21257 APPLICANTIO FILL IN INFUHMA'HUN WI'I HIN HEU LINES — USE BALL PUIN i PL-IV ONLY
HuBdIng I'ns'ect Identification PEI4MITNO.
Building Address:
IOd 21257
�oo `�tgl-+'•N-I C'f AJC, c.-�r t37X�tt••)v . GA �t5� 1 1
Owner 9 Name:
Phone: A
P6d1:e 1-jii;x> 0^'"LAa* CITY OF CUPERTINO-BUILDING DIVIS19N It O/j lj
C.nt 'aN..: ,}_ /�LNa APPLICATION / PERMIT
d6UL AYMt+yIJ W. �Y X3 � 1 BUILDING-ELECTWCAIPLUMBING-MECHANICAL CATEGORY CONTROL
Archited/Enginesr: Lie.No:
M'A✓1-m C'Sl>WiutJ SNy�Ws.• C_- . 'a zt . . •w*: a' tkaxr �.e a 'a+. to ,s',` BUII:DING PERMITyINFOy„ +...`:t
-QTYe.v, ,a i tELECTRIC PERMIT �` t TV, FEE@ -. k;t .._ _
Addr a Imo+ JIIFakj a„4', N> N'T. /I tial I'QthIITI55UANCE ❑ ('4t1
LICENSED CONTRACTOR'S DECLARATION fL�,
I herebyaffirm thmm
at lam licensed under provlsl.ns.(Chapter, 9 hxenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingeollh5enion 7000)of Dlvlslon3ofthe Buslnessand ProfasalOnsCOde,and my
lirense le In foil f e a�ed dfeR. `` PANUS
Date� �g Contnator
ARCHITECTS DECLARATION 00 AMPS
understandn
p I understand my plans slug records, OVFR
be used as public records, OVER 1000 AMPS 5Q.IT.FLOOR AREA $/SQ.FI.
o�j Licensed Pr.femlonal SIGNS ELECTRICAL
G OWNER-BUILDER DECLARATION SPECIALCR4CUIT/MISC
L., y Ihereby affirmthat l am exempt from the Contradorb Lt...Lawf.rthe
7 O "s followingreason.(Section 7031.5,Buslnem and Professions Code:An city r
O% y y° TEMP.METER OR POLE INST.
county which rcqu tree a permit to construct,alter,Improve,demolish,or repair
nystructure prior to its Issuance,also requires the applicant forsuch permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provlsl.m of the
Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi. S L RIC
H OS sion3 ofthe Business and Pr°femloroCode).rthal he Is exempt there(romand VALUATION
the basis for the alleged exemption. Any violation of Section 7041.5 by any
'ryp0� 01
applicant fora permitaubjectathe applicant to a civil penalty of not more than
no��pyyy$ five hundred doll..($500). WE
7 ❑i,as owner Of the property,or my employees with wages as their sole NE STORIES TYPE CONSTRUCTION
compensation,will do the work and lhestructurc Is not Intended or offered for /
0 sale(Sec.7044,Buslnem and Profemlum Code:The Contractors License Law
due.act applytoan owner°(property war,builds or Improves there.nand OCCGROUIa RES.UNITS
CC.• who does such work himself or thorough his own employees,provided that such
improvements are not Intended oroffered forsale.If,however,the building or TOTAL:
Improvement Issold wlthinoneyearolcompldion,the owner-builderwlll have
t1la burden of
..'oing ut
the p he did arty'. build or improve for purpose
with
11 sale.). e,PLO1bIBING.PERMIT.a<.•, FLOOD ZONE APN
LI Lee owner of the property, Se exclusively contracting with niCodd PERMIT ISSUANCE Zatfl
contractors m cOmWd the project(Sec.7044,Business and ProlemlOm Code:
The Cm%mcfi rb Lt...Law dues not apply to an..at of property who ALTER-DRAIN&VENT-WATER(EA)
Wild'
or Improves thereon, and who contracts for such pr°k=ts with a p .$
On'01(ad.r(a)licensed pursuant I.the Contractor's License Law. M,
IJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OwnerDRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Data RECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES-PER IRM SCHOOLTAX Y N
[:11 hereby affirm that I have a certificate of consent t.self-Insure,ora a CA7 RECEIPT N
3800,CertifLab of WOrken'Compemau.nimuranreorarerttfied copythereof(Sec. GAS EA.SYSHM-1 INCAOUTLETS 2r� PARK FEE Y N
3800,Lab C.)
1'oliryp — RECEIPT#
Com an GAS.y BUILDING DIVISION FEES
Certified copy Is herebyth the ed.city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
OCertlfied ropy Is filed with the city Impectlon division.
