24849 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C. ..EC'1'RICAi, PERMIT NO.
CITY OF CUPE1'LUMHING MEGHANIGAI. 24849
BUILDING DIVISION
sioN APPLICATION/PERMIT nuu.DlNr.rl:ndEer n3RN•rfrtcnnoN
BUILDING wooRpss: SANITARY NO. APPLICATIONNSSUBM/fnTAAL DATE
UNIT# _a6LOT#
OWN NAML: H L: CONTR C`RM'S NAME: LIC NO: NIC CONTROLX �^�
�. _ifo fg5�y co.vsT s s
ARCHI'rECryGNGINEI:R: LIC NO: A ESS. .�� �v � A C El
PHONE: / BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT' I'EE
q{.q0 ELECT PLUMB MF.CH
PERMIT ISSUANCE. LMF �]► � ❑
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB pESIrl
pyZ Ihereby 700(or Divikitl am licensedBusiness pmvisiomof C'hapa,and mmecense with '{ y^rL`
�i100 Section](00)of DivisinnJof me Business and Professions Code,end my license is in PANELS
full force and cif
Q . , m TO
U. oJa S9S A L1
y< Date no cmr S' Sy a
SQ.IT.PI,OOR AREA / SrsQ.IT
Z O,,,z ARCHITECTS DECLARATION OVER I"AMPS
O Zui--O ]understand my shalt be used as public records.
SIGNS ELECTRICAL
Q L n Licensed Professional
Xg < OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
oaxx,OaU I hereby mfirm mal I ma exempt from Ou Cmumli is License Law for the
tal�pa fallowing reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.METER O0.POLE(NST.
which requires. .it to cornWcl,tiller,improve,demolish,to repair any atm orae
¢7 pkamitsi....se.olsn requires theapplicard fmsuch pe.iuo file.signed smumem POWER DEVICES
W K sbar he is licensed paean.to the provisions of the cmonscmes License Law(C'hopter
a OO�' 9(commencing with Semion7000).Mivision]mhhc Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
�or or that he is exempt therefromtind the basis for headege exemption.Anyvination of
Se,lom 703 L5 by any applicant fora t hjects Nee 1' uo.civil penult f OUTLETS-SWITCI IFS-FIXTURES
k Z Penni esu ' PP scan Y a
f
not more than live hundred dollars($500).p NEW RESIDENI'IAI.LLECIR _SQ.FT. STORIES TYPE CONS'1'RUCTION
K ❑ Losownerofffiepmidthe. ay,or.to.imyemployedcon wed
far atheiSer.compensation,
q3. will dash,work,and the she CmunwimOnin',tanerac Law does rakpplytoministerof
ness
and property
whion.s Cade:The improves
thereon,License Law does not apply a,minister of
ownertywyees,pds Orimproveath improvements
doesauch weaktendet imsfietedhmugh his OCC.GROUP RES.UNITS
employcesilding rimatsuch improv menthin not earioeoroff,red forsole.mer.
however,the
avet a tarimprovementissold withinoneyear or improve
for purpose of TOTAL:
builder will have the burden of proving that he did net build or improve for purpose of
sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
El 1,asowner oftheproperty,am xclusively contracting with licensed contractors in
..trod the project(See ]Ova,Business and Profcaimns Cade:)The Contractor's PERMITISSUANCE License Lawdoesnm apply m no owncroiampertywho builds or improves therean,imJ w1
whocontmcts for such Projects with o cmnuecmr(s)lieemed,ursuas to the Centimeter's ALTER DRAIN&VENT- ATF. ( ) s w# (FEE SUMMARY
License Law. — lis
❑ I um exempt under Sec. ,11&P C for thin reason BACK FLOW PROTECT,DE ICE ^� q t eLS
I i J � 5 M!1' Y N
Owner —Date— DRAINS-FlOOR,ROOF,A .GOND. ` �� 0 RECEIPT'#
WORKMAN COMPENSATION DECLARATION TOOL TAX YN
❑ Thereby affirm that l have a cmificeta iferuem to self-insure.or a certificate of RECEIPT#
Work<n'Compcnsation Insurance ore cenifie copy thereof(Sec.3803.Lab CJ which FlXTURES-PER TRAP YN
call employee's under this permit GAS-EA.SYSTEM-II ETS— -- "- - DIVISION
imp#
BUILDING DIVISION Ff:FS
Company GAS-EA.SYSTEM-OVER 0(EA) PLANCHECK FF,1?
❑ Certifie Copy is hereby famished.
❑ Certi6eJ copy is fled with the city impemion division. GRGSFJINDUSTRL WAS":INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEF,
COMPENSATION INSURANCE
(Thissee.Ion need notbecnmplmed ifthe permit is forma,hundred dollars($IW) SEWER-SANITARY-STORM EA.211017. ENERGY FEB Is
or Ica.)
