S 1115 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELEC1'RICA]. FIERRNIFT NO,
BUILIAI GDIVISION APPLICATION/PERMIT ILUMBING-MECHANICAL S 1115
non.omc r1eoJEer IDeN'rIHICA'nory
SANITARY NO. APPLICATION SUBMITTAL DATE
UILDING ADDRCSS: I
NIiN:S NAME: PHONE: CONTRACTOR'S NAME: hIC NO: NIC CON IRULM
/ ARCHITECEHNGI :ER: LICN'O: ADDH ESS'. ❑
N Cb
CONI'n ('DONE: BUILDING PERMIT INFO
Js t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME NIECE
L-di7_5Zr�' t
LICENSEDCONTRAMOR'SDECLARATION Q Y ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I nm licensed ander provisions of Ch+plar 9(cmnmencing
mwz nlfull force and eRnn)ivuionJofIM1,Iiu....round Is frsio I,Cale.andirylicemcis RESIDENTIAL
!APPLI!ANCFS
SUANCE
I+I W= ❑$IUWI. El KITCHEN RIiMODIiI.
Cu'F
FFQ--UV License Class Lica -RESIUI_NTIAI, ,UI.T'ION ❑STRUBINGRL-I'il'liL )a¢ TSDE L MULTI-0Nll' ❑STRUCTURAL
ARCHITIiCTS UIiCLARATION MOOIFICA'IION
ZI uodulntund my plans lall he recdx.e public raonl.s ASUN ❑INTERIOR ❑CHIMNEY REPAIR
��� LicenscJ Pmfensinl MPS IMPROVEMENT QSWIMMING POOLS
�W�; OWNER-BUILDER DECLARAI[ON OVER Half , CS ❑HAfH RIiMOUIiI/Rlil'AIR �UI3MOLI'1'1(� )N
C
W, I hereby union,that I am exempt from the Contractor s License Law Lor the ❑OTHER �'�-�
N�xm O IS i
ad O fallowing reason.(Section 71315,Basioess and Profession'Clubs.Any city or county SIGNS ELF.CFRICAI. �T"
ilc h which regains a pemlit to dmarmt,alar,improve.Jemollxh,or repair any mmctore �—
I�'u'�; prion kLm q the PPIic If hpermin Ile gcJ Slam oat SPF.CIALCIRCUITIMISC.
sE�p. 'icon I' Jp rsu: n h p m I'th C t hent L Wh lac,9 COMMERCIAL'
�a0�0 (cam g thScJ 100(y.1Divisio \ fob B ours dProfession,Calu)or IEmp..METER OR?01.13 NST. El NEW BLDG/ADDITION ❑DEMOLITION
L k c e' Ihm M1e is exempt thercfmm and the basis for the alleged exemption.Any violation of
4• Section 7031.5 by any applicant for n punnit subjects the applicant a civil Penalty ofMPLUMBING,
, CF17E
'I'IiNAN'I' ❑FOOD SERVICE
�..y I moa than five hundred dafter,S5a)J IMPROVEMENT
,=Q Las owner of the pmpcnn nnny employees wilM1 wages us their sole a,mlxncadon, LF IOTHER
p. will Jit the work,and The structure is not intended or uttered fnr sole(See.70,14.BusinessTCHES- U
W 3.2 and Professions Code:Toe Contracmr'License Inw don nm apply Tm an owner of
prop ny M1 builds p Th h does: h workh' If throughNEWIAL EL.C'1tio n PI Y P J d th'1 h' p t- Ito t d J IfereJ for SQIT,FLfOR AREA 9SQ.F..
Ie.11 h th M1uldbF pit 1 Id Th m s fe PI lion the (1_/—y\\�Ib 'IJ illi ll b l nth 11 !d nh IJ p fnrptn Sore f. le)wnerofthe property,um exclusi elY T T g with I d I actors to
esisvum The prujml(See 70W.Puxincec and Prra...ons Code 1'111,ComrarallI I.i-
cerittLawdms not apply u,an owner of pmpeny whit builds or improves Thereon.and MBING PERMIT
who conlredsfor such p,.j,,,, all a courtrooms)Iian.W pursuant ut the Common''
I'morem Low, PERMIT ISSUANCE
1 am exempt under Sec. .N&I'C far tM1i'rcnsnn
q� Q� N:Ii?R-DRAIN.S VI3N'f-WAS 13R(1iA) VAIAA'I'ION
01 )wncr, atc�Y/ . L
WORK 'S COM1IYCNSAfION DECLARATION BACK PhOW 1'R(JrECI'.DEVICE 1/� S�
V Fl I hereby alllrm under penally of perjury ane of the following Jcclannions:
I have and will murmur
..murmur..Certificate of Cnnunuo ulf-insure fnr Worker's Compcn- DRAINS-MOOR,ROOF,AREA.COND. STORIES TY PE CONSTRUCTION
amion,us proxiJeA for by Section 3700of The Labor Calc,for the performance clothe
walk Iia which This permit ie i.esucIT. FIX'I URES-P17R'FRAP �l
I have and will maintain Worl,res Compensation Insurance.as required by Section
39(XIoI(be Lano,Code,for l Im perlonnarce of the work for-Such Thu permi,I,oal, GAS-EA.SYSTHM-I INC.4 OUTLETS OCC,OH(lUP fl N'N
My Worker's Compensation Insurance carrier and Policy turnover art: GA5-ICA.SS'S'I'EM.OVIiRd1P.A) JAN ANS
°D
Cmdcc i'olicy No.:
cwriVICAI'1701:EXIiM1'1'ION PROM WORKERS, GREASEd NDUS'I RL WASTE INI'ERCEITOR
COMPENSATION INSURANCEBUILDING DI V(SIO
N tau On
flbisxeelimrm,u nal be rnmpldediftM1cpermitisfnnmeM1unJrcd dollen181(NII CBS All TRAP ° kil
ar IcssJ PhANCIIIiCK PE.