CERTIPICATF.OFIIXEMMON FROM WORKERS' GREASETRM PAID /0/ Vo 5E339,9 .^too [�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date ReceI t#d07 78
(ThIsm
alon need nm be completed lithe permit Is foram hundred dollars
(ciao)°`Tem.) WATER .�W,/VFNr/EtEelx ENERGYFEE Y N
I certify that In the performance of the work forwhlch this permit la Issued,
I shall not employ any person In any manner as as to become subjsd to the q
Workeri Compensation WATER SYSTTM/7AEATING
laws of California. Date PAID 1015140
OZ App°cant Date ReCel t#
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQbT. I CPO,
Hshould becomasubjcct m the Workers.Compensation provislotu of the Labor TOTAL:
CC 01 Cod,ynu..at iorthwlth comply withauch pmvialom or this permit shall be BUILDING -'E 3
q.
LU 9 deemed revoked.
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE CD
I hereby affirm that there Is a construction lending agency for the perform, ELECTRIC FEE
Z ance ofthe w.rk(or which this permit is Issued(Sec.3097,Civ,Q 'TOTAL:
U O 1.ender'sName PLUMBING FEE 1G.—cc
LL r- lender's Address QTY. ',4Pt MECHANICAL`Ptft;Fl{}.y,t�, FEE,q-' MECHANICAL FEE � t�
O W IrertifylhatlhavencedthIsapplicatio...delatethattheabovelnformatiOn
iscorred.I agree to comply with ail city and county Ordinances and mate lawn PERMRLSSUANCE �Zlav FEES PAID:
1 relating to building construction,and hereby authorize representatives ofthis
N city to enter upon the above-mentl°ned property for Inspection purposes, ALTERORADDTOMRCH.
Z ' Date Receipt#
— (We)agree lO cove Indemnify an d keep harmiem the City of Cupertino a�,.�
against llabllltfc,judgmrm.,cramsand expenseawhlch may In anywayaccrue / AIR HANDLING UNIT 10,000 CFM) rw SUBTOTAL:
g1a/�W,{.yldCily In as#seque of the graining of this pcmnll. AIR HANDLING UNIT(OVER 10,000CEM) CONSTTpRt�U�1CcTIONTAX
51gA: re of Ap� dor L a � EXHAUST HOOD(W/DUCT) CONS'c7'�tIDN TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle havrdous HFATINGUMT(TO100,0)0BTU) teo (' CeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilcahh and Salcty CooQQe�S�pplon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) , TOTAL:
Yes M N. y� �qq p �g
Will appllcmn,ail reminabuilding Occupant by the BayequipmentAre.
VFNDLA710N FAN(SINGLE RESID) 1 1a,1af 1'TITsUriiPT DATE
which emit hexon oua air contaminants ae defined by the Bay Area Alr ,_�il�'Tj
Quality Mamgemcnt Disl 7 BOILER-COMP(3FR'OR 10QIXq BTU) p
4Yes o
havnread the haves -so—serials requirements under Chapter 6.95 of BOILER-COMP(OVER BTU) r„�5kJ0
the Gl lfornla Health&Safety Cod,Sectkm,2550S,25533 and 25534.1 �Isl t '1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECI{. SQ.FT. JIM Ra
reoponsibllltyt°nWify the occo ant oftherequiremenbwhlchmustbemet
Erin uance of a C�rtllica Ocapanry. /// d Xa'�sP.i,ra��•
City, yq�`:�lt�
.0u.
Oraulhorlaed agent
Date art ISSUED BY��C VJ.Y�Vsaa—�<<
TOTAL: "L —
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 2 1 2 5 7
1Ogoo 1-'E . p>t.,.•a.P�l�vY PJC; . c,�r1.'Ktl'INv , C..4
Name: one: Ar=A .
CITY OF CUPERTINO-BUILDING DIVISION 10
�j+ n
Cent r.Name: L,c.No: APPLICATION / PERMIT ( —I V
3 BUILDING-ELECTRICALPLUMBIN&MF MCAL CATEGORY CONTROL
Aahltect/Engineer, Lk.No:
1tA✓1-O ESY'+�'+�^� SNyplds.- L-2 BUILDING PER MIT INFO
QTY ELECTRICPERMIT FEE
A e: l VIbU VC. No . 2.v #-T-JI13a1 rERkIT[B9uaNCE M
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provislonsof Chapter 9(rommene- APPLIANCES-RESIDENTIAL JOB DFSCRIPDON
Ingwith Secdon70W)of Dlvislon3otthe BuMmmandlsrofess,onsCode,and my
license is in full( ^a�d effect. PANELS
LIcen�Lk.
Date ContractorUP TO 200 ANTS
ARC hall be used
as p ORATION OVER201.1 00 AMT'S
�2 I understand my plans shall be used as public records. OVER]000 AMI'' SQ.FT.FLOOR AREA S/SQ.Fi.
pp�u COC
Fi�() Limnxd Pro(essierul SIGNSELECTRICAL
<«<� OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
Ihereby affirm that am exempt from the Contractor's License Law for the _
2 t- following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST.
