S 2424 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPIiRTINO BB
U .DING"LLEC'I'FUCAL PERMIT'No.
BUILDING DIVISION APPLICATION/PERMIT rEsG PROJECT ICHANIITIC S 2424
ItUILI)ING 1'RO.IRI;'1'IDI?N'r119CA'1'IQN
HUIyLDING/AU,D�R L_SS: SANITARY NU. AI'PLICAI'IIIN SUBMI'1'1'AL UATIi
PHONE: " ACTOR'S NA Lr- I,IC N
1 k-4 aZ1l!}k_' `���'J ICS• Z� ' rv/c coNTxQl.x
I�ARCHI TEC']'/];N(iINI;FR: LIC NO: nD)RLSS EJdib , 8�. ,,.4-,>7.A- (
CONTACT; PHONE BUILDING PERMIT INFO
ft7[
,] �// /7/ ❑ Consultant Fces Paid by Applicant(Initial) BLDG EI.ECr PLUMII MECH
I/ ❑ ID ❑ Ev
I.]CENS]!DCONTRACIOR'SDECLARAI'a)N IQTY ELECTRIC PERMIT FEE
I herchy ter ol thin I:Int hcerseJ under provkinaa of chapter 9(commrnbug JOB DESCRIP'T'ION
Ze sine..and Pond..{.,CnJe,andmylicemck RESIDENTIAL:
Z tn5ectinn]txxgnrUrvision3nf me Bu _
UOO with p��P;�n I'IiRMI'1'ISSUANCIi
�UF �eZ9a.s �V�.3Ej �� 6�_7 _ ❑SFDWI. ❑KITCIII:N RI;MOUEI.
aUU Ltmnx 1 I"m.N Ilyo 6t_ / APPLIANCES-xLSIUIiNI'IAL ❑AUDITION El PLUMBING RIi-PIPE
h Q w Dam Cnma� -
ARCHHECl"S DECLARATION ❑MCI
I'ANIiLS ULTI-UNIT ❑5'rRU 'URAL
ZONh
Z Inalusld my own—h.11 be used..puliemimad. MOUII KATION
OZ4- UPT0203AMPS ❑ ❑
INTERIOR CHIMNEY REPAIR
14E:
I=y. W Licensed Prufcsxionul 201-IIXMIAMPS IMPROVCMEN'I' SWIMMING POOLS
y s1E� OWNER WILDER UCCLARA'I'[ON OVER I(R)OANIPS ❑BATH RENODELIREPAIR C1 DEMOLITION
C C 6 I Imrchy.triter Ihm I am exempt front the Cantmcutrs License Law for the
X O i U G9lnwing reenn.(Section 7117 L5.Business and I'mfussiuns Gnic;any city nr umntY SIGNS E..CfRH A1" ❑OTHIiR
m 3 a y¢ which rcquirc.:l perm)m enmmad,deer.improve.demolish,nr repair any amcmm
1_"�OJ priori I I: y d 'PI l' tf 1p 'n II 'b LTwnent SI'LCIAI.CI RCjU IM SC. of
`"yam than licensed p tt ther : nn C I I s 1,, (Chapter9 COMMERCIAL:
3dC' (cnnneutgwill,SWon7000) 1Ovs'u3olthuBmua.tull I '.' :Cnd)nr JENEMCI'IiRORPULPINS'r.
q o y thin he is exempt therefrom mJ Inc basis for the alleged eacmption.Any violation of ❑NEW HLUG/ADD 11 ION ❑DEMOLITION
if w Section9n]L5hyanyuppllcum l'orulnanil snM1)mta the appllc:muu ucivll pcnuhynf NAVER DEVICES �,' Q\NI' ❑FOODSERVICE
y y nm more Than five hunJrW dollars(SSIp).
