S 1753 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO IUM.UNG-&A:C'rRICAL Pr:I IT"° 1753
BUILDING DIVISION APPLICATION/PERMIT PLUMIn NG-nn?cHANICAL
inin.DINO'PROJECT IDENTIFICATION
HUI1I1C ADDRESS� I �� SANITARY NO. AI'I'LJCATIU4 IUHM0 c5l 'If
cksfOWN("' AME; O I'l1ONE: CO ACI'URS A is �IC I� (��// 22//rrYYJR l(77nn
NIC CONTROLp
�ARCIII rECI'/EGINF.F.R: LIC NO'. A RFS : ❑
C�I Pope
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL ls;i
103 El 1:1 ❑
I.ICI?NSI?[)CONTRACTOR'S DI'.CI.ARAI'ION QTY. FLECTRIC PERMIT FEE
I hereby anion thin I tam licensed under pmvisinns II Clalpmr 9(commcnaing JOB DESCRIPTION
O�Z with Scction 703O)ol Division 3 ofthe for,massund l' fq Cadc.and my license is RESIDENTIAL:
Ccc qJ� PERMIT ISSUANCE
W F in full force unit cliect.0 LV �I ❑SFDWL ❑KITCHEN RIiMODIiI.
QUU Licen.gC�htsx Lic.p APPLIANCES-RESIDEN'T'IAL []ADDITION El PLUMBING RE.PI E
vl-ZW hate-W Comrecmr
ARCHITECTS DECLARATION ❑MUI:PI-l1NIT ❑STRUCTURAL.
F p w PANELS MODIFICATION
O Z-1 I undcmmnd my plana shrli be usM as public reauJs
OZ=� UP TO 209 AMT'S ❑INTIiNIOR ❑CHIMNEY RIiI'AIR
F=I:w Licemad Professional 201-IBWAMPS IMPROVEMENT C]SWIMMING POOLS
C C Q I hereby afEnn hat Niam exempt ifromC n Cannot License Law for the OVER I(Np AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
O d U followin•mown.(Section 703 L5.Business and Prommions Code:An t t ❑OfHIiR
g Any SIGNS F.LF.CTRICAh
F�O3 W yG which it,coma permit m tmotal ct.aper.impress,demolish,or repair any structure
J prinnnits issuance,also rcyuims the applicant for such permino flcasigneJ s[memem SPECIALCIHCUIT/MISC.
ythat he is licensed pursuant or the previsions ofthe Contractor's License Law(Chapter
^�� (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.MET EH OR POLE INST. COMMERCIAL'
I Goa' that he's nnmnpt Iherctonn.,,it the basis for the alleged cxcmptax.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
X1 Section 70315 by any applicant for a permit subject,the upplicaru m a civil pMulty of POWER DEVICES ❑'IIiNANT El FOOD SERVICE
of� lnoru lbao Ove lmndred dollars($500), IMPROVEMENT Q ❑ I,'ax nwnenll thepmpeny,or myempinyeeswithwagesuslheirsole compensation, SWIh1MIN0I'OOLI?LIiCI'RIC
NO will domewurk,and the structure is not intended or olliad litrsule(Sec.JD14,Business D01 HER
C^m unit Professions Cale:The Conwcior's License Law Lines an apply w an owner of OUTLETS-SWI'I'CIIES-InIXTUHN_S
3 pmp<•ny who builds or improves Iharcon,and who Jas such work himself or through
his own employees,provided that such improvements am nm intended or offered for NEW RESIDENTIAL ELECTR SQ FIr.
sale,If,havarcr,the building orimpmvement issold within one year ofasmpletion,the .IT.FLOOR AREA $/SQ.FI'.
owncobudda,will have the bureau of proving that he did not railcar impmvc for pur-
ryrm of sale.).