countywhich mquimsa perMttommtmd,alter,Improve,demmish,orrepair
gee .n anystrudure Intermit,Issuance,also requlrestheappllcant forsuch permltto POWER DEVICES
f9 K file a signed statement that he le llrenxd pursuant to the provisions of the
Ow{� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- S L RIC
30a sion 3 of the Business and Professions Code)orthat he V exempt therefrom and / VALUATION
o.•,1.1 the basis for the alleged exemption. Any violation of Section 7071.5 by any O
�Ck`J applimat for a permit subjects the applicant to a civil penalty of not more than
$ five hundred delta.($500), NE IR ,STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wage•as their sale
compensation,will do the work and the structure Isnm Intended or offered for
psale(Sec.7044 Business and Profewion•Code:The Contractors License Law
$ does not apply to an owner of property who Wilda or Improves thereon.and OCC.GROUP RFS.LNITS
who does suchwork herself orthrough his own employees,provided that such
improvements are net intended or offered for sale.If,however,the building or TOTAL:
Improvementl•sold withinoneyearofcompietion,the owner-budderw,ll have
UAmden of paving that he did net Wild or improve for purpose of sale.). QW. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ{as owner of the property,am exclusively contracting with licensed PERMITISSUANCE Z� -
contractions to construct the project(Sec.7044,Business and Profession•Code:
The Contractors License Law door not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) ,
Wilds or Improves thereon,and who contracts for such p(ojecta with a FEE SUMMARY
cat dor(s)Emitted pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
IN am exempt under Sec. B&P C for this reason
OUTSIDEFEES
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT#
WORINIAN COMPENSATION DECLARATION FIXTURE-PER TRAP SCHOOLTAX Y N
[]I hereby affirmorluer that I have o Insurance
nsura c of consent to copy thereof
or a RECEIPT#
certificate of Worken'CompersaHon lrsurenceora certified ropythereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS era PARKFEE Y N
policy3800, ab C.) `sem RECEIPT#
Polity# GAS EA.SYSTEM-OVER 4(EA)
Co. any - BUILDING DIVISION FEES
ffCertltled copy Is hereby furnished. GREASE/WDITSTRL WASTE INTERCEPTOR PLANCHEGK FEE
MCertitied copy Is filed with the city Inspection division.
CERTIFICATE OF FXEMPHON FROM WORKERS' GREASETRAP PAID lol 90 5838 a� a'
COMPENSATION INSURANCE SEWER-SAMTARY-sroRM EA.2(IOPI'. Date Retei t#A 78
(Thissection need nm be completed lithe permit isfor one hundred dollars
(SI(X)orless.)
Icerticss.) Nthe performance o(thework(orwNch this permit is Weed, WATER HEATER W/VENT/ELFOTR ENERGYFEE Y_ N_
I shall not employ any person in any manner so as to became wbjed to the WATER SYSTEM/TREATING
Workers Compensation lawsof California.Date PAID �0�5 f40 `�g38y
0Z Applicant NEWRESIDENTIAL PLMB. SQ.FT. Date Recei t# co
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subject to the Worker a Compensation provisimu of the Labor TOTAL:
IN Code,you=at forthwith comply with such provisions or this permit shall be BUI DING FEE
W > deemed revoked.
CL F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE CD
I herebyaftlrrathat there is a construction lending agency for the perform- ELECTRIC FEE
D Z ance of the work for which thin permit is Issued ISM.3097,Civ.C.) TOTAL: (�
U O Lender's Name PLUMBING FEE
F- Lenders Address QTY. MECHANICAL PERMIT FEE
O W ImA[fylhatl have readthisappllcationand statethatthe above Inforrtation s''� FEES 00 MECHANICAL FEE �'
1 facetted.l agreeto comply with all cityand county ordinances and dale laws PERMIT ISSUANCE Lard
} (n relating to building construction,and hemby authorize representatives ofthl,
F city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MUCH. IT,2 Date Receipt#
(We)agree to save,Indemnify an of keep harmless the V of Cupertino
�t^,against liabilities, expenses which may In
anywayareae f AIR HANDLING[NIT CIO 10,000 CFM) tw SUBTOTAL:
aga,na' d City In C%.Nue of the granting of this permit.
AIR HANDLING INH(OVER I0,00a CFM) CONSTRUCTION TAX
Sig re of Applicant/Cont dor ).t,. EXHAUST HOOD(W/DUCT) CONS7MBi TAX PAID: -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) jqq
(pin eCfl t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and SafetyC non 25532(x)7 HEATING[NIT(OVER 100,000 BTO TOTAL:
❑Yes No gj��
Will the applicant (u mbuilding occupant use equipment or devices VENTILATION PAN(SNGLE RESID) ypy:� dSSjIANtCE DATE
which emit hamnlous air contaminants as defined by the Bay Area Air 4 91
MTT IEWt_!(,t
Quality Management Dist 7 - BOILER-COMP OHP OR t00,IXU BTU)
4 Yen o
have mad the bma ousmalerials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,0(0 BTU) H
the Glifornin Health&Safety Code,Sections 25505,25533 and 25534.1 r ((''47v I
understa ad that lithe building dcea not currently have a tenant,that It is;my NEW RESIDENTIAL MECH. SQA. �k7
respmotib,lity to notify theioccu ant of the requirements which must be met
pdort unto,ma QCtlitka Occupancy. ��g Msand}IMI1
Uv or authorized agent /I Date /3 ISSIIGU S
TOTAL: "L
OFFICE COPY