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30553APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING - ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATIONITERMIT PLUMBING. MECHANICAL 30553 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DAD c, `,. . I q6 ER'S NAMESx fPHONE: - ONTRACfO`'S NAME: LIC. NO:O NIC ❑ CONTROL p C.� /� Q re�t CHITECUENGINEER: LIC NO: q n G a~ / CONTACT.. PHONE: � BUILDING PERMIT INFO ❑ Consaltant Fees Paid by Applicant (Initial) BLDG - ELECT PLUMB MECH X El LICENSED CONTRACTOR'S DECLARATIONEl❑ QTY. ELECTRIC PERMIT FEE - JOB DESCRIPTION I hereby effm+then I am licensed under provisions of Chapter 9 (commencing with Section 7010).1 Division 3cfthe Business and NoNsaims Calcium]my license is RESIDENTIAL: Lt full force it affect. PERMIT ISSUANCE , ❑SFDWIL K�IsTCHEN REMODEL Dague Class Conor APPLIANCES - RESIDENTIAL Date Contractor DADDITION LIfLUMBING RE -PIPE GMULTI-UNIT STRUCTURAL b DELL ARCTIITECPS DECLARATION PANELS trade monJ my plana shall he used as public receMs MODIFICATION UPT02MAMPS [IINTERIOR 0CHIMNEY REPAIR IMPROVEMENT Licensed Pudesaional 201-1000 AMPS OWNER -BUILDER DECLARATION OVER 1011(IAMPS El DATE REMODEVREPAIR DEMOLITION 1 hereby affirm that 1 am exempt from the Commences License law for the fallowing reason. (Section 7031.5, Business and Professions Cale: Any city or county SIGNS ELE C D OTHER which requires a permit to consumer, alter, improve, demolish, or repair my s r care .prior to its issuance, also requires the applicant for such permit to file a signed statement SPECIAL CIR TdAISC. that he is llccased pursuant to the provisions of rhe Contractor's License Law (Chapter 9 COMMERCIAL: (commencing with Section 7000) of Division 3 of Ne Business and Professions Code) or THAIR MET EINST, that he is exempt therefrom and the basis for the alleged exemption. Any violation of D NEW BLDG/ADDITION D DEMOLITION Section 7031.5 by any applicant for a panim subjectthe applican,toa civil permhy of POWER DB ICES CITIENANT C1FOOD SERVICE not mom than five hundred dollars (5500). IMPROVEMENT El Las owner office properly or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC D OTHER red for sale (Sec.7(, Business will do the work, and the structure is not intended oroffeW and Pmfexxims Code: The Contractor's License Law does not apply no an owner of OUTLETS -SWITCHES -FIXTURE property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. SQ. FL FLOOR AREA $/SQ. FT. and, IL however, the building or improvement is sold within one year of completion the owner -buil ler will have the burden of proving that he did not build or improve for put- ' Prase of sale.). -. 1, as owner of the pmpery, mm exclusively contracting with licenses) contmcmrs to TOTAL: container the project (Sec. 7044. Business and Professions Cuds, The Contmcmr's LI- -Qj� case Low does not apply to an owner ofproperty who builds or improves thereon, and QTY, PLUMBING PERMIT FEE P who contracts for Inch Projects with a contmcur(s) licensed pursuant m the Canmcmrk 6� nn� Lirense tow. PERMIT ISSUANCE ❑lam exempt under Sec. this reason 27 X 9 (" ,B&PCfm ,•,L Owner Dane ALTER - DRAIN & VENT- WATER (EA) " • I // VALUATION WORKER '5 COMPENSATION DECLARATION BACK FLOW PROTECT, DEVICE 1 hereby offrm under penalty of perjury one of the following declarations: I have and will maintain a Ceaifcale of Consent to self -insure for Worker's Compen- DRAINS- FLOOR, ROOF. AREA, COND. STORIES TYPECONSTRUCTION scion, as provided for by Section 37M of the Lab, Cade, for the performance of the work for which this permit is issued. FIXTURES _ PER TRAP 64k - Fl I have and will maintain Worker's Compensation Insurance, as require) by Section 37M of the Labor Code, for the performance .(,he work far whicbthis permit is issued. GAS - EA. SYSTEM -I INC.4 OUTLETS OCC.GROUP APN : My Wmkerpfoyt(pensmionlnsutaare carie, and Policy '!!!I- Cartier: /J 11 V�� Policy No.: GAS -EA. SVSTEM�OVER4(EA) a CERTIFICATE OF EXEMPTION FROM WOR R' COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This (this action need not becompletWifthepennit is (mane handled Jnllars(5100) FEE or less.) GREASETRAP I certify ohm in the per'0nnuncc of the work for which this permit it ilsued,lshall SEWER - SANITARY - STORM HA. 200 FL not employ any person In any rammer so as to lamome subject to are Worker'Compen- ENERGY FEE scion Laws of California. Dote WATER HEATER WNENTAELECTR Applicant GRADING FEE NOTICE TO APPLICANTtIf. after making this Ceniftcau of Exemption, youshord WATER SYSTEM/IREATTNG become subject to the Worker's Compensation provisions of the Labor Code, you must SOILS FEE forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F-L PAID t I hereby union that hen isacunsmnion lending agencyforthe perfarmamain' Data ceipr the work for which this permit is issued (Sec. 3097, Civ. C.) Lsedees NameTOTAL: Lendees Address BUILDING 1 cenify than I have read this application and sat¢ but the above information is cancer. 