30974 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'-USE BALL POINT PEN ONLY Q
CITY OF CUPERTINO BUILDING-ELECTRICAL PER ONO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL.
UILDING'PROJI?Cp IDENTIFICATION
BUILDING ADDRESS: SANITARY NU. APP^/LICATIO UAl'E
OWNEI AME: g� 1 PHONE: CO ' ACT'OR'S NAME - LIC NO: _ • ��
IT 7 2 NIC CON'fR01.q
ARCHITE (ENGINEER: LIC NO: ADD/N�+LSS R� / �'j t .J ❑
/ D Y..CJ IO / « r
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB METH
❑ ❑
LICENSED CONTRACTORS DECLARATION - QTY, ELECTRIC PERMIT FEF,
I hereby affirm Nm 1 am licensed under provisions of chapter 9(eommenc)ng JOB DESCRIPTION
�04Z with Section 700mof Division 3oflhe Businessvnd Professions Cale,and may license iv RRSIDENTIAU
Iyy�L
cc PERMIT ISSUANCE
f Wp mfull force and A. g ` ❑SFDWL ❑KITCHEN REMODEL'
U License Claf b Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
r TIDE FtJi F
ARCHITECTS DECLARATI N [I MULTI-UNIT ❑STRUCTURAL
Ft2K- I understand my plans shall be used as public records PANELS MODIFICATION
OZ_ UP TO 200 AMPS [1 INTERIOR [I CHIMNEY REPAIR
F-� Licensed professional 201-1010AMP5 IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IBIXIAMPS D BATH REMODEUREPAIR ❑DEMOLITION
,��' I hereby affirm Nat I am exempt from the Contmcmr's License Law for the
O y U f'llo in evs...(Section ON I.5,Business and Professions Code:An r county g r y city or am Y SIGNS ELECTRICAL. E]OTUPR
W
fs] 0 which its isas i permit e,also re ennswm,alter,improve,demolish,or repair any structure
O that hor nitscense amincmyo theres the vof for such Comdr an'S Livems)rile aeLwgned nment SPECIAL CIRCUITIMISC.
6E thmheeacin with
pSectio 7 Nc provisions1Dvion 3 the Convactnr'andprfLew(Chapter,Cde)or
..00 teat he
ixemith Sendromandtf basis
rnf Ne Business exemption.
Any
violation of
or TEMP.METER OR POIA(NST. COMMERCIAL:
a q o C Sec he is exempt Nerefmm and the basis for the alleged exemption.Any violation of []NEWTEN BLDG/ADDITION ❑DEMOLITION
4• Section hLSby hundred
dollars($500).
the applicant ,,.civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
w t more Nen five hundred dollars y employees
IMPROVEMENT -
QOLoamewoowner kf the property,mmyemntendes ed orowags,sas rsalei(See.c04,Buri lon.ess SWIMMING POOL ELECTRIC _[^C,_`
(•.O will Pr Newons and the he Contractor's
ontis roti License Law does
wo apply 9044,owner
of ❑DTHI:R
L3� and Professions Code, inn Com thereae License Lawsowsnm apply toanowner of OUTLETS-SWITCIIILS-I+(%TURES
his o ny who builds or aided that
thsuch i and who fines such wnrk deed o r or through
his awn employees,e provided thin such improvements are not amended or offered that NEW RESIDENTIAL GLfiCTN SQ FT.
sale.ILhowever.the building nrimprovemenf is sold within one year of completion,the SQ.FT FLOOR AREA S/SQ.FT.
Mer-builder will have the burden of proving that he did not build or improve for put-
pose of sale.).
