21842 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification I ',T - PERMIT NO.
' Buuding Address: / xa �60 f1 a� (1 A n
P1 - Rcvk l�.e' !� G I l8 4 G
Phone; A A A
�
[ Y / vpe, CITY OFCUPERTINO-BUILDING DIVISION -2/, y/
® Contractor's Name: �/ No: APPLICATION / PERMIT
/ Lfa.S BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Archted/En r. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE BLDG ul�l
� I 1 �� 3—
LICENSED Ia CONTRACTOR'S DECLARATION �T�
l hersectio 7D lbatlam.iox3 fth,B.inessa!under dPrul hapter9(m and APPLIANCESRESIDENCfAL JOB DESCRIPTION
'nenseISection 7000)of Di died, lthe Buainevand ProfesslomCodq and my
license bin full(ora dd(ect, PANELS '
Date Clam Lich �97
Date Contractor
ARCHITECTS DECLARATION 00AMI5
pQ��70. I understand my plans shag be used v reco
public rds OVER1
SQ.FC.FLOOR AREA f/�.FT.
E d E Licensed Professional SIGNSELECTRICAL 1
Q w� OWNER-BUILDER DECLARATION SPECIAL GIRL
7 N-IA.-moi Iherebyafffrenthatlamezemptfromthe Contrador.Lf¢nelawfcrtheUTJ '
ppfollowingreason.(5aelon7015,Businessand Profmions Cade:Anydiyor
OTFMp.MEIERO PO 'I
F� mmtywhichrtryfresapermittommtmd,alter,improve,demolbh,ormpafr
anyswcturt pdarto its isswnce,abortqulrtstheapplantfanuch parmitto POWFRDEVIX
file a sued statement that he Is licensed pursuant to the provisions of the
F�OiContractor's License Law(Cha er9(commencin with Section 7000)ofDivi.
skm3 ofthe Business and Preffemions Code)orMtl hebexemptthemfromand SWQ.IMINC POOL ET.FCTRIG ( VALUATION
Sn.•�.tt the basis for the alleged exemption. Any ,violation of ScaHon 7015 by any IS
OUfLESWHC
O
applicantfor a permit subjects the applicant to a dvll penalty of not more than _ /DJ 8�✓
m � Eve hundred dollars (10).(55
NEW RCSIDEN7IAL ELFCTR SQ.FT. STORIES, TYPECONS"(RUCTION
f] �, ❑1,asowner ofthe property,
work,aor my employees Inwithwagesa theles ole
k76 compF..761,wWdothe
ents and PrfdthestrudurtbnatintaWN or offeredLaw
dosales not
to anowandf property
Cade TheCImproves hemor,Law
s$ docs not apply torn owner ofdprough whobuilds moyee,provided
eoRand OCCGROUP RFS UNITS
who does work tInthimself edorarghedown e,11,ho eprwWedthat such inger
improvements are not Intended...!bred pl elle,If,howeveruilder Edingve TOTAL:
improvement is sold within oneyearofcompldlon,the owner-bullderwlll have
th rdenofpmvfng that he did not bold orfmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD 7DNT APN
Lj 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract.to constact the project(Sec.7016,Businessarta Profeaelom Code:
The Contractor's License Lw does not apply to an owner of property who ALIIILDRAIN&VENT-WATER(FA)
Wilds or improves thereon,and who contracts for such pojecta with r FEE SUMMARY
on,Rt�actor(s)licensed pursuant to the Contractor'.License Law. BACK FLOW PAO'I'ECT.DEVICE
IJ 1 am exempt under Sec B 4 P C for this re
aann•
Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
WORKMIO
AN COMPENSATN RECET'TN
cement
FIXTURE'S PER TRM SCliOOLTAX Y_ N
❑I hereby affirm that I have a certificate offconatnt self-Insure,ora RECEIIT'N
adffiram ofW.,lum'C..,. ion Inuranmora certified Copy thereof(Sec.
WcIL IEC.) CAS EA.SYSITM-]INCA OUTLETS PARK FEE Y_ N_
Policy N RECEIPT N
Com
�Cany GAS.EA.SYSTEM-0VER4(EA) BUILDING DI VI SI ON Fr.ES
edified copy 0 flied with
the city
Inspection division.
herebyte
Certified copy b GREASEANDUSTEL WASTE INTERCEPTOR PLANCHECK FEE
ity
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE 5E}VER.SANITARYSTORM EA.X F]'. Date Recel t# sdM
- Rhlasectlon need rad be compiled lithe permit isforora hundred dollen
W W)orlev.) WATERIIFI IFR W/VFM/ELFCTA ENERCYFEE Y N
I¢dlfythat in the pedm
orance of the work forwhich this permit is Issued,
I shall not employ any person In any.runner so v to become subject to theWATDi SYSITM/TR[ATING
Wodni C.nn,.sationiawaof UlBomb.Date PAID
O Z Applicant NEWRESIDENTIALPI2dB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT;If,after raking this Certificate of Exemption,you
should bemmnsubject to the Warken'CompensatloR provisions ofthe Labor TOTAL:
F fA Codgyou most forthwith comply with such provisiovarthbpermit shall he
W 9 deeDUI DINCFEE
deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE 12-0.4
Iherebyaf@mthat there b a construction lending agency for the perform ELECTRIC FEB js
Z once of the work!or which this permit Ip d(Sec.3097,CIv.C.) TOTAL:
U O Iender's Name/l PLUMBING FEEO.jy-
LL ~ Ienaer.Aaanss i QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Ow 1¢dffythat]have mad thbappuatmnand stmethattheaWveInformation _70.A-357
ll ismrnd.Lgreeto mmplywlth all cttyand Countyordinan¢land LLate laws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and herebyauthorize representatives of this
F Z city to enter upon the above-mentioned property for impedion purposes. ALIFRORADDTDMUCH.
