00050033APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�144'O00
S 00 33
CITY C
BUILDING-ELECTRICAL
EtMIT Sir
BUILDING DIVISION
APPLICATION/PERMIT
PLUMP N.-MECHANICA
S0001
n
BUILDING PROJECT IUIN11iTcATION
'
BUILDINGADDRFSS:
SANITARY NO.
APPIACATA'R
'I'[ON SUBMITTAL D;
10131
1
i 11ckl
OWNER'S AME:
J.Hone
CONTRACTORS NAME: I,IC NII:
/�(.
NIC
CONTROL#
anrl40$-0"153-Ut?4
❑
\IZCIII'I'ECT/P.NGINEER: LIC NO.
ADII��RESX
La�tD Q.Up .cpYUTAwm& h
/
CONTACT: PHONE:
/,wwerc✓ 140S-721-1,�slke
I herein 2,111.... afar I on. I'metned nndcr provisions of Charter 9 (wnnencitg
wfth SF,6 190001 of Division 3 ofthe Business and Probe ssian'Coda and a,, license is
in all force end effe, e ce L5 -D ca ce
Liccmc Cl... Llc, #
uvm Ob Cmntal-lOS
ARCHITECT'S DECLARATION
I undersandny Plans null be rated as pahhc coed,
Liecnsed Pri fieV imnl
OWNP.RTUILDER DECLARATION
I herehy .fans that I at t xenyl fol he Contractor, Li case I.aw for dm
Fallowing saam. (Section 913 L5 Business and Proressions Code Any city or cnranry
widen redid a P—Ra m amsm.ch alien infero q demolish.. or repair any snnemre
Paid, m its "snne, lm regaires,he applia.n far such dnint to file itsignedtmmmen,
Thal he is lieemed puou:mnoute pmt Film, Con,mnlors Li cense Law (Cl .apmr9
(m. icarre ng with Section ]00(1)of Dif Ision 3 or BusinmS and Professions Cade) or
Thal he is exenyn du re0bn and the nasal For Inc alleged esuch,a F. Any violation of
Seclin i 7WIS by any uppliranl foan pe hu(suh)eGs the applicant In a civil Penally of
oat none than Bvo hundred doll... WW),
L as owner at rho Fri it my cr,loyccs with wages as l heirsole.... a tion,
rill do the work and themn.earnis ooh intended or, offered faradic ISce. 7044. Rosiness
and Francis.., Code: Thin Cmrncmr, L 11al" Law docs no, apply n an owner of
Property who builds or in 2,r... thereon, and who done such work himself or through
his own employees, provided Ira such arpmaanents he nm intended or o0crcd for
sale, 11; however, tiro building Uri ugfmve.nenl i, sfld waluo one year al conplmian, flue
owncr laildc.will have the hunlen of posing thin he did not huild or inyaovin in rnr-
po,, of 441Q.).
❑ 1 f tine hur rit'lurvey amn,onfir, is Ur licensed rourad,tor, In
eor,la,tth l) 1,Ld San. 7UL Resins, ,adP C ) Tire Corridors Li-
crus
tt .l -
s Law dies ota'pllY it) an owner if pi-preary who hunliN or dghII d
who Counties for Loh pm)w, with a o Fir. wort) I darted po t t tto tire C n'uuf 's
License law.
❑ faun exempt under See. ,B& P C or this reason
❑ Consultant Pees Paid by Applicant (Initial)
Owner Dwc
WORKER'S COMPENSATION DECLARATION
I hcnhy affun nndcr penally of per Fit, one nfthc following dedarelionc
I base and will noinurn a Cer iffc-nm at Cominnuo self-imnre for Worker'e Coor
emion, as provlJed for by Sedinn 3900 nF the lahnr Cade, for the pedarmmm attire
r which ods panne it i....ea
wort have end will mninedr, Worker, Conpeialion Insurance, as required by Se,hon
3900of the Lab Code, for the p rl...lance of the work rorwhich ads rental f, ltwed.
My Workor'sC pent 't lin era co mer and Policy Fauber are
p$1[tt
Carrier
C%� rl �� Policy Nn.:
CERTIFICATE. OFEXEMPTIINN PROM WORKERS'
COM PENSA'SAI 1Ii'1 ION ONINSURANCE
p'nin ncetinn need at,, be ca.npmmd irate pin, nn It Efrenmfrandml toll...151 W)
or msx.)
1Can dy that int he perfnnnancan'the I ruchnne Larhalispoliof.ismaoIdall
per -
null n. Law any person iaany .,,toner so es m hea.nu. whjecl to the Worker: Cnmpen-
OZ Falun LuWS of C.lifnTIR D:IIC.
Applicant
y NOTICE TO APPLICANT: If, after making this Certificate of IinnnPticar you should
bsone subject to (be Workers Cnnpcnsahnn provisions of the Labor Calc, you must
!�
It comply wt Ir Loch provisions ,, Its Pc,ndl shall be declared revoked.
W Q
� z
CONS 'rROCeisa c IONLENDNO AGENCY
hereby efli.'hi Ihm nal is i a rnI Sce. 30 lending agency for lhe Perfonn:mm of
W � the work for which his pennil is isrnal [Sw. 3097, Cie. C)
0 U Lender', Nature
r Dal Lender's Address
I cuddy that I have read Ihis application Find score that the above inftnmmion is
-a h mmrer 1 agree to ComPly with all city and county ordith noes and sate lows reaming la QTY.
U Z huilding construction, and heohymdhorixe representatives of erupon
this city,, entthe
atvwo-mcnlinnnl pmpeny for inspection (Imposes
(We) agree to Navin, indannEy and keep hantda.s Ihu City of Cupertino agnitnl
liahilhicx,judgmenls,nnls a Iexpenses which may in any way scene egain,I avid City
in consequence of the gra gulf tbispennit.
AP ICANFUN UE ANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MA'IERIN.S DISCLOSURE
Will lir Ii car fumtc hidddingtxe.paannr
nr slum or handle hdo..ntmanal
as der nrd by t :T n o
npen.nU Municipal Code, Chapter 9.12, and me Hadco and Safely
Cndu, Section 255321101
Fl Yes
Will Wa applicant or fnurc Wilding occupunl use equipnmnl Fir devices which
�anit Imeaalous it or annfnns it, dEincd by me Bay Area At, Quality Mam.gcncnt
D.1ricl"
❑Yes No
I hava mad than haeanlo is materials rcqui... cau s nude, Chapter 695 of Ise Cali-
adriu Herb & S R y Code, Sent us 25505, 25533 and m.nd it th
25534. 1 undaThal e
bnildingdae urn . ctulyhavew 1, Into it is my respnnsihility In notify theocnlpanl
m
nnhn mu- wflleh nn,yha -a, an lnraaneeora exitineane aro'cnpanny.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -BESIDES I'TAI.
PANELS
UP'ro 21x1 AMPS
OVER IWIIAMPS
SIGNS LI.ECTRICAL
SPECIAL CIIZCUI UMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- SWITCHES -FIX I URES
NIIW RESIDENTIAL ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT' -WATER (1'A]
N K FLOW PROTECT'. DEVICE
TRAIN- FLOOR, ROOB ARE ;=
GAS - EA. SYSI - 1-I wC.4
GAS-EA.SYSTEM-( ER4
GREASE✓INDUSTRL WAS
DREAM"'IRAE'
SBWHIt-SANI'I'AItY- 'OI
WATER IIEA'f131t WI EN'I'IE
WATER SYSTI? 'BEATING
WAI'F.It SI' VICIi
NIiW .$IDIiN'I'IAI. PI,M1IIt.
MECHANICAL PERMIT
SQ PC
SQ IT
PERMIT ISSUANCE
ALTER OR ADD TO MP.CIL
AIR HANDLING UNIT' (TO 10,000 CPM)
AIR I IANDI.ING UNIT' (OVER 10,000 CPM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 RTI L
HEATING UNIT' OVER 100,000 RTU)
VENTILATION FAN ESI NOLF. RES] D)
ROILER -COMP (3f 111 OR 100,000 It I H
BOLI ER -COMP (OVER Iall BTUI
A]R CONDIT'I ONE R
NEW RI,SIIIENT'IAI. MECII. SQ. INC
TOTAL:
FEE
JON DFiSCRIP'I'ION
RESIDENTIAL:
❑SPDWI. ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RPPIPE
❑MIJIA I -UNIT ❑ST'RUCI URAL
MODIFICATION
❑IN'lPRIOR El CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
OPATH REMODEUREPAIR EDEMOIIT}QN
❑GFH lilt �I-l.tlY�Cp
COMMERCIAL:
❑ LL IU.DGIADDITION ❑DFMOLI'I(ON
01'FNAN'I' ❑ FOOD SERVICE
IMPROVEMENT
❑ OTI LER
SQ, PI', FLUOR ARBA $ISQ. Pr.
FEE
2/072—
BUILDING DIVISION FEES
PLANCHECK FILE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dain II ..,#
TOTAL:
BUILDING FIT. -
FEE SEISMIC FEE
ELECT BIG EHE
PLUMBING FEP_
MECHANICAL LINE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dale Recclpl#
TOTAL:
ISSUANCE. DAM
ISSUED BY:
OFFICE 9
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
�144'O00
S 00 33
CITY C
BUILDING-ELECTRICAL
EtMIT Sir
BUILDING DIVISION
APPLICATION/PERMIT
PLUMP N.-MECHANICA
S0001
n
BUILDING PROJECT IUIN11iTcATION
'
BUILDINGADDRFSS:
SANITARY NO.
APPIACATA'R
'I'[ON SUBMITTAL D;
10131
1
i 11ckl
OWNER'S AME:
J.Hone
CONTRACTORS NAME: I,IC NII:
/�(.
NIC
CONTROL#
anrl40$-0"153-Ut?4
❑
\IZCIII'I'ECT/P.NGINEER: LIC NO.
ADII��RESX
La�tD Q.Up .cpYUTAwm& h
/
CONTACT: PHONE:
/,wwerc✓ 140S-721-1,�slke
I herein 2,111.... afar I on. I'metned nndcr provisions of Charter 9 (wnnencitg
wfth SF,6 190001 of Division 3 ofthe Business and Probe ssian'Coda and a,, license is
in all force end effe, e ce L5 -D ca ce
Liccmc Cl... Llc, #
uvm Ob Cmntal-lOS
ARCHITECT'S DECLARATION
I undersandny Plans null be rated as pahhc coed,
Liecnsed Pri fieV imnl
OWNP.RTUILDER DECLARATION
I herehy .fans that I at t xenyl fol he Contractor, Li case I.aw for dm
Fallowing saam. (Section 913 L5 Business and Proressions Code Any city or cnranry
widen redid a P—Ra m amsm.ch alien infero q demolish.. or repair any snnemre
Paid, m its "snne, lm regaires,he applia.n far such dnint to file itsignedtmmmen,
Thal he is lieemed puou:mnoute pmt Film, Con,mnlors Li cense Law (Cl .apmr9
(m. icarre ng with Section ]00(1)of Dif Ision 3 or BusinmS and Professions Cade) or
Thal he is exenyn du re0bn and the nasal For Inc alleged esuch,a F. Any violation of
Seclin i 7WIS by any uppliranl foan pe hu(suh)eGs the applicant In a civil Penally of
oat none than Bvo hundred doll... WW),
L as owner at rho Fri it my cr,loyccs with wages as l heirsole.... a tion,
rill do the work and themn.earnis ooh intended or, offered faradic ISce. 7044. Rosiness
and Francis.., Code: Thin Cmrncmr, L 11al" Law docs no, apply n an owner of
Property who builds or in 2,r... thereon, and who done such work himself or through
his own employees, provided Ira such arpmaanents he nm intended or o0crcd for
sale, 11; however, tiro building Uri ugfmve.nenl i, sfld waluo one year al conplmian, flue
owncr laildc.will have the hunlen of posing thin he did not huild or inyaovin in rnr-
po,, of 441Q.).
❑ 1 f tine hur rit'lurvey amn,onfir, is Ur licensed rourad,tor, In
eor,la,tth l) 1,Ld San. 7UL Resins, ,adP C ) Tire Corridors Li-
crus
tt .l -
s Law dies ota'pllY it) an owner if pi-preary who hunliN or dghII d
who Counties for Loh pm)w, with a o Fir. wort) I darted po t t tto tire C n'uuf 's
License law.
❑ faun exempt under See. ,B& P C or this reason
❑ Consultant Pees Paid by Applicant (Initial)
Owner Dwc
WORKER'S COMPENSATION DECLARATION
I hcnhy affun nndcr penally of per Fit, one nfthc following dedarelionc
I base and will noinurn a Cer iffc-nm at Cominnuo self-imnre for Worker'e Coor
emion, as provlJed for by Sedinn 3900 nF the lahnr Cade, for the pedarmmm attire
r which ods panne it i....ea
wort have end will mninedr, Worker, Conpeialion Insurance, as required by Se,hon
3900of the Lab Code, for the p rl...lance of the work rorwhich ads rental f, ltwed.
My Workor'sC pent 't lin era co mer and Policy Fauber are
p$1[tt
Carrier
C%� rl �� Policy Nn.:
CERTIFICATE. OFEXEMPTIINN PROM WORKERS'
COM PENSA'SAI 1Ii'1 ION ONINSURANCE
p'nin ncetinn need at,, be ca.npmmd irate pin, nn It Efrenmfrandml toll...151 W)
or msx.)
1Can dy that int he perfnnnancan'the I ruchnne Larhalispoliof.ismaoIdall
per -
null n. Law any person iaany .,,toner so es m hea.nu. whjecl to the Worker: Cnmpen-
OZ Falun LuWS of C.lifnTIR D:IIC.