C]1,ew owner of the property,em exclusively contracting with licensed contractors to TOTAL: -
nnstr me,the pray e,(See,70,14,Business and Pmfudn.Cm1ej The—a—um.Li PAID
cense law docs not upplyR.an owner of property who build,,.,improves,herwn,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a con rectons)licensed pursuant to the Contractors •�
License Law. PERMIT ISSUANCE J 1
I um exempt ec
under S . .B&P C for dis reason )
4 Doo.
Owner Date A1:1'ER-URAIN,FVENT-WATEff f R(EA) U' V ON
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I �'urc111jN p
1 hereby affirm under penalty of perjury one of the following declarations:
.Q I have and will maintain a Carioca,ofConscnt to self-insure for Worker's Compen. DRAINS-FLOOR,ROOK AREA,COND. STORIES ,TYPECONSTRUCTION
s tion,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is lowest. FIXTURES-PERTRAP
❑ I have and will maintain Walker's Compensation Inmrarec.as required by Section
37M of the Labor Code,for the performance of No work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.CROUP APN
My Workers9 Cc 1pem,m Insuv, carie,and Policy Muppr��
Cartier:$( Policy No.:-u.Ls 7_I(p1-^R.Q GAS-EA.SYSTEM-OVER4(EA)
CERTIPI TE OFEXF,MPTION FROM WORKERS' 6530I GREASI➢INUUS'1'RI.WAS'TEEDERCEP01i
COMPENSATION INSURANCE BUILDING DIVISION MLS
(This section need not becompleted ifthe permit is forams,hundreddellum(Shalt GREASETRAP
or less.) PLANCHECK FEE
I certify that in the perfomwnceof Ne work for which this permit is issued,I.shall SEWER-SANITARY-STORM EA.20o FE
not employ any person0o
any counter so as to become subject the Workers'Commit ENERGY FEE
O Z smion laws of Califnmio.Date WATER HEATER W/VENT/ELECIR
O Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificme of Eacromion,you should WATER SYSTEM,TRnA'rING SOILS FEL:
hecmne subject m the Worker's Compensation provisions of the Labor Code,you must
fmhwith comply with such provisinnso,this permitxhull he devoted resulted WATER SERVICE
Q
U O 1 hereby affirm CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.Cr PAID Date Receipt p
that there is a conmmnion lending agency for the performance of
U. w. the work for which this Nowit is issued(Sec.30G.Civ,C.)
Lenders None,
Leaders Address - TOTAL.:
Cta I certify Nm
that I have read this application and state that the above information is BUILDING MH
V3 correct.I agree to comply with all city and county ordinances and state laws relating in QTY, MECHANICAL PERMIT FEE
U 7, building comaruction,and hereby uuNoriu representatives ofthis city to enter upon the SEISMICFEE
above-mentioned property far inspection Purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against F.LIiC'IRIC FBI,
liabilities,judgments,costs and expenses which nay in any way acerae agaias"wil City ALTER OR ADD TO MECH.
in con l encenf Negranti
ng of this permit. PLUMBING FEF.
APPI CA]T UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM)
MECHANICAL.FEF.
SOIL CE EGULATIONS
A ryA -P f�74-41�h' /� 7 AIR HANDLING UNI'IyOVER 10,fXp CFM) CONSTRUCTION TAX
Si owre o(Applicent/ onhatm, a�/'Da� EXHAUST HOOD(W(DUCI} HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapdieent orl'uturc buildingoccupant stareorhurdle hazardous material HEATING UNIT(TO 100.000 BTU)
us defined by the Cupenion Municipal Code,Chapter 9,12.and the Health and Safety
Cole,Section 2553200? HEATING UNIT(OVER 100,000 BTU)
❑Yes [-I No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt is
WLII the applicant or future building occupant use equipment of devices which
emit haeardI,asmous air uminsms as Oefiraed by the Bay Area Air Quality Morogcmem BOILER-COMP CLIP OR I00,00(l BTU) TOTAL:
District? BOILER-COMP(OVER 100.00 BTU)
❑Yes ❑No
I have read the heat muteriuls mquiremems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATA
(omit Health&Safcty Code,Sections 8505,25533 and 25534,1 understand that if the NEW RESIDENTIAL.MECH. SQ.IT.