I cerify that in the performance of the work for which this permit is issue,l shall WATER HEATER WIVENT/ELECHt
not employ any person to any manner so as to become subject to the Workers' PAID
Cmnpenatlon Lawsof California. Dam WATER SYSTEM(fREVDNG ate Rmci #
Oz Applicant
Z 0 NOTICE.TO APPLICANT:IL after making this Cmificate of Exemption,you should NEW RESIDENTIAL PLM. SQ.FI'. TOTAL:
r � subject become subjeco the Worker's Compareationptovisionsofthe Labor Code,you must
7 forthwith comply with such provisions orthis permit rhall be deemed revoked. BUILDING FEE
o CONSTRUCTION LENDING AGENCY SEISMIC IEE
z I hereby affirm that here is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
O the work for which this Permit is issued(Sec.3097,Co.C.)
Lender's Name a a a, PLUMBING PER
U. r_-' Lender's Address QTY. MECHANICAL PERMIT LLE
0 U I certify Cha 1 have read this application and state that the above information is MECHANICAL FEE
correct.l agree to comply with all city and county onlinances andstare laws miming to PERMIT ISSUANCE.
I" 6 building cormunation,wad hercbyaollmore representativesafthis city to enterupon the CONSTRUCTION fAX
U z above-mentioned propmy for impemion purposes. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep harmless the City of C.I mmo against
liabilities.judgmems,etntsandexpenses winch may many way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
incmnaequamc hegmn6. permit. � p
�"Oote I AIR HANDLING UNIT(OVER IB,WO CPM)
SilfralunTed AppiicarmContraclor Date EXHAUST HOOD(W/DUCD
At
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 101),0001 BTU) Ft
Will the applicant or future building occupant store or handle hvardous material HEATING UNIT(OVER 103,000 B3'll) T
as defined by the Cupertino Municipal Code•Chains,9.12,and the Health and Safety
Code,Section 265]21,)? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No I Ell MAN Z
Will the.pplicantorfmum buildingoccupwt use eVuipmcmordeviceswhicherrt BOILER-COME IMP OR 100.000 BTU) dS�� , _
haamdnus air cnmami aunts us defined by the Bay Are.Air Quality Management BOILER-COMP(OVER I03,W0 BTU) ftt�
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FF. INSPECTION DEPART
`ILcumently
L Y�l����''pp���������#�mad the hazardous rmtions requirements under M. Iur erst of the L46RIYSdea06&Sofety Cnde.Sections 25505,25533 and 25534. l understand Net
ing does not cunemly have.mnan4 that it is my responsibility to notify the
f the rarylrereents which mum be met prior to issuance ofa Certificate mf
. IZuthorivd agent Date TOTAL: ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
BUILDING-ELT. IRI AI.
TTY OF CUPEPERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PftIIJECI'IIIICN'OFICATION 25892.
BUILDING ADDRESS: SANITARY 0.. APPLICATION
SSUUBBMUTAL DATE
TTX eA1 �/ W L+
OW f?RS NA E. II NE: CONT//gqACafOk'g NAME: //�� LICNO: � `
� '�� ^'WC' ^.(/Lr{/.IONS S eS36 NIC CONTROL#
et�ARCHITECT/F GINEHR: LIC NO: SS:
.0
oN urU On. . 5.(4,4 957, ❑
CON'T'ACT: PHONE.:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOC ELECT PLUMB ECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION MAPPLIANCES-RLSIDENTNL
pyZ Ihereby affinntet l an licensed underpmvisiona of Chapta9(commencing wit TOB DESCRIPTION
[WOO C Section 7000)of Divi'on S of the Buxinas an Ptp(exy� Code d my license is in
RUE fall larceanderred. L� I/1(JsnS' 1` PANELS
FZm L' nseClass Lic.# �7 ✓ ✓ / UP TO4(NIAMPS
y6q ate Commcmr �N' GO.U,X 201-IOW AMPS
ZOyjg ARCHITECTSDFCLARATIO OVER IOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
OZ-4Z I underslard my plum.shall be used m public recOms.
Pm .p4 SIGNS ELECTRICALgCyQ sw
Licensed Profeonel OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xOily, 1 hereby affirm but I am exempt from to Crarmmols License raw fine to
trs3o'y following reason,(Section ITO 1.5,Businessinl Professions Code:Any city or county TEMP.METERORPOLEINST.
�LLJ ry; whicM1 rcyuires n Permin0 dmnrvcL ober,improve,Demolish,or repair any hwnum
C N� prionuits issumce.also rcyuims to applicenl forsuch pemlilmfile asigned scatoma., POWER DEVICES
q00that he is licensed pursuan 1.the provisions of to Contro rm's License Law(Chapter
x� 9(commencing with Section 70(kdof Division 3 oft,Business and Proreasi...Code) SWIMMING POOL ELECTRIC VALUATION
W y or dint he is exempt teret'rom:mdthehalt,far gardened exemption.Anyviolationef
JtZQ Section]031.5 by any applicant for a Peronn subjects the applicant m o civil penalty of OUTLETS-SWITCHES-FIXTURES
SFO , merhonfivehundreddollars(SSW).
