28295 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-ELEC I RICAL PE,RMD'NO.
PLUMBING-MECH .
BUILDING DIVISION APPLICATION/PERMIT BUILDING PNOTE(Pf 11 ?NTiFICAf1ON _ 28295
BUILDING ADDRESS ��!! SANITARY NO, APPLICATION SUBMITTAL DATE
�/e W UNIT 0 LOT H � �
OWNERS NAM PHHSONG C RA 'S NAME: LIC NOl� NIC CONTROLq
�ARCHIT'ECT GINNER: v L1 NO: A ESS
Gp ff�9
s' . is E3
C0NTACf: PHONE: BUILDING PERMIT INFO
QTY, ELECT .PERMIT FTiE
_ BLDG ELECT PLUMB MECH
y PERMIT ISSUANCE BLDG
F-1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIITFON
09Z Ihetehy affirm that l am licensed under pmvisionsof Chapter9(commenciagwith
!00 Sxtion7MO)ofl)ivision3of Ne Businessand Rofessions CMd,andm licemeisin PANELS
,,Wt— fullfnme and eifc
Fyco Licemu I.ic.M UI'TO 2M AMP5
m G y Date Comrunor 201-IMO AMPS
ZOyZ ARCNITECPS D: LAItATION -IOM AMPS SQ.Ff.FLOOR AREA $/SQ.Ff.
CZ—] I nndernanA my plans ahel l Fs used as public records.
F m E; SIGNS ELECTRICAL
Licensed Professional
E, 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC...1
a'C) 1 herchy affirm that 1 am exempt from Ne Contractor's License Law for the
3Oto following meson.(Section]031.5,Business and Professions Code:Any city or coumy TEMP.METER OR POLI?INST.
y; which inquires a a.it 1.consumer,altar;improve,dcnmlish,ar repvr any,uncture POWER DEVICES
C!!d Y7 priorto its issuance,alsoreyuites the applicant for such Permit file aligned statement
W <0 that he is licensed pummum to the provisions of the Contmator's License Law(Chapter
d 0� 9(commencing with Section]OM)of Division 3ofda H,cdrmsswd Prolbssima Cudm SWIMMING POOL ELECTRIC VALUATION
_rc, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTI.EI'S-SWITCI{ES-FIXTURGS
1_ Ta
Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
t more than five hundred dollars($500).
props y,ormyemployees with wogesastheirsolecnmpermetinn, NEW RESIDENTIALELECIR S .IT.
Wim ❑ ousvork.ands n Q S'1'0RII:S 'ITEC C0NSTRUCf1ON
n.3. will dalhEwons and theCWmlanot immmdWoroffered
snot sale
apply to an owner
and Profwhobu Cordbuilds.,
'Befbe Contractor License Law taros num apply to an owner of
pmpeny whabuilJsorimproves 0terean,end whodaessuchwmdF6rfifanbmpgb his... - OCC.GROUP RES.UNITS
employees,providcd that such imprnvemems nrgqtta inecnded 6rorfeitti for'3We.If, •
however,thebuildingarimprovemcm is soldori (0 b;4yarofcomplatmL ricinver- •'
builder will havelle burdenorproving that he not buildor prove for purTx^eof 1 TOTAL
sole.). I'1 pp QT'S', PLU HIND PEIiMI9' FEE FLOOD ZONE "N❑ I,usownerofthe propeny,am exclusively 9 vac ns wt vaemram:
construct due project(Sec.70,14,Business and•Profe ion ode:)*Hm Cmannampr's { PERMIT 1 CI
License Lawdaeanotapplytnanownerol proper whobuilds proveathemen,andlt Is .e
whocmttsforsuchprajenswithacon=tor(s�licensedpid%LU..othe Comrvetnr s VENT, A'fEk IRA) FEE SUMMARY
Limiroa Law, ) IR )
❑ I ern esempt under Sec. I B&P C w�this meso fS DEP:
T- 1 N
G PROTG , WICB�
SANITARY Y
0. = Dam RFCEIPI'N
DRAINS-FLOOft,ROOF,AItFA.COND.
1 WORKMAN COMPENSATE)%1mt. ATION _ ... SCHOOL TAX Y_N
❑ Ilmmbyruffinand,Nnsationinsmne or ificamofcopylho60ite,I.S n,aceniwhich FIXTURES-PER TRAP RF,CBIPI'Y
Worked Compensation Insurance nracenifiedcopy ihltltN(SlC780d;SCJ which PARK FEE V_N
covers all employee's under this permit. GAS-F.A.SYSTEM-1 INC.4 OUTLETS R 'I'#
Policy q ECEIIBUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 HAI PLANCUECK ITE
❑ Certified copy is hereby furnished.
❑ Cenified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTUCATH OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($IN) SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE
or less.)
I cenifythat in rhe prfomtance offle work for which this .it is issued,l shall WATER I{EATER W/VFNT/F,LECI'R
not employ any pe n may.mrh
anner o e Worker' PAID
Compensiili .i a — WAIERSYSTEMITREATING Date Receipt Is
O Z Applicant as s
0 NOTICE TO APPLICANT:IL after akingthis Cenifiesm of Emerp ma,youshoulJ )ENTIAL PLMB. SQ.FT. TOTAL:
Fy becumenubjact to the Worker's Compensation provisions of the Labor Code,you must
� ; forthwith comply with such provisions m Nis permit shat l be deemed revoked. BUILDING FEL?
w CONSTRUCTION LENDINGAGFNCY SEISMIC FEE
Z
CJ 1 hereby affirm that hem is a construction lending agency for the perfnmmnce of
the work for which this issued(Site3097,Civ.C.) TOTAL: ELECTRIC FHE
U O lenders Name Permit is issu
0 U Lender's Address Q9'Y. MECHANICALPERMIT FEE PLUMBING DIE
U 1 certify that I have mad this application and state that the above information is
correct.l agree to comply with all city and county ordinances and stain laws relating to PERM IT ISSUANCE MECHANICAL FEE
In ildingeonswaction,and hereby authorize repmsenmtives ofthis city toenlerupon the CONSTRUCTIONTAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agme m save,indemnify and kap harmless the City of Cupertino against
liabiblies.judgment,coses anicspenses which may in any way acemeagaimt said City AIR HANDLING UNIT G I0,000 CFM)
in consequence of the grunting of this permit.
AIR HANDLING UNIT(OVUR 10.010O CFM)
Signature of ApplicmUCommucror Dna EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE. HENTING UNIT(T0100,000 BTU) Data Receipt Is
Will the applicant nr future building oceupam arrear handle haamdo.,mammal
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HRATING UNIT(OVER 100,000 BTU)
Cade,Senior 25532(0)? J VENTILATION PAN(SINGLE RESIDE a
❑Yes No
/ BOILER-C0MP(3HP OR IN,"RTU) IS EDA
Will Nse
eapplicantorfutumbuildingoccuponr uequipment ordevi ,
ceswhichemir 0
hasuntous air contaminants as defined by the Bay Area Air Quality Management �� ?
r snct+ BOILER-COMP(OVER 100,000 BTI!) yG
❑Y. Na NEW RESIDENTIAL MUCH. SQ.FIL (vG�LL 1g9�
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 23505,25533 and 25534.1 understand Dun
if the building Anes nut commit,have u tenant,that it is my responsibility to notify the
occupant of rhrhf-�)9o' cuts which mus/t k met prior to issuance of o Ceniftcate of
Uccupancy/ g ae—& J
Oummmmahonmd ager 6� '�caim TOTAL: ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING-ELEC I RICAL PE,RMD'NO.
PLUMBING-MECH .
BUILDING DIVISION APPLICATION/PERMIT BUILDING PNOTE(Pf 11 ?NTiFICAf1ON _ 28295
BUILDING ADDRESS ��!! SANITARY NO, APPLICATION SUBMITTAL DATE
�/e W UNIT 0 LOT H � �
OWNERS NAM PHHSONG C RA 'S NAME: LIC NOl� NIC CONTROLq
�ARCHIT'ECT GINNER: v L1 NO: A ESS
Gp ff�9
s' . is E3
C0NTACf: PHONE: BUILDING PERMIT INFO
QTY, ELECT .PERMIT FTiE
_ BLDG ELECT PLUMB MECH
y PERMIT ISSUANCE BLDG
F-1 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. JOB DESCRIITFON
09Z Ihetehy affirm that l am licensed under pmvisionsof Chapter9(commenciagwith
!00 Sxtion7MO)ofl)ivision3of Ne Businessand Rofessions CMd,andm licemeisin PANELS
,,Wt— fullfnme and eifc
Fyco Licemu I.ic.M UI'TO 2M AMP5
m G y Date Comrunor 201-IMO AMPS
ZOyZ ARCNITECPS D: LAItATION -IOM AMPS SQ.Ff.FLOOR AREA $/SQ.Ff.
CZ—] I nndernanA my plans shell Fs used as public records.
F m E; SIGNS ELECTRICAL
Licensed Professional
E, 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC...1
a'C) 1 herchy affirm that 1 am exempt from Ne Contractor's License Law for the
3Oto following meson.(Section]031.5,Business and Professions Code:Any city or coumy TEMP.METER OR POLI?INST.
y; which inquires a a.it 1.consumer,altar;improve,dcnmlish,ar repvr any,uncture POWER DEVICES
C!!d Y7 priorto its issuance,alsoreyuites the applicant for such Permit file aligned statement
W <0 that he is licensed pummum to the provisions of the Contmator's License Law(Chapter
d 0� 9(commencing with Section]OM)of Division 3ofda H,cdrmsswd Prolbssima Cudm SWIMMING POOL ELECTRIC VALUATION
_rc, or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTI.EI'S-SWITCI{ES-FIXTURGS
1_ Ta
Section 7031.5 by any applicant for a permit subjects the applicantto a civil penalty of
t more than five hundred dollars($500).
props y,ormyemployees with wogesastheirsolecnmpermetinn, NEW RESIDENTIALELECIR S .IT.