building does not currently have a Baum,Nat itis my rcerymsihility m nosily the rccupanL
of the requirements which must be met prior to issuance of a Ceniliceateof 0s cupancy,
Owner or amounted agent - Date TOTAL: ISSUED BY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT _ PLUMBING-MECHANICAL 30974
- UILDBSCPROJECS'IDKNI'IF-ICA'IION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMI ITAL DATE
L �Oro Z 1/►'1 x 11� �L C�ptyt,Ta•�a W 4 1 014- �1��
OWNERS NAME: PHONE: / mss(, CONTRACTORS NAME: LIC NO:
S 2x�
SPC CC'Rx-r ah `•!'• St, 41sT'' 1a SN AI 53�� O NIC /�.�CO�NTR�O/Lsp
RCHITECT/ENGINEER: LIC NO: ADDRESS; ❑ /yI�J/\ n�(/r{�
\ �O PW;'•��4�4��� 4ECL. 1 OI i • —' IC AWTD 611 ✓ V�f�
`t�TTrn¢T. �E. A"f KrtiS, 15.01P I - ',;` f ILDING PERMIT INFO
hyEE.• t ^Consultant Fees Paid by Applicant(Initial), BLDG HLECT PLUMB MECH
N. Yn" ume_C" 2o°r 521,�`Jf'� -aC ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O0Z
WOO with Section 70110)of Division 3ofthe Buxlnessaal ProfessionsCoale,andmyliciareis
PERMIT ISSUANCE [I SFDW L ❑KITCHEN REMODEL
NITIAL:
F- � in full force ramal effect.W - ❑SFDW
�<�U DteLicense Cimx Lie.x
Dom - Conw tor_ APPLIANCPS-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Z r�::)n ARCHITECrs CLA 10 ❑MULTI-UNIT ❑STRUCTURAL
b Tun rand t lora shall be PANELS
y mpu crccnNs MODIFICATION
OZ - UI'T0211U AMPS
Lmcnsc Pr CI INTERIOR - 11 CHIMNEY REPAIR
e�+p� OWNER-BUILDER DECLARATION OVERIMOAM IMPROVEMENT
sWfp�y5 g 1 hereby off rte the 1 am exempt rroin the Comruram's License Law for the OVER II%IBAMPS ❑BATH REMODEL/REPAIR 0 DEMOLITION
W a 4 F ......wing res....(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELF.CIRICAC ❑OTHER
LLI WO which requires a permit to constrwt,alter,improve,demolish,or repair any swcture� -
snprior m its issuance,also requires the applicant for such permit..file a signed ammmem SPECIAL CIRCUIT/MI
y m
that he is licensed pursuant to the provisions of the Cmarctor's License Law(Chapter 9
d <f (commencing with Section 7000)of Division 3 of the Business and Professions Code)or •TEMP.METER O LE INST. .COMMERCIAL:
y o moi' that he is exempt therefrom and the basis far the alleged ascan lu n.Any violation.f
aXl 0. Senior 703156y any applicant forepennit sub'ecn Ne applicant too civil ❑NEWBLDG/ADDITION []DEMOLITION
POWER DEV
penalty of I []TENANT ❑FOOD SERVICE
Fq.Z} not marc than five hundred dollars($500). -
20 I,uownerof the pmpeny,or my employees with wages ax their sole compensation, SWIMMI POOL EIkCTRIC IMPROVEMENT
y will do the work,and Neswctere isnm moramdoroBered forsale(See 7014,Bus / S
iness ❑0TH
tren
0. and Professions Code:The C.nor's Lierm4 Law does not apply to an owner of OUTL -SWITC ES- TURES
property who builds or improves thereon,and who does such work himself or through
his sewn empl.yees,powided,that suchfurprovnnnus uta not breached or offered for Nil W fSIDENTI SQ FT.
sale.ll'.however,the building tirimpruvemem iss.ld within one yearofcompletion,the SQ.FT,FLOOR AREA ,VSQ,FT.
owner-builder will have the burden of moving that he did not build or improve for put. • " ,' ISTD
pose
❑1,es owner of the property,a selmively contracting with licensed nmtmnon m TAI.: .
construe the project(Ser.7044,Business and Professions Cad..The C...... 's Li- APR eta 9
se Luwdoes not apply tomowner ofpropcny who builds or improves thereon,end QTY, PLUMBING PERMIT FEE 9
who contracts for such projects with a conuanot(s)licensed pursuant to the Contract's s
License Law.