0 ❑ I,asowneroftepropeny,Orm m to eeswithwm esasthcirsolecom NEW RESIDENTIALELEC R S IT. TYPE CONSTRUCTION
3 Ya P Y B pension Q STORIES
q will datework.and the s mGma oContienea Lndeseawdosnot apply 70,14,Bunions
and Professions Code:The Com town.License Law dna not apply t as owner of
ownpoopeny who builds odmpmv.s tenon,mud who does such work himself or triage his
howemplayresilding or improvement
provemnpro�ld within not ear oficampicered ficrthe e.owner. OCC.GRO P RES.UNITS
builder will
building burden
operon is hath whin one year or improve
omm a for thebale.). wit(have the burden of proving that he did not build mimprove for purpose of TOTAL:
sale.).
❑ I,as ownerofthe property.amexclusively contracting with licensed cantrocmn to QTY. PLUMBING PERMIT FEE FLOODZONE APN
construct the project(Sec.1044,Business and profeasiom Cale:)Teo Ccouecon'a
Liceme Law does not apply mamawoerof,mr,o,who buildsor improves thereon.and PERMIT ISSUANCE
who commies for such projects with a cnmramor(s)licensed pursuant o the Contractor's
License Law. ALTER-DRAIN& FFESUMMARY
❑ I am exempt under Sec. ,B&P C for this meson BACK FLOW PRO 'Cf.DfiVIC r SID
Owner , !1 0 0 '^ L---A-
--A RY Y N
DE Date DRAINS-I100R, OOF,AREAICOND. RF.CF.IIT#
WORKMAN COMPENSATION,at,1 IATION Y1 i�i
S OOL TAX Y N_
❑ Thereby affirm that have ecenificem ofcansenu0 mlf-i mum,orattnificama( FIXTURES-PER TRA RECEIPT'#
d
Workers'Compensaien Insurance ora certified copy ter.of(Sec.350,Lab CJ which PARK E Y N
cols all employee's undenhis permit GAS-BA.S TEM-I INC.4 OUTLETS
RECE
Policy p
BUILDING DIVISION FEES
Company GAS-EA.SYSTEM OVER 4(EA)
❑ CertiFiN ropy is hcmby famished. PLANCHF.CK FEE
Certified copy is filed with the city inspection division. GREASEIIINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICAT E OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF.
COMPENSATION INSURANCE
(This section need nm hecompleed ifth,permit is fortune hundred dollars I$l0) SEWER-SANITARY-STORM I:A.2WFT. ENERGY FEF.
or less.)
I cmify tat in the performance oft.work for which this permit is issued.I shall WATER HPAIFR WNENT/ELECTR
O.employ any person in any manner so as to become subject .o to Workers' PAID
7-. Compensition"issor Califiono. Data W TE SfEMG`RFATING Dae Receipt p
O Applicant '
Z NO'T'ICE TO APPLICAN'I':11',me,making this Certificate or Exemption,you should EW RESIDENTIAL PLMB. SQ.Pr. TOTAL:
y become Subject 10 to Worker's Compensation poevisionsofte labor Cede,you must
> fonhwithcomply with such provisions or this permit shall bedecm.d invoked. BUILDING IEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC IEE.
7 Z 1 hereby affirm That Then is a construction lending agency for the performance of
U O to work fm which this Pani.is issued(See301l,Civ.C.) TOTAL: ELECTRIC FEE
Q ULender.Name
Lendar's Address QTY, MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read This application and stale that to above information is
W
correct.lagra.o comply with ell city and county oNinances and nnelews relnlingt PERMIT ISSUANCE MECHANICAL FEE
building construction.and hereby authorize representatives Of this city To enter upon the
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Far,I Iics,jud cars,costs and expenses which may in any wayaccrue against said City AIR HANDLING UNIT(TO 1o,000CFM)
in co elan^e granting Tris persni�� n
1" L AIR HANDLING UNIT(OVER IO,WO CFM)
'ignal reof ApplicxmA`omactor ate EXHAUST HOOD(WMUCT)
PAID
HAZARDOUS MATERIAL IS .OSURE HEATING UNIT 10."BTU) Date Receipt p
Will the applicant or future building occup or handle hmnrdoas muuen.1
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100,001 BTU) TOTAL:
Code,Section
❑Yes72(e)1 0N VENTILATION FAN(SINGLE RESID)
Will the applicantorfuwre maidingaceupantusecyuipment ordeviceswhichemit BOILER-COW(1)IF OR 100,000 BTU) ISSPNJKVAU
hazardous air contaminants m define,by the Bey Arca Air Quality Managem.nt BOILER-COW(OVER IW,WO BTU) N1 1r U/'
Dixmi..? FEB
❑Yes 13 NO NEW RESIDENTIAL.MECH. SQ,FT. I?y¢ _ 1CJ C�4
I have read the haual materials re itimmenls under Chapter 6.95 of the Y FS
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that CITY fir ♦✓Llr '
if the building does not cumently have a moan.,that it is my responsibility to minify to
ocarpsnt of the myuirements which must he met prim to issuance of a Certificate of
Occupancy.
Owner or authonzed agent Data
TOTAL.: ISSUED BIY731
OFFICE