25080 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDENU-ELECTRICAL PERMITNO.
BUILDING DIVISION f�
APPLICATION/PERMIT PLUMBING MECHANICAL 2 508 O
BUILDING PRO]F,CI'IDENTIFICATION
BUILDING ADDRESS: (/////��, �n /��Jy SANITARY NO. APPLICATIONSUBMHTALDATE
I q I i'/ y ,41,, �" t. i7° AV UNIT# LOT in 5�
7
OWNER ME: PHONE: CONT'RACTOR'S NAME: LIC NO:
Gr,� II{'/_lf0�I'r S o T 7,'� /��� Il' I NIC CONHRR-OCL N'//
.ARC I 'ENC__ IfliA I/"F-/1'LLIC NO��/ -7S A n Ci CX+�T/e1'T f/VD ✓ �� ❑ 7 2U f
Co PHONE: BUILDING PERMIT INFO
{/���yJ�- /y/�� //�2� //�yf QTY. ELECTRIC PERMI FEE
I I-'• '> "'� ' �� /�✓ I— / PERMIT ISSUANCE �� BI-DG CE P.UMB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESID AL
Qyz Iherel affnm Nat l amlicened underprovisions of Chap¢r9(commencing with OB�DESCRIITION
WOO NilSection]OW)ofeet. on30f the Business Pndessiom Crde,nnJmylicenx i.in PANELS
FF full force and cffed. t
U2M ' IM
QZ� License Class Lis.#
m<or Date Cmttmctar 201 5
f z ARC]IITECI'S DECLARATION SQ.FT.FLOOR AREA $/SQ.FT.
OZ—
'l.Om❑— l understand my plans shallM used a public records. OVIi W MPS
FmE;
ION S 1 ECTIi1CAL
x
Q LiccnJ PnNcsional
Kca. OWNER-BUILOERD the ComTION SPECIAL CIR T IC.
OaO I hereby affirm Nm I nm exempt from the Conuamors License La for the
W3ay following reason.(Section 7031.5,Business and Professions Cash:Any city nr<ounty F.MP.M LE IN
1—�O which requires a permit td ennsvem,nheq improve,demolish,or repair any structure
�`vv�]ono prior to issuance,also requires the applicant for such pemtiuofileasigneJ statement POWERDE CE
<C that that he is licensed pursuant to the provisions ofthe Comracmis License Law(Chapter
dXOC 9(commencing with Section Division 3 ofthe Business and Professions Code) SWIMMING POOLE CfRIC VALUATION
W onhat he is cxcm lNertfmm and the basis forme aIle ed exem i An ....... of
W—m p 8 Aran. yvioa LETS-SWI RFS-FIXTURES ��/' O 00
FZ� Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty o[ t v
aG not more than five hundred dollars(1510).
t ❑ Lasownerof thepmParly,mayemp]oyeeswith wages aatheirsolecompeneutioa, NEW RESIDENTIAL ELECTR SQ.FT. STORIES 1'YPIiCONSTRUCTION
a3=e will do the work,and the structure isnot intendMorafPortd forsale(Sec.]044,Business
and Professions Cade:The Contractor's License Low does not apply to an owner of
property whohmld,,auapnwe,theraan,and wtraders such work hitne]for through his
own employees,provided that suchimpmv sold
wit arc net intended moffered forsale.If.
OCC GROUP HHS.UNITS
M1owevagthe building urden of parent issolde did not yen or improefor thrower- A
builder will have the burden of proving that he did not build or improve far purpose,of
❑ I,as ownerofihe property,son exduaivelyamlradingwith licensed contractors m QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7014,Business and Professions Cale:)The Contractors
t IL
License Lxwdas not apply to anownerofpmpenywho builds m impmvesthereon,and PERMIT ISSUANCE
who contracts forsuchpr,ects with acentramorts)licensed pursuant to the Contractors ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Law.
❑ I am exempt under Sec. .B&P C for Nis reason BACK ROW PROTECT.DEVICE OUTSIDE FEES
SANITARY V N
Owner Date DRAINS-FLOORHOOF.AREA.COND. RFCEIPTN
WORKM AN COMPF NSATION DECLARAT ,ION SCHOOLTAX Y N
❑ Ihercby affirm thmlhaveacenificete of<nnsent to self-insure,ora certificate of FIXTURES-PERTRAP % RI!CE1P'#
3:11Workers employee's
under
arnot. nified ropy thcrmf(Sec.3800.Lab CJ wM1ich P RN A' Y N
covers ellemployKs under this permit. GAS-EA.SYS'1 I S RECEIPI'p
iyN BUILDING DIVISION FEES Q'
Company GAS-Pd.SYSTIi -OV,H4(li )I NCH CK FEE
❑ Cenificd copy Is hereby famished.
❑ Certified copy is fled with Ne city inspection division. GRUSMNDUSTU�A��A?4(b.40_3 GRADIN FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASETRff SOILS F E
COMPENSATION INSURANCE
(ThinsectionneWntMcomplete ifmcpcnnitisforonehundreddollao($100) SEWER-SA ITARY-W-76' P FEE 00 l
or less.) - _
1revily Not intheperformanmofthe work for whichthiapo.i,is ixmed,I shall WAIIHR HEATER W/VENT/ELECTR Z
not employ any person in my artme,
eco ome as m becsubject as the Workers' PAID
Compensationlawsof Califomin. Date - WATER SYSTEM(TREAIING Date Every,#
O z Applicant
z 2 NOTICE TO APPLICANT:if, it,,nuking his Cetificnre of Exemprion,yousbould NEW RESIDENTIAL PLMB. SQ.IT. /TOTAL.
F Oo become sobject o the Worker's Com,manti inp wisms of the Labor Cale.you most p �r
forthwith comply with such Provisions or this permit shall Is,deemed revalued. EU ILDING HE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
U1 hereby affirm that there is a construction lending agency for the Performm�ce of
z EhECTRIC :13i
O the wad for which this permit is issuN(Sec.309],Co.C.)
Lenders Name PLUAf FEI3
C F` Lmders Address QTY. MECHANICAL PERMIT FEE
U 1 cenily that I have read this application and stale that the above information is MEP A. ,AI.FT:E
>" 1 correct.Iagrce to comply with all city and mumy oNinanccx and Stam laws relating mPERMIT ISSUANCELS
F" 50 building convection,and hereby autharire repmenmdves ofthiscity to enter upon the CONSTRUCTIONX
U Z aWve-mentioned property for inspection purposes. ADDTOMECH. 45
(We)agree m save,indemnify and keep harmless the City of Cupertino against (1'O O,IXg]CFM
liabi]ities,judgm ¢
en ,costs and exponses which may in any way icerueagainst said City AIR HANDLING UNIT )
in ropey harm of the gramir,of this permit.
AIR HANDLING UNIT(OVER IQtN10 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HLAI'ING UNIT(TO I00.1Nlp BTU) Date Rece'ptb
Will the applicant or future building occupem store or handle haezrdous matenal HEATING UNIT(OVER 100,000 BTU) TOT L:
rs defined f,mo Cupenino Municipal Colo,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant or linurebulldingoccuparn axequipmentordeviceawhichemit BOILER-COMP(3HPOR 10),0001ITU1
�hr,ardoux air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 11111,000 BTU)
District?
❑Yes ❑No NEW RESIDENTIAL MECIL SQ.FT. P q 1-D
1 have rend the hmurtlo.,motedrils requirement,under Chapter 6.95 of the
Callfomia Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that '���
if, wilding dos not curt yhave utenant.Nat it is yreapons{bility to Drily the
compact mems which must be m f ayce ific dto of
no, . are r � 7 /7 -lA )r UfiG1Y1IIYU
Owner or out on7A agent Da ISSUE[)BY:
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
NO 1 DIO- ",. LAA i: .. PiRblT NO,CITY OF CUPEPLUMBNGMecuANlcAI
BUILDING DIVISION APPLICATION/PERYT BUILDING PROJECT IDENTIFICATION; }_. g250J1.JOJl
PUILDING,\IIDBESS: SANITARY NO. APPLICATION SUBS/1TI'AL D,Y
l 9 �w
v UNIT N LOT a
VNER. IMF.: PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
RCt� ` NLLIC NO / S A' -A E W 4,fj 'Aa L 5/z ❑ 7
CON"LACT: PHONE: r-m� e ,.t .,5, .-.y.
QTY '^ ELECTRIC PERMI .yy BUILDING PERMIT INFO}?.,
PERMIT ISSUANCE' A} f BLDG E P UMB A -C
II
LICENSED CONTRACTOR'S DECL\RATION APPLIANCES-RESID AL
Iherebyaffina that lamlicenxdunder (Chat Y tb A JOB DFSCRIP[ON
CZZ provisianso per (commencing wi
t�OCSection]IXNI)nf Divismn3nhM1e Business and Professions Cale,and mylicenx is is PANELS
F full force anJ effect.
,•LOU License Class Lic.# U _ UF�i
iq'Ly DateContractor 201 5
Z�NZ ARCHITECTS DECLARATION OVE . MPS SQ.FT.FLOOR ARE\ 5/SQ.FT.
1 understand my,lens shall be used a public records.
=m Fu IONS ECTRICAL
<,e7, Licensed Professional
�z�Q OWNER-BUILDER DECLARATION SPECIAL CIR T, I C.
XoaU I hereby affirm that 1 am exempt from the Contractors Licenx Law for Ne
-'+fir following re earn,(Scction 7031.5.Business and Professions Cade:Any ci r P.. LEAN
—C¢ which«quires a permit to conswn,alma,improve,demolish.or«pair y"Imaraure
p CYz prior to its issuance.also requires the applicant for such permit to file a signed smmment POWER DE CE
ucC that he is licensed pursuant to the provisions of the Connectors License Law(Chapmr
d z SWIMMING PWLE CIRIC
o„ 9(<ommencing with Section DivisionJof the Business and Professions Code) VALUATION
WM,,, omhat he is exempt herefrom and the basis for the alleged exemption,Any violation of 04A IL I� �--j-
00
I_Z� Section 7031.5 by any applicant for a Permit subjects the applicant m a civil Fraud,of TLETS-SWIT&ES-FIXTUIES ` / u y /'� Q
i-C not more than five hundred dollars(5500). NEW RESIDENTIAL ELECIR _SQ.FT. 4'�- lJ
Yap ❑ i.mownerofNepmop ,ormyemploymswithwaguuthcirsulecomp maunn. STORIES TYPE CONSTRUCTIO
a3 epi will collie want,and[hemmcmrc is not mumledoroffcrcd lariat,(See. Business
and Professions Code:The Contac m,Licenm Law does not apply to an owner of
property who builds or improves therson.and who does such work hiusselfor through Ns
1 ddtha[suchim menus«notimmndedoroffemdforsde.If, OCC.GROUP RES.UNITS
M1ocrop oyccs.provi c prove
wevewtheaset a urimprovementissoldwithinone year or improve for[browner- A
builder will M1ave the burden of proving that he did not buil)or improve for purpose of
sale.) n. .fFspz .�'z.. ,Fy.o'•t3F_k`r }t'P �,yr�+v
❑ I.0 rof[he propcny.am exclusively conoaaing with licensed<ontrutorsr 9a !AY#X„y C,�PLU yBING.P.yERRMIT 4 v;moi Qv ,.�rn.E 1 FLOOD LONE APN
construct the project(See 7004,Business and Pmficmions Code:) L.I.Cammnor's
License Lowdiesnot apply toss ownerofferopertywhobuilds orimproves Nememand PERMIT ISSUANCE
whocontracts forsuch projects wiNaconwaorts)licenudpursuant to the Conwaoh
License Lw (EA)
ALTER-DRAIN&VENT-WATERFEE
License Ze.n`a''ki H syz.
