S 0814 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
FAADDRESS
INO. BUILDING-ELEcrRICAL P IT NO, ^�k w
ION APPLICATIONIPERMIT PLUMBING-MECHANICAL OX 1 4
BUILDING PROJECT IDENTIFICATION VVV y
SANITARY NO. APPLICATION SUBh11ITAL DATE
w �PHONE: CO TOR' A IC O
^�S7
NIC CONTHOLp
kCHITECf/ENGINEER: LIC NO A p
. CONTACT. PHONE: BUILDING PERMIT INFO
❑ Conn at Fees Paid by Applicant(Initial) RLIR' ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECf ,ATION 0 0
I hereby affirm Ihm 1 am licensed under provisions of Chapter 9(commencing QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1O1�Loc with5ectiain XX)�of D}ppy�1��,,it��lithe Rosiness PmfessioreC andmylicenseis
JUUinfallforce � c, PERMIT ISSUANCE RESIDENTIAL:
F.V U License lase Lia B ❑SI°UWL ❑KITCHEN REMODEL
N<L Data Commcm APPLIANCES—NISIDENTIAL ❑ADDITION El PLUMBING R&PIPE
ARCHITECTS UEC
CZHrZ. IundemmnJ my plans shall he uxd as puhlic records PANELS ❑MULTI-UNIT El STRUCTURAL
NN�C MODIFICATION
UP'10200 AMPS
rr FW 1.¢cnmd Profess..... - ❑INTERIOR /b�/���� , YREPAIR
ggN-'j OWNER-BUILDER DECLARATION 201-IfpIlAMPS IMPROVEMENT 0� SWIMMING POOLS
yy PPCC ZR,I U I hereby affirm'bill 1 nm exempt from the Cnmmcmrs License Law for she OVIiR_AMPS ❑BATH REMODEL/REPAIR EIDEMOLITION
X 3 L F following leve....(Sec+ion]1131,5,Bminers vad Prolessinns Coor:Any city or county SIGNS ELECTRICAL. ❑OTHER
{{ELL'0V
which regmmc a permit..+con.+wd,alma improve,demolish,or repair any..tenure -
w.] prinrwitivs...re.atm requires 0;eapplicam far such Permian file.signednvmmemSPECIALCIRCUIT/MISS. -
E } that he is licensed pmmarma to the provisions of the Commerce,License Lv Ch.pmr9
6F (commencing wish Section]000)Of Division aur the Nosiness and Polfellma,Code)or
O O TEMP.MEIF.k OR POLE.INST. COMMF,R .IA
6 y M K thatSec o is exempt iacrefmm and the halos for the alleged exemption,
to Any l Pen ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
t uXl 4• Section 7031.5 by any applicant for apermii sub'enx�hea applicant
FZY not more than rive hundred dollars($5g0. 1 pp penalty or POWER DEVICES F1 TENANT ❑FOOD SERVICE
❑ 1,us ownernf Nu prnpeny,dr my employees with wages as mcirsoil cmnpens:oion, SWI MMING POOL ELECfR IC IMPROVEMENT
wdI do @e work,and the wtruutureis not Intended on+0crctl far sulc(Scc.]IW,euslness []OTHER
N :9 and Professions Code:'Me Comrecmis License Law does an,apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who huilds ar improves then....,and who does such work himself m tbmugh
his Own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL F.LECTR SQ FT.
Nine,If,however,the building or mpmvcnmm is sold within one ycuofcnmplction,the SQ.FI'FLOOR AREA $/SQ.IT
4
owneolmilder will have the burden of proving that he did not build or improve for par-
poxOf sale.). D
❑ 1,as Owner Of the Properly,am exclusively connoting with licensed ca dowses to TOTAL:
c moult NIIin
Joe pnica(Sec. W4,Busess and I'moseime;CWe:I The C.ntracmrs Li- �®p1, v Q
cense law doc,,not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT �114t
who controls for such projects with a con vactops)Becloud pursuant m the ConFEE r �ine ce% aiV
License Law.