E]1......er of the pmpeny,am exclusively contracting with licensed ommuclon to SAL'
construct the pnnjcat(Sac.]cit Business and Promssmis Code:)The Contracmtn I.I-
camelawJoesnerapplyaanownerofpropenywhoWildsorimprovestheresn,and QTY PLUMBING PERMIT FEE
who amnmnx for such projects with a contractor(s)licensed punaantlu tare Contractor s
Loan.law. PERMIT ISSUANCE
El I ant exempt under Sec. ,It k P C for this reason
ALTER-DRAIN Se VENT-WATER IEA) VALUATION
Owner Data
WORKER S COMPENSATION IIECLARAI'ION BACK FLOW PR(Ulzc'K DEVICE
I hereby off nn under penalty of pert ay..car the talk.al,dadunniom:
havat (will trot as CertifateofConsenuasullfm me ho-Worker's Conmen- DRAINS-FLOOR.ROOF,ARBA,COND. S'IOHIES TYPE CONST RUCTION
wt,nN provided Tor by Section 3700 of the Labor Code,for the purfnrmm.cant the
ork rat which this pend[is Issued. FIXTURES-PER TRAP
1 huvo I I will mnima'm Worker's Componailam Inwranee,as refuel by Sactinn
GAS-F.A.$YS'I'hM-I INC.4 OIl'I'hli LETS
371Nh1- cl nM1 ode,tan b ark fnrwhic is Penn
Ms sued. (JCC.GROUP AI's
My W'rA ( n i a Ins u.:n1 t I1
N
�pp
court r. l� \k Cj1olicy o OAS-EA.SYSTIiM�OVliR40'A)
CERTIFICATEOFEXEMPI'ION FROM ORKERSGRE.ASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi.isection neednot becom,itaod ifine permit is(orcin hundmddnllatx(SIM) GREASETRAP
or less.) PLANCHECK FEE
I amity that in the performance ofthe work forwhich this permit is issued.)shall SEWER-SANITARY-STORM EA.209 FT.
not employ any perxm in any manner so as a become subject to the Workers'Compen- ENERGY FEE
Q z station Laws of California.Data WATER I(FAIER IVNENf/ELECTR GRADING FEE
z O Applicant
r V) NOT ICE TO APPLICAN'[If,after making this Cenificum or ExempTINC,
tion,you should WATER SYSEMORT!At IN
a7 hcannc adduct to the Workers Compensation provisions of the Labor Calc,you all SOILS FEE
LkI Iiuthwith comply with such provisions or pemtit shall he deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING A(JIs.NCY NEW HISIDIiN'I'IAL I'hMlt. SQ.IT. ('AID
L) O I hereby alOnn that there is a conemmllon lmalingagency fortha perfwoance of Uum np[a
ha work far which(his permit is isaaed(Sec.3097.Civ.C.)
W. Lender's Name TGFAI.:
Lcndcls Addmxs 1WAL:
d I edd y that 1 have read this application unit xuma mm the nbase information is BUILDING FEF•
0 correct.I agree to comply with all city and county Ordinances and stem laws o lafng to QTY. MECI IANICAI.PERMIT FEE
!.) building construction,and hembyamhorim repre..nm[ives ofthiscity[center upon the SEISMIC FEE
aarovementioncd pmpcny for inspection purposes. PERMIT ISSUANCE 3
(We)agree m save,indemnify and keep harmless the City of CLpenine against Ii1.IiCl'kIC Frai
Iiahilitianjudgments,cons and expenses which may in any way accrue against said City ALTER OR AIJII'IG MECH.
in"Imm" ncc of[h in mingof[hispanniA PLUMBING FE.E
APPI.IC, T'UND SST'A UWILL COMPLY WITH AI .NON-POINT AIR HANDLING IINI'1'('1'O IRINX)CFM)
MECI1ANICAL F'.1 Z
'UV'C tl'Gl A ORS. Zq
Nk HANDLING 11N1'1'(OVIiR In,(NI(ICFM) CONS'fRUCI'ION'fAX
Signatures App cnnll ommemr Blue EXHAUS'1'lIGOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAL. :CLOSURE
Will n pliant or future building occupant stere nr handle hacoolooluared,ol HEATING UNIFill) Lk,B'I'U)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and tiro IIa[hh and Safety
Coda,Scotian 255:12110" HEA'fIN011N1'1'(OVER light(NN(11111
ex ONc
VIiNI'li.Al'ION PAN ISINCI.li I21SID) PAID
Oata Beaim a
Will the appllcum n metre building occupant use e.Air Qua nT devices which
unit humrJnas air usmaminan[s as defnetl by the Ray Area Air Qnulhy Management BOILER-COMP pIIP OR I(XI,II(XI B'1'UI T AW.