ESQ 1.wowncrO Inc n SWIMMING POOL ELECTRIC IMPNOVIiMiiN'I'
❑ pntpe Y,Isinyn intended
with sed Ela thc(Ser.cnntpuomies, )T r
t. will Jo the work.and the dracwmis urn mmnJcd nr nffcrcJfor wle(Ser.]144.Business
IW se and 1'rofcssin ,Cock:I'he Cunnnmor's I"icanne Luw Auus not dP111 uI un owner of OUTLET'S-SWITCHCS-FI%TURFS
L prnpcny wno builds m impmvc Inercb and won dries wcM1 work himaelrur through
In,own ,a,lTyccs,ProvldcJ that such impnwcrmms arc nm in¢nAW nr ,nfrcmd for NEW RESIIIENTIAL IILLCIR SQ 1"I'.
sale.IL Juristic,the bui]dingnrimprovcmenl i.asold within one year ol'dnnpininn,Inc SQ,En R!M ARE
nerhuildcr will huvc it,,hurdrn of proving th l he did not build or improve liu par
ptee of su]e.), TUFAL:
❑ I,as Owocr orthc P openy,:rte collusively contracting with licensed contractors us
ins ron the project(Sec.7144,Bdsinew and PrOlcssions COIIC:)'ror Gmuad........
h
ac Luw docs not apply hr an owncrof prnpcnywhn hui]dsor improves thcmon.nd Q'IY. PI"UMBING PERMIT FEE
won nmwds for such Prmjwrs wile n nmtmdnr(s)I Iccnscd Pursuum on the C'amntnnd
Liccnsu Law. PERSd r ISSUANCE
I an,otentpt under See .B&PCI this Taaant
ALIT:R-DRAIN k VIiNT-N'A'rER BdA) VALUAI ION
Owner Date
WORKER'SCOMPENSATION DECI.ARAIION DACKRAT FLOW POR.RO DEVICE
I hereby ntirm u.def Irenulty of p+Jury Ism of the 101ho-all dcchuaunns
�Ihavc.nJ will mamtuinaCMiOcmeof Consent to self-insurt for N'orAch Qnnpcn- DRAINS-I1.00R.ROOF,AREA.CONU' SIOREi,S 'IYI'Ii CONS'I'RUC'DON
swoon,as provided for by Section 3700 nfthe L nhor COJa I'orthe per(mrniamo of thu
k for which this permit is issued. FI%'TI1RE5-Ylilt TRAP
I huvc unit will inuinlain WurDr,'a Cmrtpensatiun Insumnle,ns required by Sell
war
l Labor Corb.in the No"ImdnceaT mk forwhich this Permit I'lard. GAS-EA.SYS'I I'm.I INC.4 OU'IUIS < 'OUP
AI'N
pal the �k�(1���1
My wm��x�svtl tilt lnsygltt'e curzic olicY t`n.nu uGa"�f._�Q tlJi GAS-EA.SYSTEM-OVFR4(IIA)
M,W... tb rlV� R V e C
CEIt'TI ICATi O1'IiXHMYTON FROM WORKERSGRCASEIINDUS'IRL WAS'HI INI'ERCHI I
CONIPENSATI(IN INSURANCE UILDING DIVISION FEES
1'l his dztinnuccd not be cno..lard if lhepernh in I....mot dmvl Jullans($100) GRIIASii IRAP
1'LANCIIE 'I i
or less.)