[:1I.m exempt under Sec. ,H A p C fnr,,,mall. PERMIT ISSUANCE C'ry�r LVr
Owner Uale ALTIiR-ORAINk VF.N'T-WATER(EAI
ta
WOR KERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy al0m;antler pcnahy of Ped tl one of the following dedamtinn
❑ IM1aa,a car dei for innths-37")'If'he Labor ode.fnrclin Wformacemfin- DRAINS-FLO(]H.ROOP.Akt?A,CONU.
oviJed for by Section 3]ql of me Labor Cole,(.r the performance of me RIPS TYI•IiCONSTHUCTION
ark rias hick thiscem'ii is issued. FIXTURES-PER TRAP
aw and will maintain lie rhos Compensation w Insurance,as required by Section
fpof th Inhor Code,liuthe rformanceofthework forwhicht +s tis issued GAS-EA.SYSI'IiM-I INGYOUTLETS
OCC.GROUP APN
Ws m .iRpgll;Ticrund Policy
Corti : Policy No GAS-EA.SYSTEM-OVER YIEA)
CF.RTIFI TEOFEXEMPTION NSUFRO WORKERS'
C[N,ma filled Hill
p,.iANCE CRFASF/INDUS'1'NL WASTE.INTERCEPTOR
(This,aril..need not b.compineJ it"the permit Is loran.hundred tlollury 13180 BUILDING DIVISION FI:I35
nor less.) GREASETRAP
Icenify that in the any-'manceo the workme -sic this Tisa,' d,ISM1aII PLANCHECK FIiT:
pemsi STORM FA.2(gl FT.
net employ'by peala in any manner sn.smbewme subjem mthe Workeri Cnmpen- SEWIiR-SAN["fANY- ENERGY FF.F.
Q Z Applicant
anws of Cnlifomiv.l3;ac
Z NOTICnt I WATER HEATIiH WN[iNT/IA.IiCfR GRADING ME
NOTICE TO APPLICANT:IL after making this Provisions
of of Exemption,you should WATER SYSTEMG-REATING
a;
become momplyct the Workers Compensationothsprovixinre.f the redfatrarCode,you must SOILS ME
fodhwim comply with tech pmvisiuns or this permit xhvll he Acemed revoked.
a � WA'1'Ek SF.RVICIi
CONSTRUCTION LENDING AGENCY
U0NEW RESIDENTIAL PLMO. SQ.FT. PAID
Plan
V0 I for
reby which thi that issed(Sec.30 lending agency for the pcRam+ance of Dm ttei p
LA
the work for which this permit is issued(Sec.3flq],Civ.C.)
U Lenders Nan+c TOTAL:
Iw•nddI Address TOTAL:
A. I certify that 1 have revJ this application end.nate that the above information is BUILDING FEF.
UV) correm.I agree to comply with all city and county ordinances and state laws rclatingm QTY. MECHANICAL PERMIT
hudding connrucrion,and herehy awhnrirerepremnmlives of chis city to call,upon the FEE SEISMIC FEE
move-mentioned property for inspection purposes.
(we)agree to save,indemnify and keep harmless the City Of Cupertino against PERM IT ISS UANCE ELECTRIC FEE
liabilitie ¢nes,costs and expense whit may in any way acme agaimt said City ALTER OR ADD TO MESH.
in co quence n the granting of t ' 'mil PLUMBING FEE
SOVRCERT I' DERSTASIM ND WILL CO 'LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.g1(ICFM)
///ssr MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Si nate ppllevnUConWetor Dale EXHAUXI GOOD(W/DUC`U
HAZARDO Al HRIALS DISCLOSURE HOUSING MITIGATION U:
Will the applicant nor fmm,int'dipate stem 0I "
Imxmmerial HEATING UNIT(TO 100,000 BTU)
n
as defined by the Cupertino Mum," Me,Chapter 412,.M the Health vnd Safety
Code,Section 25532(..)? HEAPING UNIT(OVER 100,M)BTU)
❑YesNn
VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant.r furore huilJi culvm ux equipment or devices which D'um Rtteipt p
cont h...ch, smr,cramiran its led by the Bay Area Air Quality Mvnagemem BOILER—COME(3HP OR 100,gq BTU)
L.4f,h
TOAL:
No BOILER—COMP(OVER 100.600 BTU)
hoe Joos mamrialn requi sonde apmr b95nor the Cali- AIN CONDITIONIR
Card.S`n=25505, 533 nJ 25534, adeawnJ ]or if the ISSUANCE DATE
ndy haveam hat it pnnsibiliiyt notify the sopa.. NIiW I313SIDENI'IALMECH. SQ.PT.Ino ormis, a OfaCeniO roofOcagem lie as
DOTAL:
ISS BY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC`T'RICAL PERMIT NO.
