S 0427APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY
CITY OP CUPFR PING BUILDING - ELECTRICAL
ISUII,DING BIVINION APPLICATION/PERMIT' rl.uaunrv0-htECxnNiCN.
BUILDING PROJECT' Il1EN'11FICATION
PI?RMIT NO.
BUILDING ADDRESS: r
SANITARY NO.
APPLICATION SUBMITTAL UK
2o33T STI-UZRA'�o JaU�
OWNER'S NAME: PHONE:
MR.I' MPS fl
\RCHITECI'/IiNGINEUH: LIC NO.
1 AV(D call �b
at
CONTRACTOR'S NAME: LIC NO..
ADDRESS:
N/c
❑
c`,TRDL«
7y—��
l/
CONTACT: PHONE:
BUILDING PERMIT INFO
BLDG ELLE ICI' PLUMB MUCH
N �1 K x
t Q 4 3346
k J f
4G _
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONI RACTOR:S DECLARATION
1 hereby affirm that 1 am licensed under provisions of chapter 9 (commencing
Section 7000) of Division 3ofthe easiness and Prokssinos Cade.ondmylecen.wis
in full force and effect.
Lmense Class_ Lich
pute Contractor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
DSFDWL (] KITCHEN RESIDUE
�Fg'ADDI'I'ION PLUMBING RE-PlPF
D MULTI-UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVI:MENf DSWIMMING POOLS
D BATH REMODEUREPAIR D DEMOLITION
C1 OTHER
OZZwho
W O O
CWF-
Q.UU
F-Z W
h Q d
Font
z 40
F4FW
C Y f',j
W Q
xy U
W 3 Wi
4-
F�OJ
PERMIT ISSUANCE
APPLIANCES -RESIDEN"1'I AL
ARCHITECTS DECLARATION
Iundemund my plans shall nc used as Public rcead.v
PANELS Ir N
UD)21MAMPS
Licensed Professional
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contrac of License Law far the
following mmor. (Section 713L5, Bushes, and Profe,dons Cade: Any city or canary
which requires a permit to carualter, improve, demnlsh, or repair any structure
ohm.
poor to its issuance. also requires the applicant for such Permit to file a signed statement
201400AMPS
OVER RMAMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
f y
lyajC M
d 6 c C
x-m
HZ Y
�Q
aim
that he is licensed pursuer to the provisions of the Commonr's License Law (Chapter 9
(commenving with Section ?g0)(it Division 3 ufthe Business and Pmfussams Cale)or
that he is exempt therefrnnl and the hurls for the alleged exemption. Any violmin i of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of
not mom than rise hundred dollars (55101
0Las
othewrk. the the sent', ormyemployees with wages ev tale(ee. compensation,
will drthewon% and the hestructureactor% intended Lawdosnet apply 9614,Business
Cale: The Ces themr's License Imo does not apply s if owner of
andpro who builds or improves thcrth who docs such work through
who
TEM R MITER OR POLE, I NS"f.
COMMERCIAL'
D NEW BLDG/ADDITION D DEMOLITION
DTCNANf El FOOD SERVICE
OTHER IMPROVEMENT
OTHER
MWI7R DEVICES
SWIMMING POOL hLECI"RIC
OI1TLIffS- SWITCHES _FI%TURES
Progeny
erty
m offend for
i p.. aged .0 a
arc not inmrol completion.
building tom such imp sold
M1ix awn however, the
however.11
nithat limprove ionone
did non
bur in
NEW RIiSIDF,NTIA1. ELECfR SQ FT.
��S/. Lf Ot^'NAREA
Q� �
S/50�1'I'.
of movinghe Wild or
owner-builder will nave the burden of proving that he did not build or improve for bur-
avron- have
• V
ve of led.
1 as ow r of the Propery, .,it exclti,wrly amtmaing with hero ad cmnirma s m
msaret the Project (Sec, 9(44, Bminess and Professions Cade:) The Contractors Li-
/4D
OCT 2
T' -
cenw Law does not apply to an owner of property who builds or improves thereon.and
QTY. PLUMBING PERMIT FEE
d17R�LTI'
who contracts for such projects with a rontractogs) licensed pursuant) the Contrach is
License Law.
lunderSc. 9& P C fort his reason
�� Ur t,uf'tHIDla
I'1'
PERMISSUANCEINC)
ALTER -DRAIN k VENT-WATER(EA)
Dam Q
VAI )AiUO...NNN/ ppb
WOR ER:SCOMPF.NSTI NDECLARATION
HACK FLOW PROTECT DEVICE
I handy ifiirnt uric, penalty of per a m flaw following deelardtione
v-
01have and will maintain aCertificate ofCorisen, toself-invum for Worker's Con,cm-
,mian. as Pr ided for by Seetion 3710 of the Ian, Calc, far the Performance of the
work for which this permit is issued. I
DRAINS-FLOOR. ROORAREA.COND.