1.,me to comply with all city and county oNinure. and guru laws ,eluting,, QTY. MECHANICAL PERMIT FEE building construction. and hereby uathorin representatives of this city to enter upon the SEISMIC FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE (We) agree rat save, indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs and expenses which may in any way occurs against said City ALTERORADDTOMECH. 'n PLUMBING FEE in conuque f the gm Rhis permit. APP NDE S AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT 00 Ig000 CPM) MECHANICAL EE RCE AUT. �/ AIR HANDLING UNIT (OVER 10,00(1 CFM) fC CONSTRUCTION TAX tg man PIi o ,sur Data EXHAUST HOOD HVIDUC ) HOUSING MITIGATION E HAZ lZUS MATERIALS DISCLOSURE Wil heapplicamor future building occupamsmre or handle hazardous material HEATING UNIT (TO 100,000BN) x defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety - Cade, Sectio 255320)7 HEATING UNIT (OVER 100,000 BTU) E] Yet, E] No VENTILATION PAN (SINGLE RESID) PAID pas R pt N Will the applicant m fume building occupant use equipment or devices which TOTAL: l hazardous air conmminanns as defined by the Hey Area Air Quality Management BOILER - COMP QHP OR 100,000 BTU) isnictl BOILER -COMP (OVER 100.000 BTU) ❑Yea C] No 11 I have mad the hazardous materials modiremenns under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DA fomia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understood than if the NEW RESIDENTIAL MECH. SQ. FT. buildingdoes not currently have a tenant, that it is my responsibility to notify the occupant of the requimmants which must be met prim in issuance of a Certificate of Oaaupaacy. ISSUEDBY: Moep Owner or authorized agent Date TOTAL: OFFICE APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY - ' CITY OF CUPERTINO . BUILDING a ELECTRICAL PERMIT NO. �' BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL nn r. . 3 O aJ�� i.u1 ra.—I..r....�.�....m..... • n / d - . 5 Z ❑ Consultant Fees Paid by Applicant (Initial) POO OE G U uchNNLD CON I RALTOR'S DECLARATION '1 hereby affirm that f am licensed under provisions of Chapter 9 (commencing wit Section MET) of Division 3 of the Business and Professions Code, and my license is in full force and effect- - License Class Lie. # Date Contractor QTY. PERMIT ISSUANCE ❑ KITCHEN REMODEL W4 g„ p y 4 Z �'. t� f45 C, iq5 � 6 U a E" ARCHITECTS DECLARATION I um ndersnd my plans shall be used as public records Ucrnsed Prnfessonel OWNER -BUILDER DECLARATION - 1 hereby affirm that) am exemnLfmm the Contractor's License city fallowing rcasnn. (Section 7031.5, Business and Professions Cade: Any city or County or county EMULTI-UNIT ❑STRUCTURAL PANELS UP TO 200 AMPS ,1z� w C �.V1 p.that I y e C w " y ,G ' L ' ` which requires a permit to construct, alter, improve, demolish, or repair any machine prior to its issuance, also requires the applicant for such Permit to File iiogned statement he is licensed pursuant to the provisions of the Conacmrs License Law (Chapter 9 (commencing with Section 7") of Division 3 of the Business and Professions Code)or that he is exempt terefmm and to basis for the alleged exemption. Any violation or Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of 1 more than five handled dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sale compensation, will do the work, and the sticture is not itnended reoffered for sale (Sec. 7044, Business and Professions Code: The Connector's License Law does not apply to an owner of property who builds or improves thereon, and wIn does such work himself or through his own employees, provided that such improvements are not intended or offered for 201-IOMAMPS IMPROVEMENT OVER I" AMPS ❑ OTHER sale. IL however, the building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not build or improve for pin, IMF Of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors Ira construct he project (Sec. 704,4, Business and Professions Code:) The Contractors Li - QTY use Low does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a cons