S 0353 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL � PERMIT NO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL
- O Q
BUILDING PROJECT IDENTIFICATION S
353
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
F:io v6, .
10OROENCP
7�
NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: q RE ❑
11ne cob 96)2H
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) U ELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 um licensed under provisions of Chapter 9(msmmencing JOB DESCRIPTION
Z with Seetion]0(Nl)nf Di vision 3 ofthe Business and Professions Code,andmy licenm is —"-- RESIDENTIAL'
FSB in fullforcellfwceand e PERMIT ISSUANCE ❑SFDWL �HHNREMODEI,
�U~ License a Lie APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBINO RE-PIPE
yUate Contmmor -
ARCHITECTSDECLARAO ❑MULTI-UNIT ❑STRUCTURAL
,x EOyZ Iundemand my pi ons shall be usalrs public records PANELS MODIFICATION
O,'Z,.,Q UP TO 20DAMP5 IEl INTERIOR [I CHIMNEY REPAIR
u1 Licensed Pmfessicnal 201-11"AMPS IMPROVEMENT SWIMMING POOLS
C2•�.1 OWNER-BUILDER DECLARATION OVER 1000AMP5 El BATH RGMODELRIEPAIR DEMOLITION
1 hereby amtll
ffimt I sat exempt from the Parameter's License Law home
O y U following reason.(Section 7031.5,Business and Prnfesome,Code:Any city or county, SIGNS ELECTRICAL ❑OTHER
E O m which requires a permit to amshuct,alter,improve,demolish or repair any structure _
prior o its issuance,also requires the applicant for such permit to File a signed statement PECIAL Cl RCUIT/MISC.
qq p+ that he is licensed purmard,,the provisme,of the Conlmcmrs License Law(Chapter 9
GD (commencing with Section]000)of Division 3 of the Business and Professions Crude)or TEMP.METER OR POLE INST, COMMERCIAL:
a q a y that he is exempt therefrom and the basis for the m 1alacd exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
��m
Section by anyapphimmfor.permitsubjeca the uppliwnt too civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than five hundred dollars($5IXp.
F Z IMPROVEMENT
x6 ❑ I,asowneral'Ihe prosody, myempleyees.r.fRa d anhei(Se,74.1hicompensation,, SWIMMING POOL ELECTRIC
F O will do the wink,and mesodermalhe Cis not s License Law does; of apply to an.Business []OTHER
G m and Professions Code:The Poetaster's Landow Law docs not apply is if owner of OUTLETS-SWITCHES-FIXTURES
hpropertyis men who builds or improves Hereon,and who docs such work
te himself or through -
sal own employees,e building
that such improvements aro on intended or offered for NEW RESIDENTIAL ELECTR Q -
saleJLhowevetthehuilJingorimprovememissoldwithinoneyearofcompletion,the SQ.FT.FLOOR AREA $/SQ.Ff.
n vi er-builder will have the burden of proving that he did not build or improve for Flur-
poseofsoleJ.
TOTAP C
1,m owner of Ne mope",am exclusively canamning with licensed wntmerm to L �^
construct the project(Sec.7044,Business and Professions Code,The Conaac. Li-
cense Use does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a c mmuclons)licensed promartto the Contractors I�II�II
License Luw. PERMIT ISSUANCE JUL 1�
I am exempt under Sec. ,B&P C I'or this,cams
Owner Date - ALTER-GRAIN&VENT-WAFER(EA) 'JAtTbsr
• WO RKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2�p06�'
I herebaffirm under affiunder penalty of perjury one of the roll—in,declamnons
I hale and will maintain a Certificate of Consent mself-insure for Worker's Comped- DRAINS-FLOOR,ROOF AREA,POND. STORIES TYPE CONSTRUCTION
satimm as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 havIERTIFICATE
intact Workers Compensation Insurnn quired by Section
3]00oDlotfor the performance ofihe work w ich this permit is isaueA, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
y Wer �tion lnsumacecmrier and Policy user are: GAS-EA.SYSMM-OVER4(EA)
Cameo Policy Nu:
OF EXEMPTION FROM WOBKERS'
COMPENSATION INSURANCE CREASEIINUUS'TRL WASTF,INTERCEPTOR
BUILDING UI VISION ES
(This sendmineedmt be completed lf0o permforam hard is forahardredd.IIao($I00)
or loses.) CREASE TRAP PLANCHECK FEE
Icertify that in theperfermanceofthe work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.20U FTr•
not employ any person in any manner so as to become subject m the Workeoi Comped- ENERGY FEE
,7s 'mice Laws of Califione.Date WATER HEATER WNENT/ELEM
Applicant t GRADING FEE
IA NOTICE TO APPLICANT.If,after making this Cer ifie to of Exemption,you should WATER SYSTEM/TREATING
a �^ become subject to the Workers Compensation previsions of the Labor Code,you must SOILS FEE
W ry forthwith comply withauch provisions or this permit shall be deemed revoked. WATER SERVICE
Q
O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. - SQ.PT. PAID Date Ri t#
I hereby affirm that there is constructionconstructioneccp
etinn lending agency forihe performance of
the work Par which this permit is issued
ued(Sea 3097.Ci,C)
0.I•+ Lender's Name TOTAL:
Lenders Address TOTAL:
Icertify that I have read this application and state that the shove laws
relmlon Is BUILDING PEE
U h wiled.I agree m comply with all city and county ordinanceses(if and stem lawn r updng he QTY MECHANICAL PERMIT FEE
.0 z 4�T
ngeonsredimmert hereby authorize patipresenmtives of this city brnmr upon the SEISMIC FEE
'teed prose"for inspection purposes. PERMIT ISSUANCE
agree to save,indemnify and keep hmmluss the City of Cupertino against ELECTRIC FEE
igments,costs and expenses which stay in any way accre against said City ALTER OR ADD TO MECH.