Wim ❑ ousvork.ands n Q S'1'0RII:S 'ITEC C0NSTRUCf1ON
n.3. will dalhEwons and theCWmlanot immmdWoroffered
snot sale
apply to an owner
and Profwhobu Cordbuilds.,
'Befbe Contractor License Law taros num apply to an owner of
pmpeny whabuilJsorimproves 0terean,end whodaessuchwmdF6rfifanbmpgb his... - OCC.GROUP RES.UNITS
employees,providcd that such imprnvemems nrgqtta inecnded 6rorfeitti for'3We.If, •
however,thebuildingarimprovemcm is soldori (0 b;4yarofcomplatmL ricinver- •'
builder will havelle burdenorproving that he not buildor prove for purTx^eof 1 TOTAL
sole.). I'1 pp QT'S', PLU HIND PEIiMI9' FEE FLOOD ZONE "N❑ I,usownerofthe propeny,am exclusively 9 vac ns wt vaemram:
construct due project(Sec.70,14,Business and•Profe ion ode:)*Hm Cmannampr's { PERMIT 1 CI
License Lawdaeanotapplytnanownerol proper whobuilds proveathemen,andlt Is .e
whocmttsforsuchprajenswithacon=tor(s�licensedpid%LU..othe Comrvetnr s VENT, A'fEk IRA) FEE SUMMARY
Limiroa Law, ) IR )
❑ I ern esempt under Sec. I B&P C w�this meso fS DEP:
T- 1 N
G PROTG , WICB�
SANITARY Y
0. = Dam RFCEIPI'N
DRAINS-FLOOft,ROOF,AItFA.COND.
1 WORKMAN COMPENSATE)%1mt. ATION _ ... SCHOOL TAX Y_N
❑ Ilmmbyruffinand,Nnsationinsmne or ificamofcopylho60ite,I.S n,aceniwhich FIXTURES-PER TRAP RF,CBIPI'Y
Worked Compensation Insurance nracenifiedcopy ihltltN(SlC780d;SCJ which PARK FEE V_N
covers all employee's under this permit. GAS-F.A.SYSTEM-1 INC.4 OUTLETS R 'I'#
Policy q ECEIIBUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 HAI PLANCUECK ITE
❑ Certified copy is hereby furnished.
❑ Cenified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING ME
CERTUCATH OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars($IN) SEWER-SANITARY-STORM F.A.200FT. ENERGY FEE
or less.)
I cenifythat in rhe prfomtance offle work for which this .it is issued,l shall WATER I{EATER W/VFNT/F,LECI'R
not employ any pe n may.mrh
anner o e Worker' PAID
Compensiili .i a — WAIERSYSTEMITREATING Date Receipt Is
O Z Applicant as s
0 NOTICE TO APPLICANT:IL after akingthis Cenifiesm of Emerp ma,youshoulJ )ENTIAL PLMB. SQ.FT. TOTAL:
Fy becumenubjact to the Worker's Compensation provisions of the Labor Code,you must
� ; forthwith comply with such provisions m Nis permit shat l be deemed revoked. BUILDING FEL?
w CONSTRUCTION LENDINGAGFNCY SEISMIC FEE
Z
CJ 1 hereby affirm that hem is a construction lending agency for the perfnmmnce of
the work for which this issued(Site3097,Civ.C.) TOTAL: ELECTRIC FHE
U O lenders Name Permit is issu
0 U Lender's Address Q9'Y. MECHANICALPERMIT FEE PLUMBING DIE
U 1 certify that I have mad this application and state that the above information is
correct.l agree to comply with all city and county ordinances and stain laws relating to PERM IT ISSUANCE MECHANICAL FEE
In ildingeonswaction,and hereby authorize repmsenmtives ofthis city toenlerupon the CONSTRUCTIONTAX
V Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agme m save,indemnify and kap harmless the City of Cupertino against
liabiblies.judgment,coses anicspenses which may in any way acemeagaimt said City AIR HANDLING UNIT G I0,000 CFM)
in consequence of the grunting of this permit.
AIR HANDLING UNIT(OVUR 10.010O CFM)
Signature of ApplicmUCommucror Dna EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE. HENTING UNIT(T0100,000 BTU) Data Receipt Is
Will the applicant nr future building oceupam arrear handle haamdo.,mammal
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety HRATING UNIT(OVER 100,000 BTU)
Cade,Senior 25532(0)? J VENTILATION PAN(SINGLE RESIDE a
❑Yes No
/ BOILER-C0MP(3HP OR IN,"RTU) IS EDA
Will Nse
eapplicantorfutumbuildingoccuponr uequipment ordevi ,
ceswhichemir 0
hasuntous air contaminants as defined by the Bay Area Air Quality Management �� ?
r snct+ BOILER-COMP(OVER 100,000 BTI!) yG
❑Y. Na NEW RESIDENTIAL MUCH. SQ.FIL (vG�LL 1g9�
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 23505,25533 and 25534.1 understand Dun
if the building Anes nut commit,have u tenant,that it is my responsibility to notify the
occupant of rhrhf-�)9o' cuts which mus/t k met prior to issuance of o Ceniftcate of
Uccupancy/ g ae—& J
Oummmmahonmd ager 6� '�caim TOTAL: ISSUED BY:
OFFICE