uomr(s) licensed pursuant to the Contractor's SWIMMING POOL ELECTRIC' O License Co. OUTLETS-SWITCHES—FIXTURES ❑ I am exempt under Sec. ,B& P C for this reason NEW RESIDENTIAL ELECTR: SQFT. Owner Dam WORKER'S COMPENSATION DECLARATION - I hereby affirm under penalty of perjury one of the following declarations: El I have and will maintain a Certificate of Consent to self -inure for Worker's Compen- ,alion, as provided for by Section 37M of the Labor Code, for the performance of the work for which this permit Is Issued. ❑ 1 have and will maintain Worker's Compensation Deviation, as required by Section 37M of me Labor Code, for the performance of the work for which this Permit is issued. My Worker�,d].�ti9P l summe carate rand Policy nu r{� Carrier:o-S'� Policy No.: L %� CERTIFICATE OF EXEMPTION PROM WORKERS' COMPENSATION INSURANCE (This section need not be completed lithe permit is formic hundred dollars (81 W) or less.) I certify that in the performance ofte work for which this Permit is issued.) shall O Z `0 not employ any Person in any manner so as to become subject to the Workers' Camper. smith Laws of California. Dam " Applicant G y a NOTICE.TOAPPLICANT: If, after making this Certificate of Exemption, you should became subject to the Workers Compensation provisions of the Labor Cade, you must fmbhwilhcnmply wit such provisions or tis permit shall he deemed revoked. LENDING AGENCY QQCONSTRUCTION Ihereby of mer that is a construction lending agency for the Performance of L~ Q ULender's Iy, h the work far which this permit is issued (Sec. 3097, Civ. C.) Name Lender's Address I certify that 1 have read this application and smte thanhe above imform tion is come( I agree to comply with all city and county ordinances and state laws rtlating m building construction, and hereby authorize representatives ofthis city m enterunon the above-mentioned property for inspection purposes. QTY, (We) agree to save, indemnify and keep hornless the City of Cupebino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the gmntin fthis permit. APPLICAfj,T UNDERSfyAS AND WILL COMPLY WITH ALL NON -POINT Will to applicant—mr future building occupant store or handle hazardous material as defined by the Cerebrum Municipal Cade, Chapter 9,12, and the Health and Safety Code, Section 25532(x)7 - ❑Yes 7 N Will to applicant or future building campant use equipment or devices which mit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ` FYes ❑Nm ' 1 have read me hmporkn s materials requirements under Chapter 6.95 of the Cali - brain Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant, that it is my responsibility m notify me occupant Of me requirements which most be, and prior to tonsure of a Cerlficate of Occupancy. ELECTRIC PERMIT RESIDENTIAL ro FEE PERMIT ISSUANCE ❑ KITCHEN REMODEL ❑ADDITION APPLIANCES—RESIDENTIAL EMULTI-UNIT ❑STRUCTURAL PANELS UP TO 200 AMPS MODIFICATION ❑ INTERIOR 201-IOMAMPS IMPROVEMENT OVER I" AMPS ❑ OTHER SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST POWER DEVICES SWIMMING POOL ELECTRIC' O OUTLETS-SWITCHES—FIXTURES NEW RESIDENTIAL ELECTR: SQFT. / PLUMBING PERMIT PERMIT ISSUANCE ALTER — DRAIN & VENT— WATER (EA) BACK FLOW PROTEGE DEVICE - DRAINS— FLOOR, ROOF, AREA, COND. FIXTURES—PERTRAP GAS — EA. SYSTEM -1 INC. 4 OUTLETS GAS — EA. SYSTEM -OVER 4 (EA) GREASF/INDUSTRL WASTE INTERCEPTOR GREASETRAP ' SEWER —SANITARY—STORM EA. 200 FT. WATER HEATER WNENT/ELECTR WATER SYSTEM/TREATING -, WATER SERVICE NEW RESIDENTIAL PLMR SQ. ET, MECHANICAL PERMIT PERMIT ISSUANCE ALTER ORADDTO MECH. - AIR HANDLING UNIT.(TO IQOIXI CFM) AIR HANDLING UNIT (OVER 10.000 CPM) EXHAUST HOOD(W/DUC1) HEATING UNIT (TO 100.008 BTU) - HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER,_ COMP (3HP OR 100,000 BTU) BOILER—COMP (OVER 100.000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE. FEE PERMIT INFO "LOU ELECT PLUMB MECH ❑ ' ❑ �. ❑ JOB DESCRIPTION RESIDENTIAL ro ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION 11 PLUMBING RE -PIPE EMULTI-UNIT ❑STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑BATH REMODEUREPAIR ❑ DEMOLITION ❑ OTHER COMMERCIAL: t E] NEW BLDG/ADDITION [I DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER SQ. IT. FLOOR AREA FEE SEP 2 5.1996 ,ltl I VY VS.a cosi ll\t STORIES C. GROI BUILDING DIVISION FEES PLANCHECK FEE ENERGY PEE GRADING FEE SOILS FEE PAID Dote Receipt# BUILDING FEE' i FEE ELECTRIC FEE " PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX PAID Date Receipt# TOTAL ISSUANCE DATE ISSUED BY: