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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ect Identification
BuBd Ng Addrees:
PERMIT NO.
s s-4,5
23201
one:
— UP,
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBING-MECHANICAL
Ttradn%•N•ma: eve Lie. No:
1' 1r reC IYIC 96
CATEGORY
CONTROLN GJ
a a'
ArehltM/Engl r, Llc. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address O
El ❑ 1:1LICENSED
a PERMITISSUANCE
CONTRACTOR'S DECLARATION
Iherebya(firmthatlamllceneedunderpravlsloosof Chapter9(m an
Ingwith Se on7000)of Dlvision3ofthe Busimmand ProfesdonsCode,and my
license bI•fialorycpnd f#
LiceCle
nse LION
AIlpLIANqE4RMDENTIAL A
JOB DESCRHMO�µIc(
P
-W
Date Contractor
201-] AMP"'
ARCHI SDE LARATION
ent myph eased sspubficrecordN
OVER 1000 AMPS
�j Ffj 6lQOREr App
B 'ARE'
��Q. FT.
Licensed essWnsl
OWNC - LDER DECLARATION
I hereby affirm Mu[ I em exempt from the Contractor's License Gw for the
following reason. (Section 70715, Business and Professions Code: Any city or
countywhich requires a permit toconstru, alter, Improve, deolhh,or repair
cim
anyetmchare pdorto its lssuarae,alsorequireslheapplfunt (or such permit to
file a signed statement that he is licensed pursuant to the provblons of the
SIGNS ELEC77UC L
O\NIMH PL CUT
/Q
.1//S ( G Z
TE
R
SPECIALCEICUIT/M1SC
TEMP , METER OR POLE INST.
POWER DEVICES
SWIMMING BOOL ELECTRIC
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi.
Nona of the Business and Professions Code) or that he is exempt therefrom and
VALUATION
the basis for the alleged exemption. Any violation of Section 70015 by any
applicant fora permit sub" b the applicant to a civil penalty of not more than
0[71LE.ISSV.7.fCf IfSHX.ILRES
NEW RESIDENTIAL ELECTA SQ.ET.
fin hundred dollars ($500).
I, as owner of the property, or my employees with wages a• their sole
STORIES TYPE CONSTRUCTION
compensation, wllldothe work, andthe structure Is can intended or offered for
sale (Sec 7074, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thersory and
who does such work himself or through hisown employes, provided that such
OCC. GROUP RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building or
TOTAL:
Impmvementbwld Mthlnonsyearo(caanpldl mtheowner-budderwRl Tuve
ttgLtturden of proving that he did not build or Improve for purpose ofnle.).
u L as owner of the property, am exclusively contracting with licensed
contnctan to construct the project (Sm 7074, Business and Profe••Ions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZDNE APN
PERMITISSUANCE
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pCojecta with •
cgpUactor(•) licensed pursuant to the Contndaa's License Law.
LI I am exempt under Sec. B Is P C for this reason
ALTER -DRAIN k VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS. FLOOR A, ROOF, ARECOND.
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, ora
certificate ofWorke 'Compensationlnsurance ora certified copy thereof (Sec.
3800,Iab J
Polity N
FO(711RES PER TRAP
SCHOOL TAX Y N
RECEIPT;
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT'M
Cam anv
GAS F.A.SYSTEM-OVER 4 (EA)
BUILDING DIVISION FEES
-shifted copy 6 hereby furnished. t
CertNed copy b filed with the city Inspection division.
GRFASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
p OV
8 fe
GREASE TRAP
CERTIFICATE OF EKENIPT ION FROM WORKERS'
/.,
PAID.(—Ny'1Z 66a�
COMPENSATION INSURANCE
Rhlssectian need net becampleted if the pcmut b fm one hundred dollars
CU�at—e" Recei t#
gE}yEILSANfI.ARy-SIOgM FA. fiOFT
WATQtItFATER W/VENT/EI.ECTR
ENERGY FEE Y N
0100)orlass.)
I cartifythat le the performance of the work forwhich this permit ie blued,
WATER SYSHM/TREATING
I shall not employ any person In any manner w as to become subject to the
Worknn' Compensation Laws of Callfamla: Date
PAID
NEW RESIDENTIAL I'LMB. SO,Ff.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Ra I tN
TOTAL:
BU G E
Code, you moat forthwith comply with such provisions or this permit Mall be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there hacoestmdlon lendingegencyforthe perfarrry
anceof the work for which thispermit is lsa(Se
ud c.3097, CIv.CJ
Ionder's Name
Lender'sAddm,a
I mrtlfythat I have rmd thhappUmtlanand statethattheabovelnforengton
iscorrect. I agree to complywlth all city and county ordinances and nate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMHIS9UANCE
,
FEES PAID:
relating to building construction, and hereby author representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
agree to save, Indemnify an d keep harmiess the City of Cupertino
againstllabillties, l,dgment =sa aexpenanwhichmaylnanywayacaue
ALTERORADDTOMECH.