DiuhidYa,
! BOILER-COMP(OVL'R 100.0 0IITIE
Fl
Alk CONDITIONER
ars mated macntents under Cbapt,(. 5 of the Cali- ISSUANCE DATF.famiaSection'_ 25533and25534.Ip/' Ie and the f1[he NEW RESIDENTIAL MECH. SQ.FI. - �1 �'I�buildiveatena ismyrcspmvibilit)�t y[hea upam.finei n sofaccnil L{j 1
[hs imd Eem Umc c Toll:
ISSUIiI3B�Se /
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO IUM.UNG-&A:C'rRICAL Pr:I IT"° 1753
BUILDING DIVISION APPLICATION/PERMIT PLUMIn NG-nn?cHANICAL
inin.DINO'PROJECT IDENTIFICATION
HUI1I1C ADDRESS� I �� SANITARY NO. AI'I'LJCATIU4 IUHM0 c5l 'If
cksfOWN("' AME; O I'l1ONE: CO ACI'URS A is �IC I� (��// 22//rrYYJR l(77nn
NIC CONTROLp
�ARCIII rECI'/EGINF.F.R: LIC NO'. A RFS : ❑
C�I Pope
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL ls;i
103 El 1:1 ❑
I.ICI?NSI?[)CONTRACTOR'S DI'.CI.ARAI'ION QTY. FLECTRIC PERMIT FEE
I hereby anion thin I tam licensed under pmvisinns II Clalpmr 9(commcnaing JOB DESCRIPTION
O�Z with Scction 703O)ol Division 3 ofthe for,massund l' fq Cadc.and my license is RESIDENTIAL:
Ccc qJ� PERMIT ISSUANCE
W F in full force unit cliect.0 LV �I ❑SFDWL ❑KITCHEN RIiMODIiI.
QUU Licen.gC�htsx Lic.p APPLIANCES-RESIDEN'T'IAL []ADDITION El PLUMBING RE.PI E
vl-ZW hate-W Comrecmr
ARCHITECTS DECLARATION ❑MUI:PI-l1NIT ❑STRUCTURAL.
F p w PANELS MODIFICATION
O Z-1 I undcmmnd my plana shrli be usM as public reauJs
OZ=� UP TO 209 AMT'S ❑INTIiNIOR ❑CHIMNEY RIiI'AIR
F=I:w Licemad Professional 201-IBWAMPS IMPROVEMENT C]SWIMMING POOLS
C C Q I hereby afEnn hat Niam exempt ifromC n Cannot License Law for the OVER I(Np AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
O d U followin•mown.(Section 703 L5.Business and Prommions Code:An t t ❑OfHIiR
g Any SIGNS F.LF.CTRICAh
F�O3 W yG which it,coma permit m tmotal ct.aper.impress,demolish,or repair any structure
J prinnnits issuance,also rcyuims the applicant for such permino flcasigneJ s[memem SPECIALCIHCUIT/MISC.
ythat he is licensed pursuant or the previsions ofthe Contractor's License Law(Chapter
^�� (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.MET EH OR POLE INST. COMMERCIAL'
I Goa' that he's nnmnpt Iherctonn.,,it the basis for the alleged cxcmptax.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
X1 Section 70315 by any applicant for a permit subject,the upplicaru m a civil pMulty of POWER DEVICES ❑'IIiNANT El FOOD SERVICE
of� lnoru lbao Ove lmndred dollars($500), IMPROVEMENT Q ❑ I,'ax nwnenll thepmpeny,or myempinyeeswithwagesuslheirsole compensation, SWIh1MIN0I'OOLI?LIiCI'RIC
NO will domewurk,and the structure is not intended or olliad litrsule(Sec.JD14,Business D01 HER
C^m unit Professions Cale:The Conwcior's License Law Lines an apply w an owner of OUTLETS-SWI'I'CIIES-InIXTUHN_S
3 pmp<•ny who builds or improves Iharcon,and who Jas such work himself or through
his own employees,provided that such improvements am nm intended or offered for NEW RESIDENTIAL ELECTR SQ FIr.
sale,If,havarcr,the building orimpmvement issold within one year ofasmpletion,the .IT.FLOOR AREA $/SQ.FI'.
owncobudda,will have the bureau of proving that he did not railcar impmvc for pur-
ryrm of sale.).
