30695APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN UNLY
BUILDING. ELEC'T'RICAL PERMIT 30695
WDI
CITY OF CUPE RTINO PLUMBING - MECIIANICAL
BUILDING DIVISION APPI,ICATION/F'ERMIT
ILNG PRII,IEC'I'IURNT'IPICATIf3N
NGADDRES,S:
o yob �-1r�tiv o� r, cva�,�r�-:moo
of o ,eirelleNs
19Eg1z/9zc I/,
CONTACT:"•"^•"
l �rCie✓S 93� �� ❑ Consultant Fetes Paid by Applicant (Initial)
61)Wrl vo /S
ZZO
1_
¢ c.
nn Z
LICENSED CONTRACTOR'S DECLARATION QTY
1 hereby affirm that I ran licensed under provisions of Chapter 9 (commencing
with Section 7") of Division 3 of the Business d ProfessiosCale. and my license is
in full Tome and effect.
Lis. 4
DatLime Comm— -
ARCHITECTS DECLARATION
1 undcmmnd my plans shall M used as public records
E'.
Licensed Pmfeaionul
TYPE CONSTRUCT 10
APN
OWNER -BUILDER DECLARATION
.J
Q
1 hereby .(firm that 1 at,, exempt from the Commcmr's License Law for the
a, V
following mason. (cacti.. 71131.5, sx and eio Cale: Any city m county
W N
ws. d l or any urucmrc
:Jlxr, impose,
which reyuirca u trod, atm
als ur
SOILS FEF.
h parmah.
s oBlco,LawJsmmmem
e, ire" for each e u signed
lhcappllis
PAID
Dam
that has ilraance,alarrc9nirc
aI ra,t License Law(Cnook) or
pSeviandction l.Its, pnrvlsi,i
00
Sit otsumonds
ocomort,raco,witmsrd
with Section](Nxl).f Dioikl t t
tcathe
T�
alle,inc.rmptor. Anion alismor
los the .Meted cxcmpnoa Any violation of
is exempt the
that he in exempt
apt li and the
to of
n W
pen u civil penalty
Section ]11115 by any applicant for u �rmit wbjcelx the applicant
any
_
m
not more than live hundred dollars ($500)
theirsole compsn.cation,
SD
El 1, anownerof the property. or mycmployces with wages an
yo
will do the work. and the structure s not intended or offered fmoovle(Sec. 91114. Business
m
and Professions Code: The Contractors License Law J%as nm apply 10 an owner of
3..
property no builds or improscs tlmrcnn, and who due,such weak himself or through
his own employees, provided that such improsemems am not intended or offered for
sale. If, however, the building or improvement is .sold within one yemol completion, me
tioxierr-Imider will have the burden of proving that he did not build or improve for pur-
Pox of nalc).
C 1, as owner, of the popery, um exclusively contracting with Iwrnwal comm<tors to
onsuuer the project (Sec. TI1L1, Ifusiness and Pmfessima Code:) The Contractors Li-
u Law does nal apply to on owner of propcny who builds in improve% thereon, and Q1Y.
who contract for such projects wit. u c.nwnort%) IicenaJ pursuanuo the Conuanors
License law.
I am exempt under Sec. ,B&P C for this reason /
Owner Dote
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificam of Coov,am to self -inure for Wealme, Compen-
snrmi vs providN fur by Swtinn J9W of the Wbnr Gde, for the Ixrfammnce of the
work for which this Permit is issued.
I have ..it will maintain Worker's Compcwtion Insurance, m required by Section
J]W of the labor Cost'. for rhe perfnnmmur of the work for which finis permit is issued.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL.
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAI.
SPECIAL. CIRCUIT/MISC,
TEMP, METER OR POLL: INST.