ccnity thein the pert rourreeoftheworkforwhicnt .,he tit isi ,Cd.orn,cn1 SENrER_SnNI'IARY-STORM BA.41X0
not employ'.ny person in any manner su ns m Masme wbJem m the N'orkecC Compan IiN1iR(:Y Ffili
Z conn Law'xul Culilurnia.]):ue WATER HEATER W/VENT/ELECfR B
y
NOT WE 10 APPLICANT:IL u(ter making this Cenilicme of Esonprion,you should WATER SYSTEM/TREATING SOILS ME
1•' bcdmm sahject m the Workers Compensation Provisions al the I.1, Coale,you ntusl
I'onhwith mmPly with such provisions or permit enol no deenmJ ruvaked WAI'P SIT VICE
PAID
CONS IRUCI'ION LENDING AGENCY NEW RESIUF.NTIAL I'LMB. SU t1'' Dam R t p
UO kturwhich i,curit issced(Stl.anlcnd Ott
agr'^cYforlac performanceof
W the wmk hu which Ibis pemtil n issued(Sw.709],Civ.C) T)TAI_
C
U Ic nder's Name T(YI'AL:
I,cndcr'I Aald y, BUILDING FI!E
6. 1 ca,om Wm I have rtmd This y and nimn unit dale thm the uhnve w,,mina,is
corrc<Ll:gmctocomply with ullciryand county mdinunccs and stele laxs rclaing to QTY. MECHANICAL 14iRA11T IIiE SEISMIC FEE
U Z nsingcnnswdJherehymdmrirs rcprcFcnmtivcx of lhi�city lm soler upon the
nna"entemlonnl pm,my for inspection Pugvrses. PERMIT'ISSUANCE IiLECI RIC 181i
Wet agree In nave.normally and Accp harmless the City of Cupertino against
Ilahiblics,jmlgmoul.cngsod.t ri which,cry in oY xoy local again.said City ALTER OR ADD TO MECII. I'IAMDING PEIi
nsaqucnec mf the granting of this permit.
APPLICANT*UNDERS'LANDS AND is COMPLY WI'I'II ALI.NON-POINT AIR HANDLING UNII'(To 10.000CFM) MCCIIANICAL Fl !J'
SUIIRCE :GULATIONS. (�
/ � AIR IIANULING UNI'P(OVER III,IMNI CFM) C(INSI'RUC'1'ION'I'A'
/Signuunc n(APPlicdnt/Cnmmcror Dn1c EXI DOES HOOD(w/DUCI) I IOUS I Nat M if IGAI ION FBI:
HAZARDOUSAI'ER1ALSDISCLOSURIi
Will the upplicum orlmurc Fuilding lrccupuml.aorenr handle hmannus material HI:ATINGUNI'I'rTOI1N1.(N)h0'I'U)
us d ,neo by the Cupcninn Municipal CoNIc,Chapter 9.12,anA the I IcaIIM1 iter Safety HEATING UNIT EVER 11NLBOn RT11)
CdlOSeoul,.255J2(a)'!
❑Yes Nn VIr"NTILA'f[ON IAN IS I WHAT RESID) PAID Dab Nc<ciplp
• c de
Will Inc applicant m'Ruure building umup:mt me dluipnant or devices which IR)II"ER-COME(31111 OR I(XIl")In GO
mil boardnus air contaminants as fined by the Bay Arca Air Quality Management
IJ:sui JI BOILER-COME(OVER 10000)BTU)
❑Ye
I base read Ne lrmaNn uriak nquiremcr0 artier Chapter 6.95 of the Cull- At It CON DI'I'IONIIR ISSUANCE DATE
forma Ikulth k S; Clalo Iio 5505,25577 and 25534.1 underdund that it the NEW RESIDEN1'I AL MECII, SQ.Flt
huilJin J t trendmy re
I Linto it is spm.sibilay to amity the ocauparl
Troia reqs' �wmen :� n teAPdnfar irsmm'eol�nmc.y If ted -
.!� JLGei �C.C719
��
Owner or umhuriadl ngem
Dam T .I. L' ISSUL'D IiY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOtl ILIIING-ELECI'N[CAL, PHRMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BUILDING PROJECT IDEN'rIF'ICA'I'IIIN 24452
BUILDING ADDRESS: SANITARYNO. APPLICATION SSUBMHIAL DA 11
'Z_�&aJ-7till W"00UNIT#:2!�—/yO
LOT#
OW ? . NAME Ji CONTRACI'OR:S NA L: IC NO: • l
[6+ /RJy�SG/' /� NO: ��/� NIC ^I CONI ROL#
ARCIIITI:CIYf:NGINEER: LIC NO: AW*, � RVE-Z ,04 `(-,9 • ,
CON'I'ACr: PHONE: 4! /7 BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECI(
PERMIT ISSUANCE
LICENSED CON'RACfOR'S DECLARATION APPLIANCES-RISIDENTIAL
JOB DESCRIPTION
Oy,7 Ihereby affnm.hw[am licc Bsivnu,and i,ion,nf Chapmr9(commencingene,in
¢100❑ Scction)III(q of DivisinnJnfthe Buvinessund Prol'csvum,CWc, Amylccaw isin PANCLS
WU(3 full force and effect.&—lJi1 'V
LQ.,Zrn License lass _/'W Lic.p 201-("0 20D AMPS
y,z Dale Comrac.or 201-IOW AMPS SQ.FT.FLOOR AREA $`SQ.IT.
