30839 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O 8 J(�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1TAL DAT]
h' ;
R:SSwgMF:: PIIONC: COM' ACTON'S NAME: LIC NO:
\\llirea o 1"W6 S NIC CONTROL#
49 AR'HITECUENGI •ER: LIC NO: ADDRESS: ��LL ❑
0�-97 5r Q.An24.-
CONTACT. PHONE: BUILDING P17RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
LICENSED CONTRACTORS DECLARATION ❑ ❑ A ❑
I hemb affirm that 1 ten licensed under visions of Chapter 9(commencio QT' ELECTRIC PERMIT FEE
c05 r pr.. P 6 JOB DESCRIPTION
with Section angle)ecUivisiun 3 of the Business and Professions Code.and my license is
- �00 - PERMIT ISSUANCE RESIDENTIAL:
in full force and eRe[t.
aVU License Class Lic.N ❑SFDWL (:1 KITCHEN RCMODEI.
rFQa Date Contractor APPLIANCES—RESIDENTIAL ❑ADDITION fi;YLUMBING RE-PIPE
ARCHITECYS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
I Z,OteIZ I understand my plans shall be used as public records MODIFICATION
OZ=O UPT02MAMPS ED INTERIOR [I CHIMNEY REPAIR
f—r?�W Licensed Professional 201-1000AMPS IMPROVEMENT
that I m c,amiER DECLARATION
nnem OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
^d C W Q I hereby.(Siert that 1 am exempt from @c Contra,Ca License Law for the
W3�H following masov.(Section]031.5,Business and Professions Cale:Any city or county SIONSELCCfRICAL - ❑OTHIiR
= which mquires a p:miit m contemn,ager,improve,demolish,or mpair eny shummre
pnorto its issuance,am require,the applicant for such Permit o Ne a signed statement SPECIAL CIRCUIT/MISC.
yNat he is licensed pursuant to the provisions of the Commemes License Law(Chaper9
CCO (commencing with Section]000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
that he is exempt themfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
iC u.
Section 7031.5 by any applicant for a permit subjects the applicant o civil penalty of POWER DEVICES
ul�w []TENANT [I FOOD SERVICE
t more than five hundred dollars(5500).
ZO [1 1,as owner of the property.or my employees with wages m their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
S• will do the work,and thestncwre is not intended oroffemd for Sale(Sec.]034,Business ❑OTHER
W and Professions Code:The Commcmrs Littre Low does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
4i .. property who builds or improves thereon,and who does such work himself nr through
his own employees,provided That such improvements am not intended or Offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,thebuilding or improvement Mod wilhinone yearof ionpletiou,the SQ.PT.PRA47D $/SQ.FT.
o vacolmilder will have The burden n(pmving that he did nm build or improve fur par.
pose to of sole). �� REC'Q
❑ Lot the project of ec.70y,um exchtsivdy cnmraAng with sse:)TheeConmacnon i. TOTAL; JAM
owns the esnt (Sec]fano Bus f and Pmwho bus Code:)The vesrthercon,Li- `V'
cense Low Olces not apply man owner of popcny who huilJe or improves lbercnn,and Q1Y, PLUMBING PERMIT FE•
who contracts Tor such proj.eis with a courador(s)Ilccnsed Puma nTta The Convector's CITY Ur-UUPLH I'M
License Law. PERMIT ISSUANCE
1 am exanpt under Sec. ,H&PC for thism _
Owner Ilam
ALTER—DRAIN&VENT—WATLR(EA) VALUATION
WORKER'S COMPENSA'T'ION DECLARATION HACK FLOW PROTECT.DEVICE
1 hereby affnn under Penalty of perjury one of the following declarations:
T ❑ (hove and will maintain oCeniliame ns Goncourt sdginwrefor Worker'.,ComNa. DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTNUCI'ION
sation,as provided for by Section 3]0)of The Labor Code,for the peffomwnce of The
work for which this Permit is issued FIXTURES—PER TRAP
El 1 have and will maintain Workers Compensation Insurance,as om,n ad by Sectio
3700 of the Labor Code.for the Performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Wor F C mpens dMi G sponte[artier Trod Policy n her
Cartier: x'99 Policy Nu:LrV'HJI-S—�G� GAS—EA.SYS TEM-OVER4(EA)
ERTIFICATE OFBXEMPTION FROM WORKERS' GRGASEIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
-(This section need not be completed ifthe permit is intone hundred tholims(510)
or less.) GREASCTRAP PLANCH[CK IiE.
1 certify that in the Performance of the work for which this permit is issued,I shall
notemploy any person in an � - SCWCR—SANITARY—STORM EA.200 FT.
y m er so as tr one suhjec to the Workers Co"
n ENERGY FER
z ,� ration lassT� (�Lf�f(a.Da
O Appfmc --t��1 l n — — WATER HEATER WNENT/ELECTR GRADING FEE
NOTICE T(l RF'PLICANT.If,after making this Ccn item of Exemption,you should WATER SYSTENDTI EATING
a > became subject tr the Wodters Compensation provision rf the"bas Code,you must SOILS FEE
forthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE IS I
UZ CONSTRUCTION LENDING AGENCY NEW RL•SIIIENTIAL PCMB. SQ,PC PAID Date m ll
W.0 l for which this perm.ii sawn(Seaionlendis,agency fnnhe p:rfomTuncc of
W. .r Ne work far which this pemdt is issued(Sec.3097.Civ.CJ
O F' Leaders Name TOTAL:
Lenders Address TOTAL:
p I certify that I have mad this application..it state that the abuse inforomion is BUILDING
V) correct.l agree to comply with all city and county ordinances and state lows miming to QTY. MECHANICAL PERMIT FEE
V Z building convection,and hereby authons,rcprewmudws,of this city to enter upon the SEISMIC FEE
.hove-memianed popecy for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamdesa the City of C.Nmno agaimt ELECTRIC FEE
limnlities,judgments,smaSisel c.,mesethich may many way accrue againtsaid City ALTERORADD9'OMECH.
in PLUMBING FEE
consequence of the gamins of dais permit.
APPLICANT UNDERSTANDS AV WILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE GU ATIONS. MECHANICAL FBB
O AIR HANDLING UNIT(OVER 10,010 CFM)
CONSTRUCTION TAX
Si alum ol'Applicare/ConuMfor Date EXHAUST HOOD(W/DUCfJ HOUSING MITIGATIONIGC
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant m future building o[cupam more or handle Imzmaous material 14EATING UNIT(TO 1011,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and The Health and Solely
Code,Section 25532(a)] HEATING UNIT(OVER 100,000 BTU)
E]yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building Occupant use equipment or devices which Date Rece'l a
•emit hazardous air conuminams as defined by the Bay Ama Air Quality Management BOILER-COMP(7HPOR 100.0g)(IRTU)
D '
TOTAL:
lalnCl]
❑Yes ❑Nn BOILER—COMP(OVER 100,000 BTU)
I have read ahc latoodmi,materials mooirease miler Chu"c' 95 of ase Cali- AIR CONDITIONER
P ISSUANCE DATE
form.ldi Health& cone Code,Stains 25505,25533 and 2.5534. undemaind that i1'The NEW RESIDPN]'IAl.MCCH. SQ.FT.
building don n outs whichrtly hove v ...et p.Tb.T o is mum a of n C iliry to nmifLocution, _
of the rcquircmems which nmst he met prior to issuance nl n Cenilicme of Occupancy.
Owner of mnhmired agent Date TOTAL: ISSUED BY:
OFFICE
APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL O 8 J(�
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1TAL DAT]
h' ;
R:SSwgMF:: PIIONC: COM' ACTON'S NAME: LIC NO:
\\llirea o 1"W6 S NIC CONTROL#
49 AR'HITECUENGI •ER: LIC NO: ADDRESS: ��LL ❑
0�-97 5r Q.An24.-
CONTACT. PHONE: BUILDING P17RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECH
LICENSED CONTRACTORS DECLARATION ❑ ❑ A ❑
I hemb affirm that 1 ten licensed under visions of Chapter 9(commencio QT' ELECTRIC PERMIT FEE
c05 r pr.. P 6 JOB DESCRIPTION
with Section angle)ecUivisiun 3 of the Business and Professions Code.and my license is
- �00 - PERMIT ISSUANCE RESIDENTIAL:
in full force and eRe[t.
aVU License Class Lic.N ❑SFDWL (:1 KITCHEN RCMODEI.
rFQa Date Contractor APPLIANCES—RESIDENTIAL ❑ADDITION fi;YLUMBING RE-PIPE
ARCHITECYS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
I Z,OteIZ I understand my plans shall be used as public records MODIFICATION
OZ=O UPT02MAMPS ED INTERIOR [I CHIMNEY REPAIR
f—r?�W Licensed Professional 201-1000AMPS IMPROVEMENT
that I m c,amiER DECLARATION
nnem OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
^d C W Q I hereby.(Siert that 1 am exempt from @c Contra,Ca License Law for the
W3�H following masov.(Section]031.5,Business and Professions Cale:Any city or county SIONSELCCfRICAL - ❑OTHIiR
= which mquires a p:miit m contemn,ager,improve,demolish,or mpair eny shummre
pnorto its issuance,am require,the applicant for such Permit o Ne a signed statement SPECIAL CIRCUIT/MISC.
yNat he is licensed pursuant to the provisions of the Commemes License Law(Chaper9
CCO (commencing with Section]000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
that he is exempt themfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
iC u.
Section 7031.5 by any applicant for a permit subjects the applicant o civil penalty of POWER DEVICES
ul�w []TENANT [I FOOD SERVICE
t more than five hundred dollars(5500).