Applicant
y NOTICE TO APPLICANT: If, after making this Certificate of IinnnPticar you should
bsone subject to (be Workers Cnnpcnsahnn provisions of the Labor Calc, you must
!�
It comply wt Ir Loch provisions ,, Its Pc,ndl shall be declared revoked.
W Q
� z
CONS 'rROCeisa c IONLENDNO AGENCY
hereby efli.'hi Ihm nal is i a rnI Sce. 30 lending agency for lhe Perfonn:mm of
W � the work for which his pennil is isrnal [Sw. 3097, Cie. C)
0 U Lender', Nature
r Dal Lender's Address
I cuddy that I have read Ihis application Find score that the above inftnmmion is
-a h mmrer 1 agree to ComPly with all city and county ordith noes and sate lows reaming la QTY.
U Z huilding construction, and heohymdhorixe representatives of erupon
this city,, entthe
atvwo-mcnlinnnl pmpeny for inspection (Imposes
(We) agree to Navin, indannEy and keep hantda.s Ihu City of Cupertino agnitnl
liahilhicx,judgmenls,nnls a Iexpenses which may in any way scene egain,I avid City
in consequence of the gra gulf tbispennit.
AP ICANFUN UE ANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MA'IERIN.S DISCLOSURE
Will lir Ii car fumtc hidddingtxe.paannr
nr slum or handle hdo..ntmanal
as der nrd by t :T n o
npen.nU Municipal Code, Chapter 9.12, and me Hadco and Safely
Cndu, Section 255321101
Fl Yes
Will Wa applicant or fnurc Wilding occupunl use equipnmnl Fir devices which
�anit Imeaalous it or annfnns it, dEincd by me Bay Area At, Quality Mam.gcncnt
D.1ricl"
❑Yes No
I hava mad than haeanlo is materials rcqui... cau s nude, Chapter 695 of Ise Cali-
adriu Herb & S R y Code, Sent us 25505, 25533 and m.nd it th
25534. 1 undaThal e
bnildingdae urn . ctulyhavew 1, Into it is my respnnsihility In notify theocnlpanl
m
nnhn mu- wflleh nn,yha -a, an lnraaneeora exitineane aro'cnpanny.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -BESIDES I'TAI.
PANELS
UP'ro 21x1 AMPS
OVER IWIIAMPS
SIGNS LI.ECTRICAL
SPECIAL CIIZCUI UMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS- SWITCHES -FIX I URES
NIIW RESIDENTIAL ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT' -WATER (1'A]
N K FLOW PROTECT'. DEVICE
TRAIN- FLOOR, ROOB ARE ;=
GAS - EA. SYSI - 1-I wC.4
GAS-EA.SYSTEM-( ER4
GREASE✓INDUSTRL WAS
DREAM"'IRAE'
SBWHIt-SANI'I'AItY- 'OI
WATER IIEA'f131t WI EN'I'IE
WATER SYSTI? 'BEATING
WAI'F.It SI' VICIi
NIiW .$IDIiN'I'IAI. PI,M1IIt.
MECHANICAL PERMIT
SQ PC
SQ IT
PERMIT ISSUANCE
ALTER OR ADD TO MP.CIL
AIR HANDLING UNIT' (TO 10,000 CPM)
AIR I IANDI.ING UNIT' (OVER 10,000 CPM)
EXHAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 RTI L
HEATING UNIT' OVER 100,000 RTU)
VENTILATION FAN ESI NOLF. RES] D)
ROILER -COMP (3f 111 OR 100,000 It I H
BOLI ER -COMP (OVER Iall BTUI
A]R CONDIT'I ONE R
NEW RI,SIIIENT'IAI. MECII. SQ. INC
TOTAL:
FEE
JON DFiSCRIP'I'ION
RESIDENTIAL:
❑SPDWI. ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RPPIPE
❑MIJIA I -UNIT ❑ST'RUCI URAL
MODIFICATION
❑IN'lPRIOR El CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
OPATH REMODEUREPAIR EDEMOIIT}QN
❑GFH lilt �I-l.tlY�Cp
COMMERCIAL:
❑ LL IU.DGIADDITION ❑DFMOLI'I(ON
01'FNAN'I' ❑ FOOD SERVICE
IMPROVEMENT
❑ OTI LER
SQ, PI', FLUOR ARBA $ISQ. Pr.
FEE
2/072—
BUILDING DIVISION FEES
PLANCHECK FILE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dain II ..,#
TOTAL:
BUILDING FIT. -
FEE SEISMIC FEE
ELECT BIG EHE
PLUMBING FEP_
MECHANICAL LINE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Dale Recclpl#
TOTAL:
ISSUANCE. DAM
ISSUED BY:
OFFICE 9