STORIES
TYPE CONSTRUC'D
FIX'I'UR1iS-PER TRAP
D 1 have and will maintain Worker's Compersmlov Insurance, as required by Section
.1ILL /V
3900nfthe Labor Cade. fnrthe perlinmancenfthe work for which this mm,, issued.
GAS -EA. SYSTEM-] INC.4 OUTLETS
OCC. GROL'
MIN
My Worker's Compensation Insurance carrier end Policy number am:
Carrier: Poll, No:
GAS - EA. SYSTEM.OVER4(EA)
CERTIFICATE OF 1iXEM VI'ION FROM WORKERS'
COMPENSATION INSURANCE
IThisrutionnaJ not be admple,ediCthc pennitkhuone hundrtddollam (SIIN))
or less.) 1
GREASFIINDUSTRL WASTE INTERCEPTOR
I UI G DI\gS10N FEES
IF
PLANCHEC 9s'E O ��
GREASE TRAP
SEWER-SANI'T'ARY-STORM P.A. 200 IT.
l eenily thminthe p,if ..marcao the work mi-which this pa,oil I,-red.Isbull
not employ any paean in any manner m as to become subjesno the Workers' Compen-
IiNIikGYAJ I
WATER HEATER W/VENT/IiLUCTR
OZ
Z O
ti
vtion Lawsof California. Date
Applicant
GRATA ' �
NOTICE TO APPLICAN'1. If, after making this Certificate of Exemption, you should
become subject to the Wader's Cnmp'aszuon Provisions of the tabu, Code, '..'am
WATER SYSTEMTREATING
SOILS FEE
a ,
a
5Z
UQ
W F
O
fortnsvith comply with such previsions or this permit shall h deemed revoked
CONhat hem is aTONLENOINGACENCY.
Ifhereby whic this Permits ivaed(Soconstruction .30TI.lending agency for the performance of
the wad for which this permit is issued ISm 309]. Civ. CJ
fender. Name
WATER SERVICE
PAID
Ilam - p
NEW RESIDENTIAL PLh18. SQ. FI'.
'I'O'TAI-:
lender's Address
U
F`
UZ
BUILDING
SDISMICI
1 venify that I have mad this application and state that the above impartation is
correct. I agree to comply with all city and county ordinances and state laws relating uo
huildingcomorelion. road hereby authorize m,mw.odivcvof this On,a. eater uphe
QTY. MECHANICAL PERMIT FEE
PERMIT' ISSUANCE
ahovomemloned property for in Traction purposes.
(We) agree ud save, indemnify and keep harmless the City of Cupertino against
ELECfRI LEL
ALTERORADDTOMECU
PLUMBING FEI
IiaFililies,judgmenev.costs and expenses which may in anyway accrue against said City
msegacrcc of the gmalmg of thi.a pemaL
AIR HANDLING UNIT(TO I10.000CFM)
d C4IANICAI.
APPLICAN'P UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,01)) CFM)
CONSTRUGI'IUN X
Signvturcof APpEcmUCommem, Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATI NFEE
HEATING UNIT(TO 100,001 BTU)
Will theaPPlicatnorfnvre Wildingoc..... tsmreorhandle loomdouv manual
as defined by the Capetiinn Municipal Cade. Chapter 9.12, and the Health and Safely
Code, Section 25532m)?
HEATING UNIT (OVER 100,0k) BTU)
El Y., DN.
Will the applicant or future building I use a ui t or devices which
1 paten
pr gby the
t s, hamNoux air conmminnn,s as Joined by We liay Area Air Quality Managcmm�t
Ois,nct?
Dyes E) No
PAID
Date R«
VENTILATION FAN (SINGLE RFSIU)
BOILER-COMPLPIPOR 100.0(110B U)
'I OI'AU
BOILER - COMP IOVER III(I,(NIO BTU)
AIR CONDITION]?K
I have read the hmuNays materials nubemems under Chatter b, 95 of the Cur-
V p
ISSUANCE DATE
NEW RIi.SIIIF:NTIAI.MF.CH. SQ. FT.
and if the
TendoHealth &gdoesn Safety Qde.ea annual.
25533ea125534.1uMctify the m
building docs ratify the
currently haves tenant. that o is my responsibility Cediy
a
of the rcyuimmenu which mum he tom Prior to i.vnunnce of a Cenificute of (kcupancy.
a pone,
ISSUED BY: _
Owner or authonzcd agent Dam
TO 'AL: ,
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY
CITY OP CUPFR PING BUILDING - ELECTRICAL
ISUII,DING BIVINION APPLICATION/PERMIT' rl.uaunrv0-htECxnNiCN.
BUILDING PROJECT' Il1EN'11FICATION
PI?RMIT NO.
BUILDING ADDRESS: r
SANITARY NO.
APPLICATION SUBMITTAL UK
2o33T STI-UZRA'�o JaU�
OWNER'S NAME: PHONE:
MR.I' MPS fl
\RCHITECI'/IiNGINEUH: LIC NO.
1 AV(D call �b
at
CONTRACTOR'S NAME: LIC NO..
ADDRESS:
N/c
❑
c`,TRDL«
7y—��
l/
CONTACT: PHONE:
BUILDING PERMIT INFO
BLDG ELLE ICI' PLUMB MUCH
N �1 K x
t Q 4 3346
k J f
4G _
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONI RACTOR:S DECLARATION
1 hereby affirm that 1 am licensed under provisions of chapter 9 (commencing
Section 7000) of Division 3ofthe easiness and Prokssinos Cade.ondmylecen.wis
in full force and effect.
Lmense Class_ Lich
pute Contractor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
DSFDWL (] KITCHEN RESIDUE
�Fg'ADDI'I'ION PLUMBING RE-PlPF
D MULTI-UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVI:MENf DSWIMMING POOLS
D BATH REMODEUREPAIR D DEMOLITION
C1 OTHER
OZZwho
W O O
CWF-
Q.UU
F-Z W
h Q d
Font
z 40
F4FW
C Y f',j
W Q
xy U
W 3 Wi
4-
F�OJ
PERMIT ISSUANCE
APPLIANCES -RESIDEN"1'I AL
ARCHITECTS DECLARATION
Iundemund my plans shall nc used as Public rcead.v
PANELS Ir N
UD)21MAMPS
Licensed Professional
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contrac of License Law far the
following mmor. (Section 713L5, Bushes, and Profe,dons Cade: Any city or canary
which requires a permit to carualter, improve, demnlsh, or repair any structure
ohm.
poor to its issuance. also requires the applicant for such Permit to file a signed statement
201400AMPS
OVER RMAMPS
SIGNS ELECTRICAL.
SPECIAL CIRCUIT/MISC.
f y
lyajC M
d 6 c C
x-m
HZ Y
�Q
aim
that he is licensed pursuer to the provisions of the Commonr's License Law (Chapter 9
(commenving with Section ?g0)(it Division 3 ufthe Business and Pmfussams Cale)or
that he is exempt therefrnnl and the hurls for the alleged exemption. Any violmin i of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of
not mom than rise hundred dollars (55101
0Las
othewrk. the the sent', ormyemployees with wages ev tale(ee. compensation,
will drthewon% and the hestructureactor% intended Lawdosnet apply 9614,Business
Cale: The Ces themr's License Imo does not apply s if owner of
andpro who builds or improves thcrth who docs such work through
who
TEM R MITER OR POLE, I NS"f.
COMMERCIAL'
D NEW BLDG/ADDITION D DEMOLITION
DTCNANf El FOOD SERVICE
OTHER IMPROVEMENT
OTHER
MWI7R DEVICES
SWIMMING POOL hLECI"RIC
OI1TLIffS- SWITCHES _FI%TURES
Progeny
erty
m offend for
i p.. aged .0 a
arc not inmrol completion.
building tom such imp sold
M1ix awn however, the
however.11
nithat limprove ionone
did non
bur in
NEW RIiSIDF,NTIA1. ELECfR SQ FT.
��S/. Lf Ot^'NAREA
Q� �
S/50�1'I'.
of movinghe Wild or
owner-builder will nave the burden of proving that he did not build or improve for bur-
avron- have
• V
ve of led.
1 as ow r of the Propery, .,it exclti,wrly amtmaing with hero ad cmnirma s m
msaret the Project (Sec, 9(44, Bminess and Professions Cade:) The Contractors Li-
/4D
OCT 2
T' -
cenw Law does not apply to an owner of property who builds or improves thereon.and
QTY. PLUMBING PERMIT FEE
d17R�LTI'
who contracts for such projects with a rontractogs) licensed pursuant) the Contrach is
License Law.
lunderSc. 9& P C fort his reason
�� Ur t,uf'tHIDla
I'1'
PERMISSUANCEINC)
ALTER -DRAIN k VENT-WATER(EA)
Dam Q
VAI )AiUO...NNN/ ppb
WOR ER:SCOMPF.NSTI NDECLARATION
HACK FLOW PROTECT DEVICE
I handy ifiirnt uric, penalty of per a m flaw following deelardtione
v-
01have and will maintain aCertificate ofCorisen, toself-invum for Worker's Con,cm-
,mian. as Pr ided for by Seetion 3710 of the Ian, Calc, far the Performance of the
work for which this permit is issued. I
DRAINS-FLOOR. ROORAREA.COND.