Date mm—elm
AIR 14ANDUNC UNIT CID 10,ODO CFM)
SUBTOTAL:
agawtwdCff Inconsequence gnmlr8&this permit.
10�—at-,n-a-- 1-- 2y -!t'>
AIRHANDLINGUNIT(OVERIQ000CFM)
CONSTRUCTION TAX
Signatus of Applicant/Contr Date
eL IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOU' TERIALS DISCLOSURE
HEATING UMT(T0100,000 BTU)
Date ReceI til
Will the applicant or fuuam5WIding occupant store or handle hazardous
material as defined by the upertino Municipal Code, Chapter 9.13, and the
I and Sa(etyC Ion 25532(a)7
HEATING UNIT I00,000 BTU)
TOTAL.
Yea No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Itheapplicant r rebuildingo pantumequipmentwdevim•
which coat hazardous air contamWnts as defined by the Bay Area Air
Ciallty Management f�stryt7 - -
BOILER -COMP OHPOR 100,000 BT1T)
4 Yrs ijrt}D�u'a
Rave read the hoz requirements under Chapter22534..95 of
�
fr
BOILER-COMP(OVFR 100,000 BTU)
the Safety Code, Se
Code, Sections75505;25533and 25536.I
ersta dt Health building
understand that lithe bulldingdceanot currently have ..t:whanL thatit ti my
responsibility to notify the occupant a requlrerrcntawhich moat be mct
Aly h'A
NEW RESIDENTIAL MECIi. SQ.Ff.
dor to Lssuan oaCertifi to parry.
j�IJGj�.�Tt�]�{��J �,
ISSUEDBIY TRW �/ ""—`a�J-
Owner raulhodzed agent Date
70TAL:
OFFICE COPY
M
C�
H y
li �
CL G
CL
L)
UO
_
U. ~
Ow
�a
H y
2
U—
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pro ect Identification
BuBd Ng Addrees:
PERMIT NO.
s s-4,5
23201
one:
— UP,
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAL-PLUMBING-MECHANICAL
Ttradn%•N•ma: eve Lie. No:
1' 1r reC IYIC 96
CATEGORY
CONTROLN GJ
a a'
ArehltM/Engl r, Llc. N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address O
El ❑ 1:1LICENSED
a PERMITISSUANCE
CONTRACTOR'S DECLARATION
Iherebya(firmthatlamllceneedunderpravlsloosof Chapter9(m an
Ingwith Se on7000)of Dlvision3ofthe Busimmand ProfesdonsCode,and my
license bI•fialorycpnd f#
LiceCle
nse LION
AIlpLIANqE4RMDENTIAL A
JOB DESCRHMO�µIc(
P
-W
Date Contractor
201-] AMP"'
ARCHI SDE LARATION
ent myph eased sspubficrecordN
OVER 1000 AMPS
�j Ffj 6lQOREr App
B 'ARE'
��Q. FT.
Licensed essWnsl
OWNC - LDER DECLARATION
I hereby affirm Mu[ I em exempt from the Contractor's License Gw for the
following reason. (Section 70715, Business and Professions Code: Any city or
countywhich requires a permit toconstru, alter, Improve, deolhh,or repair
cim
anyetmchare pdorto its lssuarae,alsorequireslheapplfunt (or such permit to
file a signed statement that he is licensed pursuant to the provblons of the
SIGNS ELEC77UC L
O\NIMH PL CUT
/Q
.1//S ( G Z
TE
R
SPECIALCEICUIT/M1SC
TEMP , METER OR POLE INST.
POWER DEVICES
SWIMMING BOOL ELECTRIC
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi.
Nona of the Business and Professions Code) or that he is exempt therefrom and
VALUATION
the basis for the alleged exemption. Any violation of Section 70015 by any
applicant fora permit sub" b the applicant to a civil penalty of not more than
0[71LE.ISSV.7.fCf IfSHX.ILRES
NEW RESIDENTIAL ELECTA SQ.ET.
fin hundred dollars ($500).