F,�Z �� '✓� r/—�ARCHITECI'S DECLARA'TI /�G�llh OVER 10N)AMPS
OX-0 IunJcrstunA my plans,holl he axed us publio reunAs. rr(,��
07.—�
vs F•61 SIGNS I:I.fCTRICAy,
QYE[4j LiccnxJ Professional
C �Q
OWNER-BUILDERpfrom DECLARATION SPECIAL CIRCUIT/MIS .
KOa F 1 hereby affirm that 1 am exempt from.he Contractor's Co License law for the
6134.n which
following a(Sectionto coni S.Bu she,, and Professions h.m w a,<ity dru unty TEMP.METER OR POLE(NST.
which rcyuiresapemtit mcmmmct.aper,improve,Demolish.nr rcpmr nny nntmurc
K Qthat he is licensed pursuant to the povieiom of t
� prior to ik aiu
issuance.also termites the applicant for such ,rout File a signed statemm
cPOWER DEVICES
K he Cmdracm''s License Law(Chapter
W
,Eo
9(comencncingwith Section 7")Ud Division 3 of Ne Business and Professions Cede) SWIMMING POOL ELECTRIC VALUATION
WM,o or that he is exempt hcrtfrom and the Basis for the alleged exemption.Any violation of
FZ� Semon 91131.5 by any applicanlfor ayem.it sabjccts.hc spplicantao it civil pcnnpyof OUILEI'S-SWITCI IES-FIXTURES
C� not more than five hundred dol lars($5W).O NEW RIiSIDENT1ALl1.[CTR _SQ.FI'. ^O TYPBCONSTRIICI'ION
m-2o ❑ Lnwwneroo propcny.ormat inunyeeswithwed Bars@eSse,7044,8 se..
a3— will do the Cash: structure Cminnnmin¢ndnse,La c does .,apply to
aware
and Pmfe,xions Cash:TTe Commnm's License Law Juea not apply k an owner of
property wholocildsorimproveathereon,and whodoes such work himselfor.hroughhis
rain employees,providedlhmaucb improvements area ninten.dcdorofl'cred hnsale.If, )C ROUP RES.UNITS
however.lhe building or improvement is sold within one yearofcompletion,0c owner- TOTAL:
builder will have the burden of provingthat he did not build or improve for purpose of
sale.). Q'f Y. PLUMHINGPERMIT PEE FLOOD)ZONE APN
❑ I.m ownerefthe property,am exclusively contracting with licensed cannot....to
instruct.he project(Sec.1044.BaMnevs and Professions Code:)The Contractor's
License Lawdaes not apply to an owncrofprnprty whnbuildsorimproves thereon,and PERMIT ISSUANCE -tI'a
whocanttacts forsuch projects with a contracmKs)licensed pursuanttothe Comeacmr's
License Low. ALTER-DRAIN&VENT-WATER(LAI ITE SUMMARY
❑ I um exempt unAcr Sec. .B&P C for this rtason BACK FLOW PROTECT.DEVICE SIDE FF:LS
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. �A RECEIPT#
A WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
4rl�❑ Ihereby officer that l have a certificate ofeonsenl mself-mance,ora certificate of FIXTURES-PER TRAP RECEIP #
Workers'Compensation Insurance or acenified copy thmeof(Sec.3800,Lab C.)which PARK FLEE Y N
covers Il employee's under this permit /1'/I�./���., GAS-EA.SYSTEM-I INC.4 OUTLISI'S RDIVISTp
PolicyfiW �/��j BUILDING DIVISION FEES
Camp: ) GAS.CA.SYST'EM.OVER 4(EA) PLANCI IECK LLE
❑ .coifed copy is hereby famished.