cenfthrgmntln(j 'is parol[ PLUMBING PEE
UNDERSND WILL COMPLY WITH A 1.NO -POINT AIRHANDLINGUNIT(TO IIL000CFM)GULAxIM[CHANICAL FEE
AIR HANDLING UNIT(OVER IQWOCFM) CONSTRUCTION TAX
scan amracrr61 Dike EXHAUST HOOD(WMUCT) HOUSING'MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicaal or future building wcigatdrre or handle hazardous namerwl HEATING UNIT(TO HK,BW BTU)
as flood by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety eeb
Code.Section 25532DU - HEATING UNIT(OVER 100,000 BTU)
❑Yes L]No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or Curr,building occupant use equipment or devices which BOILER COMP(3HP OR100,000 RTU)
mit hazardous air contaminants as defined - ,
by the Bay Area Air Quality Management TOTAL.
Dtmtst]
E]Yes ❑No BOILER-COMP(OVER 100,000 BTU)
'
I have re ad the hazardnas materials requirements under Chapter 6.95 or the Cash- AIRCONDITIONER ISSUANCE DATE
demia Health&Safety Code,Sections 25505,25533 and 25534.1 understand shot if the NEW RESIDENTIAL MECH. SQ.ET.
building does nommrendy have a tenant,thin it is my responsibility to notify the occupant
oRhe requirements which must h,met prior to issuance of a Ceniticate of(kcupan,
Ownerorauthsrizedagent - - Date TOTAL: ISSUED BY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL � PERMIT NO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL
- O Q
BUILDING PROJECT IDENTIFICATION S
353
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
F:io v6, .
10OROENCP
7�
NIC CONTROL#
ARCHITECT/ENGINEER: LIC NO: q RE ❑
11ne cob 96)2H
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) U ELE PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 um licensed under provisions of Chapter 9(msmmencing JOB DESCRIPTION
Z with Seetion]0(Nl)nf Di vision 3 ofthe Business and Professions Code,andmy licenm is —"-- RESIDENTIAL'
FSB in fullforcellfwceand e PERMIT ISSUANCE ❑SFDWL �HHNREMODEI,
�U~ License a Lie APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBINO RE-PIPE
yUate Contmmor -
ARCHITECTSDECLARAO ❑MULTI-UNIT ❑STRUCTURAL
,x EOyZ Iundemand my pi ons shall be usalrs public records PANELS MODIFICATION
O,'Z,.,Q UP TO 20DAMP5 IEl INTERIOR [I CHIMNEY REPAIR
u1 Licensed Pmfessicnal 201-11"AMPS IMPROVEMENT SWIMMING POOLS
C2•�.1 OWNER-BUILDER DECLARATION OVER 1000AMP5 El BATH RGMODELRIEPAIR DEMOLITION
1 hereby amtll
ffimt I sat exempt from the Parameter's License Law home
O y U following reason.(Section 7031.5,Business and Prnfesome,Code:Any city or county, SIGNS ELECTRICAL ❑OTHER
E O m which requires a permit to amshuct,alter,improve,demolish or repair any structure _
prior o its issuance,also requires the applicant for such permit to File a signed statement PECIAL Cl RCUIT/MISC.
qq p+ that he is licensed purmard,,the provisme,of the Conlmcmrs License Law(Chapter 9
GD (commencing with Section]000)of Division 3 of the Business and Professions Crude)or TEMP.METER OR POLE INST, COMMERCIAL:
a q a y that he is exempt therefrom and the basis for the m 1alacd exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
��m
Section by anyapphimmfor.permitsubjeca the uppliwnt too civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
not more than five hundred dollars($5IXp.
F Z IMPROVEMENT
x6 ❑ I,asowneral'Ihe prosody, myempleyees.r.fRa d anhei(Se,74.1hicompensation,, SWIMMING POOL ELECTRIC
F O will do the wink,and mesodermalhe Cis not s License Law does; of apply to an.Business []OTHER
G m and Professions Code:The Poetaster's Landow Law docs not apply is if owner of OUTLETS-SWITCHES-FIXTURES
hpropertyis men who builds or improves Hereon,and who docs such work
te himself or through -
sal own employees,e building
that such improvements aro on intended or offered for NEW RESIDENTIAL ELECTR Q -
saleJLhowevetthehuilJingorimprovememissoldwithinoneyearofcompletion,the SQ.FT.FLOOR AREA $/SQ.Ff.
n vi er-builder will have the burden of proving that he did not build or improve for Flur-
poseofsoleJ.