I, as owner of the property, or my employees with wages a• their sole
STORIES TYPE CONSTRUCTION
compensation, wllldothe work, andthe structure Is can intended or offered for
sale (Sec 7074, Business and Professions Code: The Contractors License Law
does not apply to an owner of property who builds or improves thersory and
who does such work himself or through hisown employes, provided that such
OCC. GROUP RES. UNITS
Improvements are not Intended or offered for sale. If, however, the building or
TOTAL:
Impmvementbwld Mthlnonsyearo(caanpldl mtheowner-budderwRl Tuve
ttgLtturden of proving that he did not build or Improve for purpose ofnle.).
u L as owner of the property, am exclusively contracting with licensed
contnctan to construct the project (Sm 7074, Business and Profe••Ions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZDNE APN
PERMITISSUANCE
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pCojecta with •
cgpUactor(•) licensed pursuant to the Contndaa's License Law.
LI I am exempt under Sec. B Is P C for this reason
ALTER -DRAIN k VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS. FLOOR A, ROOF, ARECOND.
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self -Insure, ora
certificate ofWorke 'Compensationlnsurance ora certified copy thereof (Sec.
3800,Iab J
Polity N
FO(711RES PER TRAP
SCHOOL TAX Y N
RECEIPT;
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT'M
Cam anv
GAS F.A.SYSTEM-OVER 4 (EA)
BUILDING DIVISION FEES
-shifted copy 6 hereby furnished. t
CertNed copy b filed with the city Inspection division.
GRFASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECIC FEE
p OV
8 fe
GREASE TRAP
CERTIFICATE OF EKENIPT ION FROM WORKERS'
/.,
PAID.(—Ny'1Z 66a�
COMPENSATION INSURANCE
Rhlssectian need net becampleted if the pcmut b fm one hundred dollars
CU�at—e" Recei t#
gE}yEILSANfI.ARy-SIOgM FA. fiOFT
WATQtItFATER W/VENT/EI.ECTR
ENERGY FEE Y N
0100)orlass.)
I cartifythat le the performance of the work forwhich this permit ie blued,
WATER SYSHM/TREATING
I shall not employ any person In any manner w as to become subject to the
Worknn' Compensation Laws of Callfamla: Date
PAID
NEW RESIDENTIAL I'LMB. SO,Ff.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Ra I tN
TOTAL:
BU G E
Code, you moat forthwith comply with such provisions or this permit Mall be
deemed revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Iherebyaffirm that there hacoestmdlon lendingegencyforthe perfarrry
anceof the work for which thispermit is lsa(Se
ud c.3097, CIv.CJ
Ionder's Name
Lender'sAddm,a
I mrtlfythat I have rmd thhappUmtlanand statethattheabovelnforengton
iscorrect. I agree to complywlth all city and county ordinances and nate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMHIS9UANCE
,
FEES PAID:
relating to building construction, and hereby author representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
agree to save, Indemnify an d keep harmiess the City of Cupertino
againstllabillties, l,dgment =sa aexpenanwhichmaylnanywayacaue
ALTERORADDTOMECH.
Date mm—elm
AIR 14ANDUNC UNIT CID 10,ODO CFM)
SUBTOTAL:
agawtwdCff Inconsequence gnmlr8&this permit.
10�—at-,n-a-- 1-- 2y -!t'>
AIRHANDLINGUNIT(OVERIQ000CFM)
CONSTRUCTION TAX
Signatus of Applicant/Contr Date
eL IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOU' TERIALS DISCLOSURE
HEATING UMT(T0100,000 BTU)
Date ReceI til
Will the applicant or fuuam5WIding occupant store or handle hazardous
material as defined by the upertino Municipal Code, Chapter 9.13, and the
I and Sa(etyC Ion 25532(a)7
HEATING UNIT I00,000 BTU)
TOTAL.
Yea No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Itheapplicant r rebuildingo pantumequipmentwdevim•
which coat hazardous air contamWnts as defined by the Bay Area Air
Ciallty Management f�stryt7 - -
BOILER -COMP OHPOR 100,000 BT1T)
4 Yrs ijrt}D�u'a
Rave read the hoz requirements under Chapter22534..95 of
�
fr
BOILER-COMP(OVFR 100,000 BTU)
the Safety Code, Se
Code, Sections75505;25533and 25536.I
ersta dt Health building
understand that lithe bulldingdceanot currently have ..t:whanL thatit ti my
responsibility to notify the occupant a requlrerrcntawhich moat be mct
Aly h'A
NEW RESIDENTIAL MECIi. SQ.Ff.
dor to Lssuan oaCertifi to parry.
j�IJGj�.�Tt�]�{��J �,
ISSUEDBIY TRW �/ ""—`a�J-
Owner raulhodzed agent Date
70TAL:
OFFICE COPY
M