❑lemesunpt unOerStt. B&PCfor this ream.. PERMITISSUANCE' CI'II•II Isl- VUj-EH INU
,
Owner - Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION• BACK FLOW PROTECT.DEVICE Clinic)Ihereby affirm under Penalty of perjury one of the following declarations: f1
❑Thous anJ will meinralna Certificate of Conserv rase.(-inaum for Worker's ComDen- DRAINS-FLOOR,ROOF,AREA,C D STORIES TYPECONSTRUCTION
sution,as provided for by Section 37W of the Labor Code,for the performance of the
akfmwhichthispermltkissued. I FIXTURES-PER TRAP m
' ❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 ofthe Labor Code,forthe performance...the work for which this proof is issuel. GAS-CA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Wor ��ptye�R�16 In ce cortierend P ( n
urticr.��'s`r/WI No,r'1 Policy Nn:�/nI�Ttl��I ' CAS-EA.SYSTEM-OVER OEA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 41 V
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDIN,❑ I. N Fill..
(This section need not be completed Ram permit is furore hundr>ido0ars(SIM)
mitts.) GREASETRAP - PLANCHECK FEE stet,
I rieify that in the perfoinunce ofthe work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM CA.200 FT.
not employ any person in any manner sons 1.become subject to the Warkm'Compen- - ENERGY FEE
�.. sation Laws of California.Date
O - WATER HEATER WNENT/ELELTR
NOTICE
GRADING FEC
y NOTICE TO APPLICANT:r after making this Certificate of of Exemption.borad you should WATER SYSTEM/1'REATING '
1"! bocumesubject y the Workers Coons or this
provisions of the Lahr Cade,you must - SOILS NF.E
{W� forthwith comply with such previsions or thi,+permit shall 6e Jeered revoked. WATER SERVICE
Q
az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB' SQ.FT. PAID
U Iherebyaffinn thauhere iseconsaunion lending agency forthe perfommence of Dam eceiptp
(Y f" the work fur which this permit is issue)(Sec.3097,Civ.CJ
0U Lenders Farre _
TOTAL:
HJ lender's Address TOTAL:
ES., I certify that 1 have read this application end tram that the above information is BUILDING FE LA ,sississis
H correcr.I agree to comply with ell city and county ordinances end zmm laws relatingm QTY. MECHANICAL PERMIT FEE O
U ,z buildingcrnsauction•and hereby avthodre mpersenmtives.(arms city toenmrupon the SEISMIC FE
a19Ve-arrembned property fm in5pK4on Purposes.
(We)agree 1.save,indemnify and keep harmless the City of Cuperine against PERMIT ISSUANCE ELECTRIC1-E
liabilities,jingnmas,costs and expenses which may. way were against said City ALTER ORADDTOMECH.
in comequenJa he granting ofmis permit. / PLUMBIN
AP.PLICA>f U DERSTANDS'AN WILL CO LY WITH ALL NON-POINT AIR HANDLING UNIT TO 11.11) MECHANICAL FEF.'
SOUR y.'REG LATIONS.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION'TAX
Sigratu fApplicinVCmaracmr N RXIIAUST HOOD fWMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT G70 100,000 BTU)
as defined by the CLpenino Municipal Calk,Chapter 9.12,and the Health and Safety
Code,Section 2553260? - HEATING UNIT(OVER 100,000 BTU)
❑Yes El No VENTILATION PAN(SINGLE RFS ID) PAID
Will the applicant m future building occupant use equipment or devices which Date Receipt p
mil Ins:11us air conmrnments as defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR 100,000 BTU) .
District? TOTAL:
71 Yes ❑No BOILER-COMP(OVER 100000 BTU)
I have read the harandons materiud requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DAT
fornia Health&Safety Code.Sections 255115,2.5533 and 25534.1 understand that if tb° NEW RESIDENTIAL MECH. - SQ.FT.
building does not curently have a tenant,that it is my responsibility to notify the occupant
of the requirements which must be mer prior to issuance of u Certificate of Occupancy.
mer or amhmissd ager Dam TOTAL: ISSUE BY:
OFFICE