Icenify That infleperfomlancemithe wafkforwhich ThispemTiTisiawial,1,all SEWER-SANITARY-STORM EA.2(X)FT. ENERGY NH3
am employ any per,....in any manner na as to Leconte school,to
the Worked Cmmpen-
Z _him L ws of California.Date WATER HEATER WNEIN ELECfR GRADING SEE
ZQ Applicant
` NOrICE TO APPLICANT:it. for,making dr,Certilicalc of Exmn,eur.yon III III WA1Y.R SYS'I'lTmfl HEATING SOILS IPE
[-^ oemasc subject to the Wnfkefs Compenwtion provisions of the WMs Calc,you must
forthwith comply with such pnrvision.c on his permit zhall he deemed revoked. WATER SERVICE
L (] UCTPAID
� Z CONSTRION LENDING AGENCY NIiW RI!SIDF.NTIALPLMB. SQ.FT. plc Rwciplx
L)O 319)
I hereby affirm that there i'u con'tmdimn lending agency for the pcdonnana of
"s the work for which This permit is issued(Sec. .Civ.C.) '('OTA h:
O I"' Leaden,Name TOTAL:
,rU Units,,Auto... BUILDING FEE
1 I cenify that I have mad this applicminn and Vale Tim the above inlimnatinn i'
Fr N conn''.l agree ns comply with all city and county ordinances moisture laws miming to QTY MECHANICAL P17RMIT IFF, SEISM IC II iE
(,.) ,Z huilJing mnsuuetinn,and hereby authorize o reannatives nfthis city menteruprnt lire
o� abavomentioned pm,eny for inspection Postpones. PERMIT ISSUANCE ELECIHIC IEE
(We)agree b,cave,indcmnily and keep humdcss The City at Cupertino against
Iiabilitiecjudgmema,costs and expenses which may in any way accrue against said City ALTER OR ADD TO NIECE. PLUMPING FEF.
in consequence of the gaming of this punnit.
APPLICANT UNDERSTANDS ANI)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO I(I,(NN)CPM) MECHANICAL,1931:
SOURCE REGULN'TONS,
1^/ - AIR HANDLING UNIT(OVER IRIXXICPM) CDNSTRUCTION'IA%
Signature of ApplicanifCOmbranclin Dam EXHAUST HODD(W/UUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dle applicant lir future building tscapanl smre lir handle h tia dnus material I HEATING UNIT(r0 IM000 14 11
as JcfinW by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEAPING UNIT(OVER 100,000 BTU)
Ir.Seaton 25532(x)?
❑Yes 0 N VENTILATION RAN(SINGLE RF.SIDJ PAID
a —Dam RacipTM
Will lb,upplicmn or Imine huilding lmaponl not cquipin,nl or deloles which BORER-COMP(HIP OR 100.0N)131 U,
crit,hmarda,air containment'nt'as defnW by the Hay Area Air Quality Malignance' TOTAL:
Lavinia? (,OILER-COMP(OVER I No NX)US US
oyes [:1 No,
AIR CONDITIONER ISSUANCE;DATE
I Mw,read the oazurdouv timsr 5 5.2553 av'under4.1 un r r,m of Tacit the
foods Health n Safety tly lo,Sooner 25505,25577 and Y55J4.I ul-tlflnd that if the NEW RESIDENTIAL MACH. SQ.Ff.
builJingpeoncrit,went unuu he act 1lhmit ismyresptmsibimil'anati(ylheocay. D
of Inc rcyuimmaT'wbicM1 oma M1c old poor m icxmintt of II C miliculc of(kuupancy.
