. i. Ne 32(.)? no MuniciPW Cole, Chapter 9.13, e, the IIeWN eoW Safety
eS«lion 25513(u71 .'
C] Yes -1 NO
Will site applicant or future Ituilding occupaou imse iiipmeal en stsvicen which
mit hmnodau air contaminants as detirsd by the Bay Arca Air Quullty taa`o `Cil
Dic ict'! e
❑Yes ❑No
II have rhvraNewn materials ".in.. anderm Cla695 cf the Car i-
fomiv I IeaINoto Per
& NRY Cede, Snvom 25105, 25533 sod 25531. I undersand .bat tf the
building dace not swoently have a temm, that it is my rarratubiliry to mtily Ue exavpua
Mthe rnpdtemrnu which twst be ten prig to usuaoat as Cmiftcve etf OcessPancY.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANEL S
UP TO 300 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUMMI.SC.
TEMP, METER OR POLE INST.
POWER DEVICES
SN'IMMINGPOOLEL IC
OUTLETS -SWffc
NEW RESIDENTIAL ELP
PERMIT ISSUANCE t •\
ALTER - DRAIN & VENT- WATER EA)
BACK PLOW PROTECT. DEVICE,
DRAINS- FLOOR. ROOF, AREA, COND.
FIXTURES - PER TRAP
GAS - F.A. SYSTEM -I INC. d OUTLETS
GAS - EA. SYSTEALOVER i (EA)
GREASFIINDUSTRI. WASTE. INTERCEP
GREASETRAP
SQ FI'.
SEWER - SANITARY - STORM FA. 300 FT.
WATER IHIATER WNENT/ELECTR
WATER SYSTEM/fREATNG
WATER SERVICE
NEW RESIDENTIAL PLMB. SQ.
r L
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTERORADDTOMECH. '
AIR HANDLING UNIT (TO 10.000 Crt
AIR HANDLING UNIT (OVER 10," CFM)
EXHAUST HOOD UV/DUCT)
HEATING UNIT TO If10,000 BTU)
HIiATINGUNIT(OVER Iftfif H'IU)
VENTILATION FAN (SINGLE RESID)
BOILER -COMP QHP OR HS,gM) H'IV)
BOILER -COMP (OVER I W," BTU)
AIR CONDI'r10NER
NEW RESIDENTIAL MECH.
OFFICE
SQ. PT.
w,.•. 29015
NITARY NO, APPLICATION SUBMITTAL DATE
NIC CONTROL
BUILDING PERMIT INFO
SQ. P.. FLOOR AREA wsQ. ET.
C
NOV 28 19" 5
VALUATION-
N,,
STORIES TYPECONSDtUCT10N
PLANCHECK FEE
ENERGY III?
GRADING FEE
SOILS FEE
PAID
Due RcceiN
BUILDING FEE
'E SEISMIC FEE
ELECTRIC FEE
PLUMBING LEE
MECHANICAL FEE
CONSTRU ITSTAX
I HOUSING MITIGATION FEE I
PAID
Uue Ranpt N
FEE
JOB DFSCRIPTION
RESIDENTIAL:
❑SFDWL ❑KITCHENREMODFI.
❑ADDITION ❑ PLUMBING RE -PIPE
❑MUUH UNIT ❑SfRUMURAL
MODIFICATION
QINTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODEUREPAIR ❑1)IiMDLOBON
❑OTH
W
`L—IC:
COMMERCIAL:
❑NEWBLDG/ADDflON ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. P.. FLOOR AREA wsQ. ET.
C
NOV 28 19" 5
VALUATION-
N,,
STORIES TYPECONSDtUCT10N
PLANCHECK FEE
ENERGY III?
GRADING FEE
SOILS FEE
PAID
Due RcceiN
BUILDING FEE
'E SEISMIC FEE
ELECTRIC FEE
PLUMBING LEE
MECHANICAL FEE
CONSTRU ITSTAX
I HOUSING MITIGATION FEE I
PAID
Uue Ranpt N