422duod copy is fled with the city inspection division. GRIEASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF 17XEMMON FROM WORKERS' GREASE TRAP SOILS FETE
COMPENSATION INSURANCE.
(This section ncednm M completed ifflcpeiona is forone hundred do11ars($100) SEWER-SANITARY-STORM FA.20l (ENERGY FEE
or less.)
I ramify that in the performance of the work for whichthis permit is issued,l shall WATER HEATER W/VENT/ELECGR 1V_02— "2
not employ any Person in any manner. as to became subject to the Workers' PAID 1�]L .J
Con.pcm;ainn Lawx of Cal'Domm.
Date so WATERSYSTEM/IRIAI'ING Date Receipt#
O Z Applicant
ZO NOTICE TO APPLICANT1':If.after narking Ibis Certificate of Exemption,you should NEW RIS(DENTAL PLMIL SQ,FT, TOTAL:
t•' y become subject 0 Ne Workers Compensation provisions of the labor Cede,you must
> forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
WQ CONSTRUCT ION LENDING AGENCY SEISMIC PLEB
Z I hereby affimn that them is a cnm.meDon lending agency for the performance of
+l— ELECTRIC FEE
U O .he work for which this penil is issued(Sec.301 Civ.C.)
m
Lender's No. PLUMBING FEE
Under'a Address QTY. MECI IANICAL PERMIT FEE
U I rectify that 1 have reid this appllculam sand serer Ibm the atone information IsMECI IANICAL FEE
�-' cormm
s.l agree to comply with all city and county ordimces and state laws m relatingPERMIT'ISSUANCE �
h" building cnnswaion,and hereby aotborim representatives of this city to enter upon the CONSTRUCTION TAX
V z above-mentioned property for inspection pmpous. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
himilitics.juI meats,costs and expenses which may in any way accrue against said City AIRIIANDLINGUNI'r(TO I0,0WCPM)
flM1egmntingo'IM1' t
in w ee e n LJY�/ / � I_ � AIR HANDLING UNI'P[OVER IO,INN)CFM) l
Sign t mof ApplicanUComractor 1///O'/(1///•1911 Date EXIIAUSTHOOD(W/DUCT) PAID �"Q�.`v �(�+
IAZARDOUSMA'ILRIALS DISCLOSURE IICAT[NO UNIT(To 100!001 BTU) Date ecept#
Will the applicum nr l umreh ilJing occupanLaorc nr handle hnsorJnm mamriul ��
re defncA by the Cupertino Mu pal Cole.Chirom 9.12,and ma lkaBh ima Safety HEAPING UNIT(OVER I W,WO B'I'U)
Conk,Section 255321a)1 VENTILATION FAN(SINGLE REMD)
❑Yes Nn
BOII.IER-COMP(3HP OR I W,1NN1 BTU) ISSUANCE DATE
Will lhenpplicvm nrlbmrch Jingrccupam useeyuipmem or Devices which emit
hasamous air contaminants as efinN by the Bay Area Air Quality M....moral BOILER-COMP(OVER 1003110111'U) NOV
����
❑Ycs No NEW NISIDF.NTIA1,MECH. SQ.FT. 2 3
1 base read the Ise atdaa,materials"'mrememx ander Chapter 6.95 of the n, CI I T VI" l#UYCn I HrV
Callfomia health&Safely Code,Scminns 25505.25533 it 25534. 1 undentand that
cremsouildingd otcum udan',ave ate .that it is myrespare Ility tomanyDoe
I It bm oft quiremerys which met pir m izmnae of a Ceoiany e
Occupin J
Owner nr.ulM1oriscsl agent ISSUED BY:
OFFICE