POW17R DEVICES
SWIMMING !l-1 CTRIC
COMI'IiNSAT10N INSURANCE
(Th'ws lion .teed nm he mnnplcmdil the lannil is forme ...decd dollars ($I W)
no
Icsx.)
leen mel uper(ormm�<c oflin whlen this pcnnil rs isueJ,I shall
ern employ a nn In nlny nlminycyl' IG�KiyJem to the Workers' Compen-
z xminn Lvwvn 'to
Bac
z 0 Applicem P neulA
NOTICE TO AI I CANT: IL alter ranking l It, CInilieam of L'xem lion, you %
F her iso", s jed ar it Weaker%..... "'i ,mien prov nionc o[ the Lahor Cadc, you must
�i fnnhwith comply wish such pnnlxinrn nr this pcnnil ehnll nc JcensJ revoked.
kA Q
,Z' CONom,,,xTOIJLENI3INGAGENCY
V l frvshich this
thereisand(See 30 len Jing agencykrr the perfonnance of
CL, f✓ the work for wnich this pcnnil is issued (Sec.7W], Civ. C.)
O U Lender's Name
} D7 I<ndcr%Add ... I
CL,I cenify that I have brud do, application and Note that the vMwc information is
sF. y tmorM I agree to comply with all city and county ordinances and seam laws miming m QTY
U Z building mnamction, and hereby aulhoriie representatives aflhis city In soar, upon the
above.memwned pmpery for inspection pmptrso.
(We) agree toxins. indemnify ..it keep harmless the City of Cupertino against
Hithilitiesjudgmerns, costs and expenses which may in any way aceme against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS e MATERIALS DISCLOSURE
Will the
eCupam11 future building occupant store or handle h Health
material
as defined by the Cupertino Municipal Cadc. Chapter 9. 12. and the Hca1tB and cafcry
Code. Section 25532(a)"
❑Yes Fl No
Will the applicant or future building occupant use equipment or devices which
ratio hazardous or canmatinanl%as defined by the Bay Arca Air Quality Management
District'?
❑Yes 7 N
I have read the nuanlous mnlcrials rquiremcals under Chapter 6.95 ,fine Cali-
buou Health & Safety C,. c, Sections 25505. 25539 and 25534. I ondemand that if the
buildingJce nor umendy have u mania. lhun it l� myrcpon.ilodily to rarity the necupunt
,,line ryuircomal ishichomo rte nal prior to lxs.ar, of a Cenilwalsoflhxupaney.
NEW
Sp Irl'.
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (IiA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLUOR. ROOR AREA. GOND.
FIXTURES -PER TRAP
GAS - EA. SYSTEM.I INC. J OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASUINDUSTRI. WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY - STORM IiA, 2(X119'.
WATER HE.M'ER W/VENTIELECTR
WArE.R SYSTEM/BEAITNG
WATER S17RVICU
NEW RESIDENT [At, PI.MB. SQ.IT.
MECHANICALPERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.001) CPM)
AIR HANDLING UNIT (OVER 10,010 CFM)
EXHAUST HOOD(W/DUCO
HEATING UNIT (TO 100.004) BTU)
HEATING UNIT (OVER I W.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (JHP OR Iholo(a) BTU)
HOILBR - COMP LOVER'(a)Isto BIT U)
AIR CONDITIONER
NEW RESIDENT [At, MECIL SQ. FT.
OFFICE
r, E3 I 83 pZ
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X_ A --
FEE JOB DESCRIPTION
RESIDENTIAL,
,a/
FDW)L KITCHEN REMODEL,
ADDITION C PLUMBING REPIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
C INTERIOR C CHIMNEY REPAIR
IMPROVEMENT rp
C BATH REMODELREPAIR ya.DEMOLITION
❑ OTHER
COMMERCIAL'.
CNEWBI.DG/ADDITION CDEMOLATION
C'I'ENANT FOOD SERVICE
IMPROVEMENT
C OTHER
SQ, FT. FLOOR AREA S/SQ. 1'1'.
3 A e
FEE 1g1996
LMI�GATION
EE
I
E
EE
FEE
AL FEE
f10NTAX
ITIGATION FEE
PAID
Dam Rreems k
TOTAL:
ISSUANCE DATE
ISSUEDBy,
•/
STORIES
OCC.OROUp
TYPE CONSTRUCT 10
APN
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEF.
