28044 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO01-U1 INC-RI.. R A. PERIvi
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING
BUILDING
/")O O n
.BUILDING PROJECT'IDENI IFICATION G o 4 4
BUILDING ADDRESS: '[/�� SANITARY NO. APPLICATION SUBMTTTALDATIE:
L i LF- UNInTpLOT 4
WNERSNAM':
V
AMC
CONTROL p
11 111 . 0NF.. LIC NO: DJ�2U.§ 0� - is� �I
ON'I'ACT: PHONE: u. N\: - BUILDING PERMIT INFO
QTY. - ELECTRIC PERMIT - :FEE`
BLDG EyEC[ PL Md MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB UESCRIPI'ION
y�z Ihereby of cat that lam licensed underpowisionvofChupter9(commencing with
00 SeGmn 9000)of Division 3 of fl a Business wd Prof es Lons Cpdc, it my license is in PANELS
y d E full force end effort. -7 OO
FQ LLLL11 Licenw Class hic.p f O UPT02MAMPS �„ w
to y Date Contractor 201-1000 AMPS
ZUKARCHITECTS DECLARATION OVER IOfI0AMP5
r� SQ.IT.FLOOR AREA S/SQ.IT.
OZ—O I understand my Plans shM u
all sed u public mcmd..
Pee .' SIGNS ELECTR ICAL
yy ,� Licensed Profen mad
x�y 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
y13LLy folloI hereby affirm that I am exempt from the Conuactors Licemic Law for the
wing mason.(Section 703 LA Business and Professions Code:Any city or county THMP.METER OR POLE INST.
f5'o which requires a pennil m constfuct,slier,improve,demolish,or ac,u any structure
N� prior to its issuance,also requires the applicant for such permit o file a signed statement POWER DEVICES
O that he is licensed pursuant to the provisions of the Co tor's License law(Chapter
aao�C 9(cmmactiong with Section 9000 Division3oft Bmt nand Profession Code) SWIMMING POOL ELECTRIC VALUATION
.,that he is exempttherefsmi nd the hasisfonhe egede. ion.Any violmionof I
< Section 0031.5 by any applicant to fu pernitsub'ctatheapplicwt malt of OUTLETS-SWITCHES-FIXIGRES
not more man five hundreD dollars(5500). - 3 �O#
propery,ormyemploy swihwagesutheirsolec.mpensati.n, NF. ESIDEN'HALELECTR _SQ.FT.
c ❑ .thm amk,rad t S'1'ORIHS TYPE CONS'fItUCTION
a3=° will dothew.in,ande noCureiamitrna iota ado Law dos ul (Sxxcapply I.an. ne,Of
�
and Professions Code:The C.nwctors rase law does not apply m sa owner of
propenywhobuildsorimpmvcstbefeon, dwhndoes h work himself.,through his - OCC.GROUP RES.UNIT'S
cmployees,providedthatsuch tmP aid a ren ttnend oroffemd rs e !
however,he btu lhngortmpmvem<nY sold wnhn o co . -
bmlder wdl have the burden of procto that he did no t d or improve for puryou of
sale.).
��
❑ I,tv ow¢rofthe propcny,umex lustvelyamtm mg Ml LenslO tuclq m ? '� 'a PLUMBING PERMITe It *Ay FEE FLOOD I1.00D ZONR APN
construct the project(Sea]044,Bus a and Ism euim s Code:)Thc Contractor's � 4
Liesnt,lawdoss not applytoanowner ss openywhobuildsorimprovuthere.n.and TISSUANCE 757.
�.
who contracts fmsuch projects with aeon a ls)liccnxedpursuenumhe ret or _
LiN. -DRAIN&VENT-WATERIPA) ¢ ' $
cenu Lew. FEE SUMMARY
C] I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT,DEVICE OUTSIDE Fl.'
SANITARY Y—N—
Dan—
Date DMINS-FLOOR.ROOF,AREA,GOND. RECEIPT# -
WORKMAN COMPENSATION DECLARATION SCHOOLI'AX YN
EIIhembyaffrmmatlliaveucenifieweefconsenitoself.insure,oracertifcateof FIXTURES-PER TRAP /' RECEIPT'# I'
Workers'Compensation lnsurancc.rucenifeJ copy thereof(Sec.38W,lab CJwhich PARK FEE YN
coven all employee's under this Permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT It
Policy BUILDING DI SION FEES
Company GAS-EA.SYSTEM-OVM4 LEA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenifed copy is fled wire the city inspection Division. GRFASEANDUSTRL WASTE INTERCEPTOR GRADING ME
CFRTIFICATE OF EXEMPDON FROM WORKERS' GREASETRAP SOILS FF.F.