TOTAP C
1,m owner of Ne mope",am exclusively canamning with licensed wntmerm to L �^
construct the project(Sec.7044,Business and Professions Code,The Conaac. Li-
cense Use does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a c mmuclons)licensed promartto the Contractors I�II�II
License Luw. PERMIT ISSUANCE JUL 1�
I am exempt under Sec. ,B&P C I'or this,cams
Owner Date - ALTER-GRAIN&VENT-WAFER(EA) 'JAtTbsr
• WO RKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2�p06�'
I herebaffirm under affiunder penalty of perjury one of the roll—in,declamnons
I hale and will maintain a Certificate of Consent mself-insure for Worker's Comped- DRAINS-FLOOR,ROOF AREA,POND. STORIES TYPE CONSTRUCTION
satimm as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑1 havIERTIFICATE
intact Workers Compensation Insurnn quired by Section
3]00oDlotfor the performance ofihe work w ich this permit is isaueA, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
y Wer �tion lnsumacecmrier and Policy user are: GAS-EA.SYSMM-OVER4(EA)
Cameo Policy Nu:
OF EXEMPTION FROM WOBKERS'
COMPENSATION INSURANCE CREASEIINUUS'TRL WASTF,INTERCEPTOR
BUILDING UI VISION ES
(This sendmineedmt be completed lf0o permforam hard is forahardredd.IIao($I00)
or loses.) CREASE TRAP PLANCHECK FEE
Icertify that in theperfermanceofthe work far which this permit is issued,l shall SEWER-SANITARY-STORM EA.20U FTr•
not employ any person in any manner so as to become subject m the Workeoi Comped- ENERGY FEE
,7s 'mice Laws of Califione.Date WATER HEATER WNENT/ELEM
Applicant t GRADING FEE
IA NOTICE TO APPLICANT.If,after making this Cer ifie to of Exemption,you should WATER SYSTEM/TREATING
a �^ become subject to the Workers Compensation previsions of the Labor Code,you must SOILS FEE
W ry forthwith comply withauch provisions or this permit shall be deemed revoked. WATER SERVICE
Q
O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. - SQ.PT. PAID Date Ri t#
I hereby affirm that there is constructionconstructioneccp
etinn lending agency forihe performance of
the work Par which this permit is issued
ued(Sea 3097.Ci,C)
0.I•+ Lender's Name TOTAL:
Lenders Address TOTAL:
Icertify that I have read this application and state that the shove laws
relmlon Is BUILDING PEE
U h wiled.I agree m comply with all city and county ordinanceses(if and stem lawn r updng he QTY MECHANICAL PERMIT FEE
.0 z 4�T
ngeonsredimmert hereby authorize patipresenmtives of this city brnmr upon the SEISMIC FEE
'teed prose"for inspection purposes. PERMIT ISSUANCE
agree to save,indemnify and keep hmmluss the City of Cupertino against ELECTRIC FEE
igments,costs and expenses which stay in any way accre against said City ALTER OR ADD TO MECH.
cenfthrgmntln(j 'is parol[ PLUMBING PEE
UNDERSND WILL COMPLY WITH A 1.NO -POINT AIRHANDLINGUNIT(TO IIL000CFM)GULAxIM[CHANICAL FEE
AIR HANDLING UNIT(OVER IQWOCFM) CONSTRUCTION TAX
scan amracrr61 Dike EXHAUST HOOD(WMUCT) HOUSING'MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theopplicaal or future building wcigatdrre or handle hazardous namerwl HEATING UNIT(TO HK,BW BTU)
as flood by the Cupertino Municipal Coda Chapter 9.12,and the Health and Safety eeb
Code.Section 25532DU - HEATING UNIT(OVER 100,000 BTU)
❑Yes L]No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or Curr,building occupant use equipment or devices which BOILER COMP(3HP OR100,000 RTU)
mit hazardous air contaminants as defined - ,
by the Bay Area Air Quality Management TOTAL.
Dtmtst]
E]Yes ❑No BOILER-COMP(OVER 100,000 BTU)
'
I have re ad the hazardnas materials requirements under Chapter 6.95 or the Cash- AIRCONDITIONER ISSUANCE DATE
demia Health&Safety Code,Sections 25505,25533 and 25534.1 understand shot if the NEW RESIDENTIAL MECH. SQ.ET.
building does nommrendy have a tenant,thin it is my responsibility to notify the occupant
oRhe requirements which must h,met prior to issuance of a Ceniticate of(kcupan,
Ownerorauthsrizedagent - - Date TOTAL: ISSUED BY:
OFFICE