PAID
Dam
Receipt M
TOTAL:
LMI�GATION
EE
I
E
EE
FEE
AL FEE
f10NTAX
ITIGATION FEE
PAID
Dam Rreems k
TOTAL:
ISSUANCE DATE
ISSUEDBy,
•/
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL. POINT PEN UNLY
BUILDING. ELEC'T'RICAL PERMIT 30695
WDI
CITY OF CUPE RTINO PLUMBING - MECIIANICAL
BUILDING DIVISION APPI,ICATION/F'ERMIT
ILNG PRII,IEC'I'IURNT'IPICATIf3N
NGADDRES,S:
o yob �-1r�tiv o� r, cva�,�r�-:moo
of o ,eirelleNs
19Eg1z/9zc I/,
CONTACT:"•"^•"
l �rCie✓S 93� �� ❑ Consultant Fetes Paid by Applicant (Initial)
61)Wrl vo /S
ZZO
1_
¢ c.
nn Z
LICENSED CONTRACTOR'S DECLARATION QTY
1 hereby affirm that I ran licensed under provisions of Chapter 9 (commencing
with Section 7") of Division 3 of the Business d ProfessiosCale. and my license is
in full Tome and effect.
Lis. 4
DatLime Comm— -
ARCHITECTS DECLARATION
1 undcmmnd my plans shall M used as public records
E'.
Licensed Pmfeaionul
TYPE CONSTRUCT 10
APN
OWNER -BUILDER DECLARATION
.J
Q
1 hereby .(firm that 1 at,, exempt from the Commcmr's License Law for the
a, V
following mason. (cacti.. 71131.5, sx and eio Cale: Any city m county
W N
ws. d l or any urucmrc
:Jlxr, impose,
which reyuirca u trod, atm
als ur
SOILS FEF.
h parmah.
s oBlco,LawJsmmmem
e, ire" for each e u signed
lhcappllis
PAID
Dam
that has ilraance,alarrc9nirc
aI ra,t License Law(Cnook) or
pSeviandction l.Its, pnrvlsi,i
00
Sit otsumonds
ocomort,raco,witmsrd
with Section](Nxl).f Dioikl t t
tcathe
T�
alle,inc.rmptor. Anion alismor
los the .Meted cxcmpnoa Any violation of
is exempt the
that he in exempt
apt li and the
to of
n W
pen u civil penalty
Section ]11115 by any applicant for u �rmit wbjcelx the applicant
any
_
m
not more than live hundred dollars ($500)
theirsole compsn.cation,
SD
El 1, anownerof the property. or mycmployces with wages an
yo
will do the work. and the structure s not intended or offered fmoovle(Sec. 91114. Business
m
and Professions Code: The Contractors License Law J%as nm apply 10 an owner of
3..
property no builds or improscs tlmrcnn, and who due,such weak himself or through
his own employees, provided that such improsemems am not intended or offered for
sale. If, however, the building or improvement is .sold within one yemol completion, me
tioxierr-Imider will have the burden of proving that he did not build or improve for pur-
Pox of nalc).
C 1, as owner, of the popery, um exclusively contracting with Iwrnwal comm<tors to
onsuuer the project (Sec. TI1L1, Ifusiness and Pmfessima Code:) The Contractors Li-
u Law does nal apply to on owner of propcny who builds in improve% thereon, and Q1Y.
who contract for such projects wit. u c.nwnort%) IicenaJ pursuanuo the Conuanors
License law.
I am exempt under Sec. ,B&P C for this reason /
Owner Dote
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificam of Coov,am to self -inure for Wealme, Compen-
snrmi vs providN fur by Swtinn J9W of the Wbnr Gde, for the Ixrfammnce of the
work for which this Permit is issued.
I have ..it will maintain Worker's Compcwtion Insurance, m required by Section
J]W of the labor Cost'. for rhe perfnnmmur of the work for which finis permit is issued.
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL.
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAI.
SPECIAL. CIRCUIT/MISC,
TEMP, METER OR POLL: INST.