COMPENSATION INSURANCE
(Thissection need not be completedO ffie ponnitisforone hundrouldolhm($100) SEWER-SANI'T'ARY-STORM HA.200PT, dNERGY PER
mless)
(certify rhos in th<performenceofine work fur which thispcnnit is issued,Ishall WATER HEATER W/VENTIELECTR
not employ any Person in any manner so es to become subject to the Workers PAID
Compensation Lows of Califomio. Date WATER SYSTEMITREATING Date Receipt#
O z Applicant
z 0— NOTICE TO APPLICANT,If.utter making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. If TOTAL:
tV) become subject to the Workees Compensation provisions of the labor Code,you most
funhwim comply with such provisions Or this Permit shall be deemed revoked. BUILDING IEE
W Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that then is a construction lending agency for the performance of ELECTRIC FEE
O he work for which his permit is issued(Sec.31#7,Civ.C.)
Lenders Name
u" U Laders Address aM_ECIIAN1CAUII RMIT'r B PFF xa PLUMBING FEE 0 "
V I certify that 1 have had this application and state that he above information9 "" x'"' z
correct. l agree to comply with all city and county ordinances sad stun laws relating to PERMIT ISSUANCE MECHANICAL ITiE
'✓ building construction,and hereby auNoaize mpresenerivesofthisciry menrer upon the CONSTRUCTIONTA
V 7 ab.vcmeationed property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep hurnleu the City of Cupertino against
liabilities,judgments,costsand expenses which may in any way ammeagainat said City AIR HANDLING UNIT G70 10,000 CFM)
ucne ofthe mntingof ie
AIR HANDLING UNIT(OVER 10,000 CFM)
q
Signature of Applicant/ on for nm EXHAUST HOOD(W/DUCI) PAID
H RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO I00,000 BTU) Date eiptp
Will the applicant or furore building Occupant store or handle haunious material
asdcfncd bytheCupenin.Municipal Col,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 10),00)BTU) TOTAL:
Cale,Section25532(u)9
C1Yes ❑NO VENTILATION PAN(SINGLE.REBID)
❑
Will theerintin torfuture building occupantuse equipment ualityc Management BOILER-COMP(3111'OR 100,000 BTU) ISSUANCE DATE
hazanl.ua air cnmuminants n Jefncd by Wu Bay Arco Air Quality Management
iatriR) BOILER-COMP(OVER IWO BTU)
- ,W
11 Yes ❑No NEW R6SIDEM'IAI.MECII. SQ.FT. PAID
I have read the bazerdous materials requirements under Chapter 6.95 of the a
California health&SafetyCode,Sections 255115.25533 and 25534. l undenti nd hat H 1995
if the building does not currently have a tenant,that it is my responsibility to notify he y{�
occupant of the requirements which must be mm prior to issuance.(e Cenificme of
OceaPan.y. Cfly or e; Nt
Owner or authorized agent Date L. "� ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
i BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER -
BUILDING n APPLICATION & PERMIT `'
ADOR s Z . 15383
N �h• BUILDING -
OWNER'5 PLAN CHECK VALIDATION
"AmE - UTV. ELECTRIC PERMIT FEE
4 V PHONE
CONTRACTOR'S ,"
OUTLETS-SWITCHES-RECEP .10.00/1.00 -
��BM_ TrP•VTI - LIC.NO LIGHTING FIXTURES 10.00/1.00
WNTRACTOR'SLA•' PPLIANCES=RESIDENTIAL 4.00 .
7^V
l �•'IT
PHONE Z0 PANELS • ,10.00 DATE OF APPLICATION -
ARCHITECT - PLAN CHECK FEE - P.C.NO.
OR . . " PANELS (OVER 200 AMP) 20.00
ENGINEEfl
' I sec.NO ISIGNS TRANS. ' ' 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
zu, .EMP.METER OR POLE INS. 20.00
APPLICANT A#y55 S MOTORS - - SEE FEE SCH. s- .,
e-' 1 I�• �{'7,I'y- SERVICE CHANGE, 20.0011
/ '
wO o - LICENSED CONTRACTORS DECLARATION �//
< u W I hereby affirm that'[am licensed under provisions of Chapter 9 111///SSUANCE DATE -
y¢ N (commencing with Section 7000)of Division. of fire Business and -B-LOG. ELECT.
o_r w y�•f��tZ •❑ ❑ P❑LG. MJECH
.
zProfessions Cod license Is In full to
i �--LicNumber_mLicense Cass
L F ca [)are �.� /e Contractor1 -
ce M w ¢ , OWNER-BUILDER DECLARATION BUILDING PERMIT
- 0 A 0 ,.` - INFORMATION
wr.LL N I beleby affirm that I am exempt from the Contractor's License MISC- REFER TO ORD
LL0¢ Law for the fallowing reason. 7031.5,Biuiness and Professions VALUATION E/FT.