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date " Receipt#
agaWtllabi@les,pdgmenta,astund azpensn which may In anywayacaue AIRHANDLINCUNI7fOOI0,0)0CFM) SUBTOTAL:
agalnstsal i con en¢of the gra rating of this perm / l/
�(/]/ "i AIR HANDWNG IMIT(OVER IO,0)0 CITf) CONSTRUCTION TAX
tiignat of AppB t/Contractor ate D(HAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE p
Will theappBcantor future Wildingoccup.m.tnrear handle haeardeus ITE1TWGUNIT(710100,000BTIn Date Rccei t# 3i1.�.8�
ramrial a.definM by the Cupertino Munidpal Code,Chapter 9.12,and the a-sr��O/p�
Iirolth and Safety Code Section 75532(&)7 HEATING UNIT(OVER 10,000 BTU) TOTAL: V`oagb
❑ Yes M No
Will the applicant on future building occupant use equipment or device. VEN'E LATION FAN(SINGLE RESID) - ISSUANCE DATE
which emit hasrdous air contaminants as defined by the Bay Area Air OA�'�
QualitYr,aagument District?
BOILER-WMP OEN OR100,0[tl BTU) .9
4haver,ad the bazardoumterialsrequirements underChapter6.95of MOILER-COMPNVFR100,0WBTU) r4 w a�
the California I lealth ASa( Code,Sections 2550.5,7593 and 255]/. 1 s 4 `5!7
undontandthaHfthebuildingdoonaanentlyhaveatenanl that it is my NEW RM- DENMAL MECH. SQ.FF.
responsibility to notify the oocapant d the requirements which most be met
poor res a teof Occupancy. Q.O.v orfs agent IDs ISSUE l 2Im2w
TOTAL:
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification I ',T - PERMIT NO.
' Buuding Address: / xa �60 f1 a� (1 A n
P1 - Rcvk l�.e' !� G I l8 4 G
Phone; A A A
�
[ Y / vpe, CITY OFCUPERTINO-BUILDING DIVISION -2/, y/
® Contractor's Name: �/ No: APPLICATION / PERMIT
/ Lfa.S BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Archted/En r. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE BLDG ul�l
� I 1 �� 3—
LICENSED Ia CONTRACTOR'S DECLARATION �T�
l hersectio 7D lbatlam.iox3 fth,B.inessa!under dPrul hapter9(m and APPLIANCESRESIDENCfAL JOB DESCRIPTION
'nenseISection 7000)of Di died, lthe Buainevand ProfesslomCodq and my
license bin full(ora dd(ect, PANELS '
Date Clam Lich �97
Date Contractor
ARCHITECTS DECLARATION 00AMI5
pQ��70. I understand my plans shag be used v reco
public rds OVER1
SQ.FC.FLOOR AREA f/�.FT.
E d E Licensed Professional SIGNSELECTRICAL 1
Q w� OWNER-BUILDER DECLARATION SPECIAL GIRL
7 N-IA.-moi Iherebyafffrenthatlamezemptfromthe Contrador.Lf¢nelawfcrtheUTJ '
ppfollowingreason.(5aelon7015,Businessand Profmions Cade:Anydiyor
OTFMp.MEIERO PO 'I
F� mmtywhichrtryfresapermittommtmd,alter,improve,demolbh,ormpafr
anyswcturt pdarto its isswnce,abortqulrtstheapplantfanuch parmitto POWFRDEVIX
file a sued statement that he Is licensed pursuant to the provisions of the
F�OiContractor's License Law(Cha er9(commencin with Section 7000)ofDivi.