BUILDING DI VISION APPLICATION/PERMIT PLUMPING-MECHANICAL S 081Q
BUILDINGPROJECTIDENOFICATION V 1 V
UILDINGADDRESS'. SANITARY NO. AP PLICATION SUBMITTAL DATE
e �-e�wev l l lal q
NER'$NAME: J ��PHONE: CO RA R'SNAME: LIC NO:
.JL C � fO ME: /N/ a NI CONTKOLa
'ARCHITECT/ENGINEER: LIC NO: ` /
CONTACT: PHONE: BUILDING PERMIT INIrO
❑ Consultant Fees Paid by Applicant(Initial) ItLfX: ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FIiE ❑ ❑
I he arfimt that 1 Mtn licensed seder provisions a chapmr v mammeming JOB DFSCRIPTION
Cx with Seninn 9(XX))afDivisionJ nfthe Business and l'rofessims Ccs Lund my license is RESIDENTIAL
full force andel PERMIT ISSUANCE
CU^ '" sr Otcz ❑SfUWL ❑KITCHEN REMODEL.
aU�j Littnsc P.c Lic.g APPLIANCES ❑ADDITION ❑PLUMBING RE-PIPE
•Ta 4 Date T`S DECLARATION
NCHITECTS D,uhlva AT1pN ❑MULTI-UNIT ❑MODIFI MODIFICATION PANELS
RAL
ZOZIs3� lundurnand my plans shall he use)as public records CHIMNEY
:..41 UP'1'03g1AMPS ❑INTERIOR ❑CHIAINCY REPAIR
lensed Professional IDI-1000AMPS IMPROVEMENT SWIMMING POOLS
�yF, c OWNER-BUILDER DECLARATION OVER]"AMPS ❑BATH REMODEVRIiPA1R El DEMOLITION
ti C 6 I hereby affirm that 1 tun exernpt from the Cm meme,License Law for the
0.0 following reason.(Section 9031.5,Business unit Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER,/�g/���.�—�
LL b" which requires"permit to consmtn,alter,improve,demolish,or opear any stmclure %
prior to its issuance,also requires the applicant for such Permit oFla asignedsmemcat SPECIALCIRCUIT/MISC. vii
N that he is licensed pursuantto the provisions of the Comment's License Law(Chapter 9 w
lm
X
MC) (commencing with Section 7")of Division 3 ofthe Business and Professions Cold or TEMP.METER OR POLE INST. COMMERCIAL:
A.0.c y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
#n Section 7031.5 by any applicant for a permitsobjims the applicant a civil penalty of POWER DEVICES
W^sea []TENANT ❑FOODSERVICE
znoO
more than five hundred dollars($500). - IMPROVEMENT
(DLos owner ofthe pf"peny.or my employees with wages",their solecnmpenvtier, SWIMMING POOL ELECTRIC
_ will do the work,and the structure is not intended connected for sale(Sm.9044,Business El OTHER
L'3 g ^ and Pramsm
sinCode:The Contractor's License Law does not apply to An owner of OU'1LETS-SWITCHES-FIXTURES
property whir huilds or improves thereon,and who does such work himself or mmugh /
his own employees,presided that.such improvements are not intended or offered for NEW RESIDENTIAL EL[CTR SQ Eff
sale.if,however,the building or improvement is sold within one year ofcompletim,theSQ.FT.FLOOR AREA S/SQ.ET.
ci�rmr-huildrr will have the harden of proving that he did not build or improve for put- /
pose attic.),
❑L as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.IOM.Business and Professions Code:)The Contractor's U.
cense law docs not apply to an owner ofpropeny who builds or improves thereon.and QTY, PLUMBING PERMIT FEE h�
whocontmets forsuch projects with o contmm
erts)Iicensedpursuant India,Contrecmrs ff I D
License Law.