H - PERMIT ISSUANCE' 10.00
Code Any city or County which requires a permit to construct,alter,
WR 2ivdemolish,
Q O mproe, emos ,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. '
y A 6 requires the applicant for such permit to file a signedstatement that TOTAL pER IT TO
y w$ he is licensed purstmnt to the provisions of the Contractor's License: r`
Law(Chapter 9(commencing with Section 7000)o'Division 3 ofthe �z 7y
4 0 Business and Professions Code)or that he is exempt therefroin and OTV. PWMBING,PERMIT FEE _-/
¢ r the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).):
t ❑ 1,as owner of the property,or my employees with wages as BACKFLOW PROTECT:.DEVICE 4.00 OCC.GROUP RES.UNITS
heir sole compensation,will do Die work,and the structure is not
intended or offered.l'or sale(Sec: 7044: Bus!n.....ad Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
'`ham property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 $O.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or ol'tered for sale:If,however,the building GAS-EA':'SYSTE M-1�I NC.4 OUTLETS 6.00
I, or improvement is soldwithin one year of completion,the owner- GAS EA:SYSTEMOVER 4 IEA) 2.00
^•kYY Q-'/ builder will have the burden of proving that h -e did not build or im- - .
- BUILDING USE
'ems• RES IND .CON PB ONer
prove 1,as owner ofsule.). INDUSTRIAL;WASTE INTER. - 30.00 - - O. � .
❑ 1,as owner ol'the property,am exclusively contracting wills0 El
licensed contractors to construct tire project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
i to an owner of property who builds or improves thercon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 "
contracts for such projects with a contractorls)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.00
the Contraclor'S License Law. TRACT NO. PARCELING. .
❑ Imo exempt under 5eu. ,B.&P.C.for this -WATER HEATERW/VENT " 6.00
reason
Owner - Date .WATER SYSTEM' 5.00 ACCDATE ACC.FILE NO.
' WORKERS'COMPENSATION DECLARATION. WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to silt-insure, {� ZONING ENG.SITE NO.
or a cert rlcste of Workers'Compensglioy lnsurancY,pro cerlil icd L'
co ii L Lab.C.l. '�/�/r(IT'{d�.f/3d4� i4
rg1mvullr
O ❑ Certified copy is hereby furnished. FIRE SPR INK ENERGY Tod
Z Z Certs opy iS fi .with-the city inspection division. ❑ ❑ ❑ ❑
F• p A pI cant_f�"�/,_•].�,�1y�_ - • MISC- EEE -TO ORD. v N v N
CIiR' FIII CA'I'E OF E%EN TION FROM WORKERS" ,PERMIT ISSUANCE, ..: �F x1110.00 FLOOD ZONE A.LUA.
LU COMPENSATION INSURANCE PLG.CONTE. .LIC.NO. las sl' PLG. '
Z (This.section need not he completed if the permit is for OIIC TOTAL Y[D NO V.❑ NEI
hundred dollars($100)or lessr
U O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mil is issued,1 shall not employ any person in any manner so'es to - -
O W become subject to Workers'Compensation Laws/sf Cu,lifornia.
d Dutc Apphcam - ALTER OR ADD TONECH. 5.00 BUILDING
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex^
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions if lite Labor Code, you must forthwith comply Poth FEE
C.1 such provisions or this permit shall be deemed revoked. 'AIR HANDLING UNIT(TO 10=C.F.M.) 4.00 '
I CONSTRUCTION LF-NDINGAGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
Y hereby affirm that Dtere'is a construcbon,lcnei gagency for EXHAUST HOOD (WITH DUCT) 5.00
„ tiro performance ouf,th.e work or which this permit-is issued(See. MICROFILM
3097.CivU.). UryN �I� /��f. _ HEATING UNIT(TO 100,000 B.T.U.) 8.00
1 Lenders Address' ewe•- _I> HEATI NG UN IT(OV ER 100,000 B.T.U.)9.50
ELECTRIC
I certify that[,have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply.with all city and countyVO� PLUMBING.
4 mm
ordinances and state laws relating to building construction, and . BOILER-COMPI3 H.P.Cr 100,000 B:T.U.) 6.00
• hereby aulharize representatives of this city lo'enler upon the BOI
41401
aboveenn. d.property,for inspection purposes.
LER-COMP (Over 100,000 BTUI SEE FEE SCH. M MECHANICAL
-(WOLagree to save, indemnify and'kccp harmless the City of MISC.=• REFER TO ORD: -
Cupertino against liabilities,judgments, costs and,ex senses which PERMIT ISSUANCE - 10.00 CONST:TAX'
ay any way ace a against Said City I, onset ence'.r the
lane fthis per ' R MECH.CONT., LIC.NO. MECH: •-
I 88' • TOTAL /E 00 TOTAL
'\Signa reof Appli nt/Co actor+ I Date fl
;OFFICE$OPY ` .''