POW17R DEVICES
SWIMMING !l-1 CTRIC
COMI'IiNSAT10N INSURANCE
(Th'ws lion .teed nm he mnnplcmdil the lannil is forme ...decd dollars ($I W)
no
Icsx.)
leen mel uper(ormm�<c oflin whlen this pcnnil rs isueJ,I shall
ern employ a nn In nlny nlminycyl' IG�KiyJem to the Workers' Compen-
z xminn Lvwvn 'to
Bac
z 0 Applicem P neulA
NOTICE TO AI I CANT: IL alter ranking l It, CInilieam of L'xem lion, you %
F her iso", s jed ar it Weaker%..... "'i ,mien prov nionc o[ the Lahor Cadc, you must
�i fnnhwith comply wish such pnnlxinrn nr this pcnnil ehnll nc JcensJ revoked.
kA Q
,Z' CONom,,,xTOIJLENI3INGAGENCY
V l frvshich this
thereisand(See 30 len Jing agencykrr the perfonnance of
CL, f✓ the work for wnich this pcnnil is issued (Sec.7W], Civ. C.)
O U Lender's Name
} D7 I<ndcr%Add ... I
CL,I cenify that I have brud do, application and Note that the vMwc information is
sF. y tmorM I agree to comply with all city and county ordinances and seam laws miming m QTY
U Z building mnamction, and hereby aulhoriie representatives aflhis city In soar, upon the
above.memwned pmpery for inspection pmptrso.
(We) agree toxins. indemnify ..it keep harmless the City of Cupertino against
Hithilitiesjudgmerns, costs and expenses which may in any way aceme against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS e MATERIALS DISCLOSURE
Will the
eCupam11 future building occupant store or handle h Health
material
as defined by the Cupertino Municipal Cadc. Chapter 9. 12. and the Hca1tB and cafcry
Code. Section 25532(a)"
❑Yes Fl No
Will the applicant or future building occupant use equipment or devices which
ratio hazardous or canmatinanl%as defined by the Bay Arca Air Quality Management
District'?
❑Yes 7 N
I have read the nuanlous mnlcrials rquiremcals under Chapter 6.95 ,fine Cali-
buou Health & Safety C,. c, Sections 25505. 25539 and 25534. I ondemand that if the
buildingJce nor umendy have u mania. lhun it l� myrcpon.ilodily to rarity the necupunt
,,line ryuircomal ishichomo rte nal prior to lxs.ar, of a Cenilwalsoflhxupaney.
NEW
Sp Irl'.
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (IiA)
BACK FLOW PROTECT. DEVICE
DRAINS - FLUOR. ROOR AREA. GOND.
FIXTURES -PER TRAP
GAS - EA. SYSTEM.I INC. J OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASUINDUSTRI. WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY - STORM IiA, 2(X119'.
WATER HE.M'ER W/VENTIELECTR
WArE.R SYSTEM/BEAITNG
WATER S17RVICU
NEW RESIDENT [At, PI.MB. SQ.IT.
MECHANICALPERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10.001) CPM)
AIR HANDLING UNIT (OVER 10,010 CFM)
EXHAUST HOOD(W/DUCO
HEATING UNIT (TO 100.004) BTU)
HEATING UNIT (OVER I W.000 BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (JHP OR Iholo(a) BTU)
HOILBR - COMP LOVER'(a)Isto BIT U)
AIR CONDITIONER
NEW RESIDENT [At, MECIL SQ. FT.
OFFICE
r, E3 I 83 pZ
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X_ A --
FEE JOB DESCRIPTION
RESIDENTIAL,
,a/
FDW)L KITCHEN REMODEL,
ADDITION C PLUMBING REPIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
C INTERIOR C CHIMNEY REPAIR
IMPROVEMENT rp
C BATH REMODELREPAIR ya.DEMOLITION
❑ OTHER
COMMERCIAL'.
CNEWBI.DG/ADDITION CDEMOLATION
C'I'ENANT FOOD SERVICE
IMPROVEMENT
C OTHER
SQ, FT. FLOOR AREA S/SQ. 1'1'.
3 A e
FEE 1g1996
LMI�GATION
EE
I
E
EE
FEE
AL FEE
f10NTAX
ITIGATION FEE
PAID
Dam Rreems k
TOTAL:
ISSUANCE DATE
ISSUEDBy,
•/
STORIES
OCC.OROUp
TYPE CONSTRUCT 10
APN
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEF.
PAID
Dam
Receipt M
TOTAL:
LMI�GATION
EE
I
E
EE
FEE
AL FEE
f10NTAX
ITIGATION FEE
PAID
Dam Rreems k
TOTAL:
ISSUANCE DATE
ISSUEDBy,
•/