Ostan,aragam,Cdnnenl Date TOTAL: ISSCCD IT)': �— ^—
_OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELEC1'RICA]. FIERRNIFT NO,
BUILIAI GDIVISION APPLICATION/PERMIT ILUMBING-MECHANICAL S 1115
non.omc r1eoJEer IDeN'rIHICA'nory
SANITARY NO. APPLICATION SUBMITTAL DATE
UILDING ADDRCSS: I
NIiN:S NAME: PHONE: CONTRACTOR'S NAME: hIC NO: NIC CON IRULM
/ ARCHITECEHNGI :ER: LICN'O: ADDH ESS'. ❑
N Cb
CONI'n ('DONE: BUILDING PERMIT INFO
Js t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUME NIECE
L-di7_5Zr�' t
LICENSEDCONTRAMOR'SDECLARATION Q Y ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I nm licensed ander provisions of Ch+plar 9(cmnmencing
mwz nlfull force and eRnn)ivuionJofIM1,Iiu....round Is frsio I,Cale.andirylicemcis RESIDENTIAL
!APPLI!ANCFS
SUANCE
I+I W= ❑$IUWI. El KITCHEN RIiMODIiI.
Cu'F
FFQ--UV License Class Lica -RESIUI_NTIAI, ,UI.T'ION ❑STRUBINGRL-I'il'liL )a¢ TSDE L MULTI-0Nll' ❑STRUCTURAL
ARCHITIiCTS UIiCLARATION MOOIFICA'IION
ZI uodulntund my plans lall he recdx.e public raonl.s ASUN ❑INTERIOR ❑CHIMNEY REPAIR
��� LicenscJ Pmfensinl MPS IMPROVEMENT QSWIMMING POOLS
�W�; OWNER-BUILDER DECLARAI[ON OVER Half , CS ❑HAfH RIiMOUIiI/Rlil'AIR �UI3MOLI'1'1(� )N
C
W, I hereby union,that I am exempt from the Contractor s License Law Lor the ❑OTHER �'�-�
N�xm O IS i
ad O fallowing reason.(Section 71315,Basioess and Profession'Clubs.Any city or county SIGNS ELF.CFRICAI. �T"
ilc h which regains a pemlit to dmarmt,alar,improve.Jemollxh,or repair any mmctore �—
I�'u'�; prion kLm q the PPIic If hpermin Ile gcJ Slam oat SPF.CIALCIRCUITIMISC.
sE�p. 'icon I' Jp rsu: n h p m I'th C t hent L Wh lac,9 COMMERCIAL'
�a0�0 (cam g thScJ 100(y.1Divisio \ fob B ours dProfession,Calu)or IEmp..METER OR?01.13 NST. El NEW BLDG/ADDITION ❑DEMOLITION
L k c e' Ihm M1e is exempt thercfmm and the basis for the alleged exemption.Any violation of
4• Section 7031.5 by any applicant for n punnit subjects the applicant a civil Penalty ofMPLUMBING,
, CF17E
'I'IiNAN'I' ❑FOOD SERVICE
�..y I moa than five hundred dafter,S5a)J IMPROVEMENT
,=Q Las owner of the pmpcnn nnny employees wilM1 wages us their sole a,mlxncadon, LF IOTHER
p. will Jit the work,and The structure is not intended or uttered fnr sole(See.70,14.BusinessTCHES- U
W 3.2 and Professions Code:Toe Contracmr'License Inw don nm apply Tm an owner of
prop ny M1 builds p Th h does: h workh' If throughNEWIAL EL.C'1tio n PI Y P J d th'1 h' p t- Ito t d J IfereJ for SQIT,FLfOR AREA 9SQ.F..
Ie.11 h th M1uldbF pit 1 Id Th m s fe PI lion the (1_/—y\\�Ib 'IJ illi ll b l nth 11 !d nh IJ p fnrptn Sore f. le)wnerofthe property,um exclusi elY T T g with I d I actors to
esisvum The prujml(See 70W.Puxincec and Prra...ons Code 1'111,ComrarallI I.i-
cerittLawdms not apply u,an owner of pmpeny whit builds or improves Thereon.and MBING PERMIT
who conlredsfor such p,.j,,,, all a courtrooms)Iian.W pursuant ut the Common''
I'morem Low, PERMIT ISSUANCE
1 am exempt under Sec. .N&I'C far tM1i'rcnsnn
q� Q� N:Ii?R-DRAIN.S VI3N'f-WAS 13R(1iA) VAIAA'I'ION
01 )wncr, atc�Y/ . L
WORK 'S COM1IYCNSAfION DECLARATION BACK PhOW 1'R(JrECI'.DEVICE 1/� S�
V Fl I hereby alllrm under penally of perjury ane of the following Jcclannions:
I have and will murmur
..murmur..Certificate of Cnnunuo ulf-insure fnr Worker's Compcn- DRAINS-MOOR,ROOF,AREA.COND. STORIES TY PE CONSTRUCTION
amion,us proxiJeA for by Section 3700of The Labor Calc,for the performance clothe
walk Iia which This permit ie i.esucIT. FIX'I URES-P17R'FRAP �l
I have and will maintain Worl,res Compensation Insurance.as required by Section
39(XIoI(be Lano,Code,for l Im perlonnarce of the work for-Such Thu permi,I,oal, GAS-EA.SYSTHM-I INC.4 OUTLETS OCC,OH(lUP fl N'N
My Worker's Compensation Insurance carrier and Policy turnover art: GA5-ICA.SS'S'I'EM.OVIiRd1P.A) JAN ANS
°D
Cmdcc i'olicy No.:
cwriVICAI'1701:EXIiM1'1'ION PROM WORKERS, GREASEd NDUS'I RL WASTE INI'ERCEITOR
COMPENSATION INSURANCEBUILDING DI V(SIO
N tau On
flbisxeelimrm,u nal be rnmpldediftM1cpermitisfnnmeM1unJrcd dollen181(NII CBS All TRAP ° kil
ar IcssJ PhANCIIIiCK PE.