ZO [1 1,as owner of the property.or my employees with wages m their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
S• will do the work,and thestncwre is not intended oroffemd for Sale(Sec.]034,Business ❑OTHER
W and Professions Code:The Commcmrs Littre Low does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
4i .. property who builds or improves thereon,and who does such work himself nr through
his own employees,provided That such improvements am not intended or Offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,thebuilding or improvement Mod wilhinone yearof ionpletiou,the SQ.PT.PRA47D $/SQ.FT.
o vacolmilder will have The burden n(pmving that he did nm build or improve fur par.
pose to of sole). �� REC'Q
❑ Lot the project of ec.70y,um exchtsivdy cnmraAng with sse:)TheeConmacnon i. TOTAL; JAM
owns the esnt (Sec]fano Bus f and Pmwho bus Code:)The vesrthercon,Li- `V'
cense Low Olces not apply man owner of popcny who huilJe or improves lbercnn,and Q1Y, PLUMBING PERMIT FE•
who contracts Tor such proj.eis with a courador(s)Ilccnsed Puma nTta The Convector's CITY Ur-UUPLH I'M
License Law. PERMIT ISSUANCE
1 am exanpt under Sec. ,H&PC for thism _
Owner Ilam
ALTER—DRAIN&VENT—WATLR(EA) VALUATION
WORKER'S COMPENSA'T'ION DECLARATION HACK FLOW PROTECT.DEVICE
1 hereby affnn under Penalty of perjury one of the following declarations:
T ❑ (hove and will maintain oCeniliame ns Goncourt sdginwrefor Worker'.,ComNa. DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTNUCI'ION
sation,as provided for by Section 3]0)of The Labor Code,for the peffomwnce of The
work for which this Permit is issued FIXTURES—PER TRAP
El 1 have and will maintain Workers Compensation Insurance,as om,n ad by Sectio
3700 of the Labor Code.for the Performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Wor F C mpens dMi G sponte[artier Trod Policy n her
Cartier: x'99 Policy Nu:LrV'HJI-S—�G� GAS—EA.SYS TEM-OVER4(EA)
ERTIFICATE OFBXEMPTION FROM WORKERS' GRGASEIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
-(This section need not be completed ifthe permit is intone hundred tholims(510)
or less.) GREASCTRAP PLANCH[CK IiE.
1 certify that in the Performance of the work for which this permit is issued,I shall
notemploy any person in an � - SCWCR—SANITARY—STORM EA.200 FT.
y m er so as tr one suhjec to the Workers Co"
n ENERGY FER
z ,� ration lassT� (�Lf�f(a.Da
O Appfmc --t��1 l n — — WATER HEATER WNENT/ELECTR GRADING FEE
NOTICE T(l RF'PLICANT.If,after making this Ccn item of Exemption,you should WATER SYSTENDTI EATING
a > became subject tr the Wodters Compensation provision rf the"bas Code,you must SOILS FEE
forthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE IS I
UZ CONSTRUCTION LENDING AGENCY NEW RL•SIIIENTIAL PCMB. SQ,PC PAID Date m ll
W.0 l for which this perm.ii sawn(Seaionlendis,agency fnnhe p:rfomTuncc of
W. .r Ne work far which this pemdt is issued(Sec.3097.Civ.CJ
O F' Leaders Name TOTAL:
Lenders Address TOTAL:
p I certify that I have mad this application..it state that the abuse inforomion is BUILDING
V) correct.l agree to comply with all city and county ordinances and state lows miming to QTY. MECHANICAL PERMIT FEE
V Z building convection,and hereby authons,rcprewmudws,of this city to enter upon the SEISMIC FEE
.hove-memianed popecy for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamdesa the City of C.Nmno agaimt ELECTRIC FEE
limnlities,judgments,smaSisel c.,mesethich may many way accrue againtsaid City ALTERORADD9'OMECH.
in PLUMBING FEE
consequence of the gamins of dais permit.
APPLICANT UNDERSTANDS AV WILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE GU ATIONS. MECHANICAL FBB
O AIR HANDLING UNIT(OVER 10,010 CFM)
CONSTRUCTION TAX
Si alum ol'Applicare/ConuMfor Date EXHAUST HOOD(W/DUCfJ HOUSING MITIGATIONIGC
HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant m future building o[cupam more or handle Imzmaous material 14EATING UNIT(TO 1011,000 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and The Health and Solely
Code,Section 25532(a)] HEATING UNIT(OVER 100,000 BTU)
E]yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building Occupant use equipment or devices which Date Rece'l a
•emit hazardous air conuminams as defined by the Bay Ama Air Quality Management BOILER-COMP(7HPOR 100.0g)(IRTU)
D '
TOTAL:
lalnCl]
❑Yes ❑Nn BOILER—COMP(OVER 100,000 BTU)
I have read ahc latoodmi,materials mooirease miler Chu"c' 95 of ase Cali- AIR CONDITIONER
P ISSUANCE DATE
form.ldi Health& cone Code,Stains 25505,25533 and 2.5534. undemaind that i1'The NEW RESIDPN]'IAl.MCCH. SQ.FT.
building don n outs whichrtly hove v ...et p.Tb.T o is mum a of n C iliry to nmifLocution, _
of the rcquircmems which nmst he met prior to issuance nl n Cenilicme of Occupancy.
Owner of mnhmired agent Date TOTAL: ISSUED BY:
OFFICE