skm3 ofthe Business and Preffemions Code)orMtl hebexemptthemfromand SWQ.IMINC POOL ET.FCTRIG ( VALUATION
Sn.•�.tt the basis for the alleged exemption. Any ,violation of ScaHon 7015 by any IS
OUfLESWHC
O
applicantfor a permit subjects the applicant to a dvll penalty of not more than _ /DJ 8�✓
m � Eve hundred dollars (10).(55
NEW RCSIDEN7IAL ELFCTR SQ.FT. STORIES, TYPECONS"(RUCTION
f] �, ❑1,asowner ofthe property,
work,aor my employees Inwithwagesa theles ole
k76 compF..761,wWdothe
ents and PrfdthestrudurtbnatintaWN or offeredLaw
dosales not
to anowandf property
Cade TheCImproves hemor,Law
s$ docs not apply torn owner ofdprough whobuilds moyee,provided
eoRand OCCGROUP RFS UNITS
who does work tInthimself edorarghedown e,11,ho eprwWedthat such inger
improvements are not Intended...!bred pl elle,If,howeveruilder Edingve TOTAL:
improvement is sold within oneyearofcompldlon,the owner-bullderwlll have
th rdenofpmvfng that he did not bold orfmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD 7DNT APN
Lj 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract.to constact the project(Sec.7016,Businessarta Profeaelom Code:
The Contractor's License Lw does not apply to an owner of property who ALIIILDRAIN&VENT-WATER(FA)
Wilds or improves thereon,and who contracts for such pojecta with r FEE SUMMARY
on,Rt�actor(s)licensed pursuant to the Contractor'.License Law. BACK FLOW PAO'I'ECT.DEVICE
IJ 1 am exempt under Sec B 4 P C for this re
aann•
Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
WORKMIO
AN COMPENSATN RECET'TN
cement
FIXTURE'S PER TRM SCliOOLTAX Y_ N
❑I hereby affirm that I have a certificate offconatnt self-Insure,ora RECEIIT'N
adffiram ofW.,lum'C..,. ion Inuranmora certified Copy thereof(Sec.
WcIL IEC.) CAS EA.SYSITM-]INCA OUTLETS PARK FEE Y_ N_
Policy N RECEIPT N
Com
�Cany GAS.EA.SYSTEM-0VER4(EA) BUILDING DI VI SI ON Fr.ES
edified copy 0 flied with
the city
Inspection division.
herebyte
Certified copy b GREASEANDUSTEL WASTE INTERCEPTOR PLANCHECK FEE
ity
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE 5E}VER.SANITARYSTORM EA.X F]'. Date Recel t# sdM
- Rhlasectlon need rad be compiled lithe permit isforora hundred dollen
W W)orlev.) WATERIIFI IFR W/VFM/ELFCTA ENERCYFEE Y N
I¢dlfythat in the pedm
orance of the work forwhich this permit is Issued,
I shall not employ any person In any.runner so v to become subject to theWATDi SYSITM/TR[ATING
Wodni C.nn,.sationiawaof UlBomb.Date PAID
O Z Applicant NEWRESIDENTIALPI2dB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT;If,after raking this Certificate of Exemption,you
should bemmnsubject to the Warken'CompensatloR provisions ofthe Labor TOTAL:
F fA Codgyou most forthwith comply with such provisiovarthbpermit shall he
W 9 deeDUI DINCFEE
deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE 12-0.4
Iherebyaf@mthat there b a construction lending agency for the perform ELECTRIC FEB js
Z once of the work!or which this permit Ip d(Sec.3097,CIv.C.) TOTAL:
U O Iender's Name/l PLUMBING FEEO.jy-
LL ~ Ienaer.Aaanss i QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Ow 1¢dffythat]have mad thbappuatmnand stmethattheaWveInformation _70.A-357
ll ismrnd.Lgreeto mmplywlth all cttyand Countyordinan¢land LLate laws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and herebyauthorize representatives of this
F Z city to enter upon the above-mentioned property for impedion purposes. ALIFRORADDTDMUCH.
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino Date " Receipt#
agaWtllabi@les,pdgmenta,astund azpensn which may In anywayacaue AIRHANDLINCUNI7fOOI0,0)0CFM) SUBTOTAL:
agalnstsal i con en¢of the gra rating of this perm / l/
�(/]/ "i AIR HANDWNG IMIT(OVER IO,0)0 CITf) CONSTRUCTION TAX
tiignat of AppB t/Contractor ate D(HAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE p
Will theappBcantor future Wildingoccup.m.tnrear handle haeardeus ITE1TWGUNIT(710100,000BTIn Date Rccei t# 3i1.�.8�
ramrial a.definM by the Cupertino Munidpal Code,Chapter 9.12,and the a-sr��O/p�
Iirolth and Safety Code Section 75532(&)7 HEATING UNIT(OVER 10,000 BTU) TOTAL: V`oagb
❑ Yes M No
Will the applicant on future building occupant use equipment or device. VEN'E LATION FAN(SINGLE RESID) - ISSUANCE DATE
which emit hasrdous air contaminants as defined by the Bay Area Air OA�'�
QualitYr,aagument District?
BOILER-WMP OEN OR100,0[tl BTU) .9
4haver,ad the bazardoumterialsrequirements underChapter6.95of MOILER-COMPNVFR100,0WBTU) r4 w a�
the California I lealth ASa( Code,Sections 2550.5,7593 and 255]/. 1 s 4 `5!7
undontandthaHfthebuildingdoonaanentlyhaveatenanl that it is my NEW RM- DENMAL MECH. SQ.FF.
responsibility to notify the oocapant d the requirements which most be met
poor res a teof Occupancy. Q.O.v orfs agent IDs ISSUE l 2Im2w
TOTAL:
OFFICE COPY