Icenify That infleperfomlancemithe wafkforwhich ThispemTiTisiawial,1,all SEWER-SANITARY-STORM EA.2(X)FT. ENERGY NH3
am employ any per,....in any manner na as to Leconte school,to
the Worked Cmmpen-
Z _him L ws of California.Date WATER HEATER WNEIN ELECfR GRADING SEE
ZQ Applicant
` NOrICE TO APPLICANT:it. for,making dr,Certilicalc of Exmn,eur.yon III III WA1Y.R SYS'I'lTmfl HEATING SOILS IPE
[-^ oemasc subject to the Wnfkefs Compenwtion provisions of the WMs Calc,you must
forthwith comply with such pnrvision.c on his permit zhall he deemed revoked. WATER SERVICE
L (] UCTPAID
� Z CONSTRION LENDING AGENCY NIiW RI!SIDF.NTIALPLMB. SQ.FT. plc Rwciplx
L)O 319)
I hereby affirm that there i'u con'tmdimn lending agency for the pcdonnana of
"s the work for which This permit is issued(Sec. .Civ.C.) '('OTA h:
O I"' Leaden,Name TOTAL:
,rU Units,,Auto... BUILDING FEE
1 I cenify that I have mad this applicminn and Vale Tim the above inlimnatinn i'
Fr N conn''.l agree ns comply with all city and county ordinances moisture laws miming to QTY MECHANICAL P17RMIT IFF, SEISM IC II iE
(,.) ,Z huilJing mnsuuetinn,and hereby authorize o reannatives nfthis city menteruprnt lire
o� abavomentioned pm,eny for inspection Postpones. PERMIT ISSUANCE ELECIHIC IEE
(We)agree b,cave,indcmnily and keep humdcss The City at Cupertino against
Iiabilitiecjudgmema,costs and expenses which may in any way accrue against said City ALTER OR ADD TO NIECE. PLUMPING FEF.
in consequence of the gaming of this punnit.
APPLICANT UNDERSTANDS ANI)WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO I(I,(NN)CPM) MECHANICAL,1931:
SOURCE REGULN'TONS,
1^/ - AIR HANDLING UNIT(OVER IRIXXICPM) CDNSTRUCTION'IA%
Signature of ApplicanifCOmbranclin Dam EXHAUST HODD(W/UUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will dle applicant lir future building tscapanl smre lir handle h tia dnus material I HEATING UNIT(r0 IM000 14 11
as JcfinW by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEAPING UNIT(OVER 100,000 BTU)
Ir.Seaton 25532(x)?
❑Yes 0 N VENTILATION RAN(SINGLE RF.SIDJ PAID
a —Dam RacipTM
Will lb,upplicmn or Imine huilding lmaponl not cquipin,nl or deloles which BORER-COMP(HIP OR 100.0N)131 U,
crit,hmarda,air containment'nt'as defnW by the Hay Area Air Quality Malignance' TOTAL:
Lavinia? (,OILER-COMP(OVER I No NX)US US
oyes [:1 No,
AIR CONDITIONER ISSUANCE;DATE
I Mw,read the oazurdouv timsr 5 5.2553 av'under4.1 un r r,m of Tacit the
foods Health n Safety tly lo,Sooner 25505,25577 and Y55J4.I ul-tlflnd that if the NEW RESIDENTIAL MACH. SQ.Ff.
builJingpeoncrit,went unuu he act 1lhmit ismyresptmsibimil'anati(ylheocay. D
of Inc rcyuimmaT'wbicM1 oma M1c old poor m icxmintt of II C miliculc of(kuupancy.
Ostan,aragam,Cdnnenl Date TOTAL: ISSCCD IT)': �— ^—
_OFFICE