STORIES
TYPE CONSTRUC'D
FIX'I'UR1iS-PER TRAP
D 1 have and will maintain Worker's Compersmlov Insurance, as required by Section
.1ILL /V
3900nfthe Labor Cade. fnrthe perlinmancenfthe work for which this mm,, issued.
GAS -EA. SYSTEM-] INC.4 OUTLETS
OCC. GROL'
MIN
My Worker's Compensation Insurance carrier end Policy number am:
Carrier: Poll, No:
GAS - EA. SYSTEM.OVER4(EA)
CERTIFICATE OF 1iXEM VI'ION FROM WORKERS'
COMPENSATION INSURANCE
IThisrutionnaJ not be admple,ediCthc pennitkhuone hundrtddollam (SIIN))
or less.) 1
GREASFIINDUSTRL WASTE INTERCEPTOR
I UI G DI\gS10N FEES
IF
PLANCHEC 9s'E O ��
GREASE TRAP
SEWER-SANI'T'ARY-STORM P.A. 200 IT.
l eenily thminthe p,if ..marcao the work mi-which this pa,oil I,-red.Isbull
not employ any paean in any manner m as to become subjesno the Workers' Compen-
IiNIikGYAJ I
WATER HEATER W/VENT/IiLUCTR
OZ
Z O
ti
vtion Lawsof California. Date
Applicant
GRATA ' �
NOTICE TO APPLICAN'1. If, after making this Certificate of Exemption, you should
become subject to the Wader's Cnmp'aszuon Provisions of the tabu, Code, '..'am
WATER SYSTEMTREATING
SOILS FEE
a ,
a
5Z
UQ
W F
O
fortnsvith comply with such previsions or this permit shall h deemed revoked
CONhat hem is aTONLENOINGACENCY.
Ifhereby whic this Permits ivaed(Soconstruction .30TI.lending agency for the performance of
the wad for which this permit is issued ISm 309]. Civ. CJ
fender. Name
WATER SERVICE
PAID
Ilam - p
NEW RESIDENTIAL PLh18. SQ. FI'.
'I'O'TAI-:
lender's Address
U
F`
UZ
BUILDING
SDISMICI
1 venify that I have mad this application and state that the above impartation is
correct. I agree to comply with all city and county ordinances and state laws relating uo
huildingcomorelion. road hereby authorize m,mw.odivcvof this On,a. eater uphe
QTY. MECHANICAL PERMIT FEE
PERMIT' ISSUANCE
ahovomemloned property for in Traction purposes.
(We) agree ud save, indemnify and keep harmless the City of Cupertino against
ELECfRI LEL
ALTERORADDTOMECU
PLUMBING FEI
IiaFililies,judgmenev.costs and expenses which may in anyway accrue against said City
msegacrcc of the gmalmg of thi.a pemaL
AIR HANDLING UNIT(TO I10.000CFM)
d C4IANICAI.
APPLICAN'P UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,01)) CFM)
CONSTRUGI'IUN X
Signvturcof APpEcmUCommem, Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATI NFEE
HEATING UNIT(TO 100,001 BTU)
Will theaPPlicatnorfnvre Wildingoc..... tsmreorhandle loomdouv manual
as defined by the Capetiinn Municipal Cade. Chapter 9.12, and the Health and Safely
Code, Section 25532m)?
HEATING UNIT (OVER 100,0k) BTU)
El Y., DN.
Will the applicant or future building I use a ui t or devices which
1 paten
pr gby the
t s, hamNoux air conmminnn,s as Joined by We liay Area Air Quality Managcmm�t
Ois,nct?
Dyes E) No
PAID
Date R«
VENTILATION FAN (SINGLE RFSIU)
BOILER-COMPLPIPOR 100.0(110B U)
'I OI'AU
BOILER - COMP IOVER III(I,(NIO BTU)
AIR CONDITION]?K
I have read the hmuNays materials nubemems under Chatter b, 95 of the Cur-
V p
ISSUANCE DATE
NEW RIi.SIIIF:NTIAI.MF.CH. SQ. FT.
and if the
TendoHealth &gdoesn Safety Qde.ea annual.
25533ea125534.1uMctify the m
building docs ratify the
currently haves tenant. that o is my responsibility Cediy
a
of the rcyuimmenu which mum he tom Prior to i.vnunnce of a Cenificute of (kcupancy.
a pone,
ISSUED BY: _
Owner or authonzcd agent Dam
TO 'AL: ,
OFFICE