E]1......er of the pmpeny,am exclusively contracting with licensed ommuclon to SAL'
construct the pnnjcat(Sac.]cit Business and Promssmis Code:)The Contracmtn I.I-
camelawJoesnerapplyaanownerofpropenywhoWildsorimprovestheresn,and QTY PLUMBING PERMIT FEE
who amnmnx for such projects with a contractor(s)licensed punaantlu tare Contractor s
Loan.law. PERMIT ISSUANCE
El I ant exempt under Sec. ,It k P C for this reason
ALTER-DRAIN Se VENT-WATER IEA) VALUATION
Owner Data
WORKER S COMPENSATION IIECLARAI'ION BACK FLOW PR(Ulzc'K DEVICE
I hereby off nn under penalty of pert ay..car the talk.al,dadunniom:
havat (will trot as CertifateofConsenuasullfm me ho-Worker's Conmen- DRAINS-FLOOR.ROOF,ARBA,COND. S'IOHIES TYPE CONST RUCTION
wt,nN provided Tor by Section 3700 of the Labor Code,for the purfnrmm.cant the
ork rat which this pend[is Issued. FIXTURES-PER TRAP
1 huvo I I will mnima'm Worker's Componailam Inwranee,as refuel by Sactinn
GAS-F.A.$YS'I'hM-I INC.4 OIl'I'hli LETS
371Nh1- cl nM1 ode,tan b ark fnrwhic is Penn
Ms sued. (JCC.GROUP AI's
My W'rA ( n i a Ins u.:n1 t I1
N
�pp
court r. l� \k Cj1olicy o OAS-EA.SYSTIiM�OVliR40'A)
CERTIFICATEOFEXEMPI'ION FROM ORKERSGRE.ASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thi.isection neednot becom,itaod ifine permit is(orcin hundmddnllatx(SIM) GREASETRAP
or less.) PLANCHECK FEE
I amity that in the performance ofthe work forwhich this permit is issued.)shall SEWER-SANITARY-STORM EA.209 FT.
not employ any perxm in any manner so as a become subject to the Workers'Compen- ENERGY FEE
Q z station Laws of California.Data WATER I(FAIER IVNENf/ELECTR GRADING FEE
z O Applicant
r V) NOT ICE TO APPLICAN'[If,after making this Cenificum or ExempTINC,
tion,you should WATER SYSEMORT!At IN
a7 hcannc adduct to the Workers Compensation provisions of the Labor Calc,you all SOILS FEE
LkI Iiuthwith comply with such provisions or pemtit shall he deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING A(JIs.NCY NEW HISIDIiN'I'IAL I'hMlt. SQ.IT. ('AID
L) O I hereby alOnn that there is a conemmllon lmalingagency fortha perfwoance of Uum np[a
ha work far which(his permit is isaaed(Sec.3097.Civ.C.)
W. Lender's Name TGFAI.:
Lcndcls Addmxs 1WAL:
d I edd y that 1 have read this application unit xuma mm the nbase information is BUILDING FEF•
0 correct.I agree to comply with all city and county Ordinances and stem laws o lafng to QTY. MECI IANICAI.PERMIT FEE
!.) building construction,and hembyamhorim repre..nm[ives ofthiscity[center upon the SEISMIC FEE
aarovementioncd pmpcny for inspection purposes. PERMIT ISSUANCE 3
(We)agree m save,indemnify and keep harmless the City of CLpenine against Ii1.IiCl'kIC Frai
Iiahilitianjudgments,cons and expenses which may in any way accrue against said City ALTER OR AIJII'IG MECH.
in"Imm" ncc of[h in mingof[hispanniA PLUMBING FE.E
APPI.IC, T'UND SST'A UWILL COMPLY WITH AI .NON-POINT AIR HANDLING IINI'1'('1'O IRINX)CFM)
MECI1ANICAL F'.1 Z
'UV'C tl'Gl A ORS. Zq
Nk HANDLING 11N1'1'(OVIiR In,(NI(ICFM) CONS'fRUCI'ION'fAX
Signatures App cnnll ommemr Blue EXHAUS'1'lIGOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAL. :CLOSURE
Will n pliant or future building occupant stere nr handle hacoolooluared,ol HEATING UNIFill) Lk,B'I'U)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and tiro IIa[hh and Safety
Coda,Scotian 255:12110" HEA'fIN011N1'1'(OVER light(NN(11111
ex ONc
VIiNI'li.Al'ION PAN ISINCI.li I21SID) PAID
Oata Beaim a
Will the appllcum n metre building occupant use e.Air Qua nT devices which
unit humrJnas air usmaminan[s as defnetl by the Ray Area Air Qnulhy Management BOILER-COMP pIIP OR I(XI,II(XI B'1'UI T AW.
DiuhidYa,
! BOILER-COMP(OVL'R 100.0 0IITIE
Fl
Alk CONDITIONER
ars mated macntents under Cbapt,(. 5 of the Cali- ISSUANCE DATF.famiaSection'_ 25533and25534.Ip/' Ie and the f1[he NEW RESIDENTIAL MECH. SQ.FI. - �1 �'I�buildiveatena ismyrcspmvibilit)�t y[hea upam.finei n sofaccnil L{j 1
[hs imd Eem Umc c Toll:
ISSUIiI3B�Se /
OFFICE