PERMITISSUANCE.
C] I um exempt under Site ,B&l'C for this reason
Owner Date
ALTER-DRAIN&VIiN'T-WATER(EA) /s t ps,ruTION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE g(g1/j�/�(YgV�jPJL�•
I hereby a0irm under penalty of perjuryone of the following declarations:
❑ I have and will maintain a Certificate of Consentmself-insure for Workers Carman. DRAINS-FLOOR,ROME AREA,COND. STORE.. TYPE CONSTRUCTION
sation,as provided for by Section 3900 of tire m e LnMCode,for the performance of tile
work far which this permit is issued. FIXTURES-PER TRAP
❑T have and will maintain Worker's Compensation Insurance,as mil by Section
37W ofthe Lahr Code,for the Performance ofthe work for which this permit is i.smed. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier add Policy number art:
Carrier: Policy No.0 GAS-13A.SYSTEM-OVHR 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIYINDUSTRI,WAS'T'E INTERCEPTOR BUILDING DIVISION FEES
(Otis section need not be crandatcd ifthe Permit is(amuse hundred dollars(S1(0) GREASETRAP
m IessJ PLANCHECK FEE
I certify that in the ps,rfn ntt of the work forwhien this permit is issued,Ishall SEWER-SANITARY-STORM E.A.21X1 FT.
not employ nor in any /.i Ioeco.a suhim..the Workers Compen.. ENERGY FEE
O z sation Lu sofC ffomia.E _/r/ _ _ WATER RELATER W/VENT/ELECfR
Applicat / U- GRADING FEE
h NOTICE LICA :If,afro,ranking this Ccmfi,ma of Exemption,you should WATER SYSTEM/TREAI'ING
become subject to the Workers Compensation provisions of the Labor Code,you must SOU-S FEE
forthwith romply with such Provisions or this parotin shall be Deemed revoked. WATER SERVICE
DCONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMI. SQ.FT. PAID
C`.7 C I hereby allirm that tines is a construction lending agency lin[lie perfaromnee of Date p
the work for which this permit is issued(Sec.3099.Cin CJ
�(, Lenders Name TOTAL:
Lenders Address TOTAL:
W
1 certify that I have read this application and state that the above information is BUILDING FE
E
Z7A cotrcct.I agree to comply with all city and county ordinances and state lows relating to QTY. MECHANICAL PERMIT FEE
building Autm tion,and hereby authorize repramntahve,of city nt emerarysn the SEISMIC FEE
abnve-mmntioned property for'mspectim purposes. PERMIT ISSUANCE
(We)agree to save,fndemnify and keep harmless the City of Cupertino against ELF.CI'RIC FEE
IiebilitiesjuJgments.msu and expenses which may in any way acctuc against said City R OR ADD TO MECH.
consequencein of the graining of this Farrah. ALTEPW MNING FEE
APPLICANT UNDERST
O ,ONDS DWELL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) MECHANICAL FEE
SIL EGULATIO
AIR HANDLING UNIT(OVER 10,NM CFM)
��y�/��/1 � CONS'I'HIICTION TAX
Si dpp��eilsiCommichor w EXHAUST HOOD IW/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willnhcnppleam or fmme building mcuPaaatorenr handle beastral anadal HEATING UNIT(TO 100,IX)0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(09 HEATING UNIT(OVER HXtW0 BTU)
❑Yen F1 No VENTILATION PAN(SINGLE RESID) PAID -
Will thea applicant or future Wilding rt use ent or devices which Data Receipt N
pp gbythe e.Air BOILER-COMP(3HP OR 100.000 BTU)
emit hazardous air armaments ns defined by the Bey Area Air Quality hlanageme0l TOTAL:
Distrial9
❑Yes ❑Nn BOILER-COMP(OVER 11X1,000 BTU)
I have read the havuJous mraedals mquimmmts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code.Sections 8505,25533 and 8534.1 internal mat if the NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a armed,that it is my responsibility to notify me Accustom
of the requfmmentx which must be met prior to issuance of a Carolinas,of Occupancy.
Owner or anthnrlead agent Dote TOTAL ISSUHDB@
OFFICE