❑ 1 an exempt under Sec. B&1'C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE SANITARY Y N
•Owner Dam DRAINS-FLOOR.RUDE.AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX YN
❑ I herehyaffiw that l have a«aifirme ofconsenuoself-inure.cramnificomof FIXTURES-PER TRAP RF.CEIPI'N
Workers'Compensenion lnsumnceora certified copy Nereuf(See.3800,Lab C.)which P4RX, .E Y N
rs all employee's under Nis pewit GAS-EA.SY I 5 RF.0 1—
Pol cy# BUILDING DIVISION FEES
Company GAS-EA.SYSTB -OVA 4(, Y� CHECK FEE
11
❑ Cenifedcopyisla,mbyfumishW. II-- f 1r(S
❑ Certified copy is fled with[he city inspersion division GREASE1WDUS L ,AAYTE O G DIN FEE .,
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS FE
COMPENSATION INSURANCE
(Thi.sxc[ion need not be completed ifthe permit is for one hundred dollars($100) SEWER-SA ITARY- O bt .e IEpmff FEE
or less.)
I verify Nat in the peif.mssam ofine work for which this permit is imand.I shall WATER HEATER WIVENT/ELECIR Z
not employ any parson in any m m to become subject to the Workers' PAID
z Compmemcionlawsof Califomia. Dae so WATER SYSTEM/REATING Dam Receipt#
Applicant
O0 NOTICE TO APPLICANT:If.diet making this Cmuficar of Exemption.you should NEW RESIDENTIAL PLMB. SQ.FT. OTAL:
rA become subjectto the Worker's Compensation provisionsof[he labor Code,you mum p
5: forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
LS.I 12 CONSTRUCTION LENDING AGENCY SEISMIC FEE � o
1 hereby affirm that them u a construction lending agency for the perforrrw«e f
U O Ne work lar which his perms sissued(Sec 3097Civ C) ELECIRI E `
Lenders Name �.+ ++< C6'!:
Q F Lenders Address Q r Is{ 4 MEC'sefwsHANICzALPERMIT ji,r,� u� FEE" ,t• Pt.tlM Ffli
(� I ccmfy that 1 have read Nrs application and smut Nes Nc about information is u• YtEC A, AL FEE
cnwn. lagree mcomply with all<ity sad county ordinanttsanJ roam laws rtlmingm PERMIT ISSUANCE
building construction.and hereby authorize representatives of this city to enter upon the
U Z abuve-mrntimied property for inspection puryoses. ADD TO M[CIL CONS'fRUCT1UNX
(We)agree to save,indemnify and keep hamdess the City of Capitalists against
Iiabiinics,judgmems.costs andexpenses which may in any way attmeagainst said City AIR HANDLING UNIT(TO I0.00D CFM)
In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10dg)(I CFM)
Signature of ApplicamUCommcmr _—Dat,_ EXHAUST HOOD(W/DUCF PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I011.000 BTU) Date Receipt a
Will Ntapplicam or future building eceupante.om m handle hazardous mutmmil HEATING UNIT(OVER 100.000 BTU) TOT L:
as defined by the C,g,vmro Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)1
0 Yes ❑No VENTILATION FAN(SINGLE RI51D)
Will the
ISSUANCE DATE
. applicant or future buildingr pw Luxe9uipmtn zcu t ordevices which emit BOILER-COMP QHP OR IBO,BIXI BTU)
hazardous air co ntamirmnts u defined by the Bay Arca Air Quality Management BOILER-COMP(OVER M.000 BTU)
District'
❑Yes ❑No NEW RESIDENTIAL MECH. S0,FT. A 1-h
1 have mad the M1aeardous materials requirements under Chapter 6.95 of the
California Health&Safety Caf,Sections 25505,25533 and 25530. 1 understand that ju S
ifr wilding does nnt,vua tdy havea¢namJha it is yrcspicambua to miry the d�
me a aro mals which must be m �sm ct of uycc �l/ie a of
` 1F JrCri I IIFV
Owner arum arizeJ agent Do ISSUIIU R1':
Q