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99080097 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION By1L6N4TD5ERr SANITARY NO. MMO&MM 1 «� s>;¢,-Sou ��. Ow-ER'S NAME: PHONE: CONTRACTOR'S NAME LIC NO: u'L Al ET 3215-621 - / T N/C CONTROLp IITECVENGINEQR. LIC NO: ADDRESS: N G ❑ ��� 7r5AV r—PN'�t C'21-)76 CONTACT: �p PHONE: BUILDING PERMIT INFO T*v ID CT c6—;?a Cr` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH l P Y" LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE affirm that I am licensed under provisions.f Clearer 9(commencing JOB DESCRIPTION �0C with Section](100)Of Division 3ofthe Business and Pmfex,ens Code,and my license is PERMIT ISSUANCE RESIDENTIAL: Fq F in full force and effect. ❑SFDWL ❑KITCHEN REMODEL 6Vw License Class Contractor APPLIANCES-RESIDENTIAL DDITION C1 PLUMBING RE-PIPE F.^�a Uete TS DELL On ARCHITECTS DECLARATION ❑MULThUNIT ❑STRUCNRAL Fy Z lundersmnd my plans shell be usedmepublic records PATOIS ���� MODIFICATION 0Z�JQ I UP TO 200 AMPS Il7INTERIOR [I CHIMNEY REPAIR NaW Licensed Professional 201-10 N..F. N10AMPS IMPROVEMENT ❑SWIMMING POOLS OWNER-BUILDER DECLARATION OVER I000 AMPS [I BATH REMODEUREPAIR [I DEMOLITION yy tY Q I hereby affirm that I am exempt from the Contractor's License Law far the following reason.(Section 7031.5,Business and Professions Code,Any city or county SIGNS ELECTRICAL []OTHER VLL71 so,na which requires issuance.permit ac uirnwd,niter,improve,demolish, repair any ewemre Aof 4 mJ priori.slcensedpursuant acquires the theapions o thefor such Contractors Licefile. Law(ical chapter SPECIAL CIRCUIT/MISC. S 'T� �F, } thinio islicensedpurtion7 the provisions of the,Business License Inw(Chaps) 9 Qp (commencing with Section 7")of Division 3nf the Business and Pmlessi.nsCWe)or TEMP.METER OR POLE INST. COMMERCIAL, 6 ce yy that he is exempt therefrom and the basis for the alleged exemption Any violation of EW BLDG/ADDITION ❑DEMOLITION iC cols. Section 7031.5 by any applicant for a permit xubje<u the applicant I..civil penalty of POWER DEVICES ANT ❑FOOD SERVICE ey il F. not more Nan five hundred dollars(SSW). �4 ROV ENT F Q I,us owner of the norm to ees with wa csnstheir sole core nsution. SWIMMING POOL ELECTRIC ❑ ln, Y Y. Y g M1 Itis d dotheime Cade:The o.,isnot.Licensnrtieso,ot apply 1.im Nosiness ❑OT 1 u1 aroerlywhoh Cade:The Contmctuo License Law dodoesoat work hi toll ownergh 17 OVI'LETS-SWITCHES-FlXTURES 6 3^ his o Properly who builds or improves thereon, pr who does such work himself or through his own employees.provided that vao improvements arc one intended or plcrcd for NEW RESIDENTIAL ELECfR SQ FT. sale.ILhowever,the building or improvement is sold within ane year of completion,the SQ.PT.FLOOR AREA LSQ.FT. t o ner-builder will have the burden of praying that he did not build or improve for pur- a Q Pose ns len), \'�8 r of the pmpery,um exclusively countering with licensed earousue,t. L' consumer the finical(Sec.]014,Business and Professions Code:)The Contractor's Li- cameLawdoesnotapplytoanownerofpmpTywhobuildsorimprovesdamogaM QTY. PLUMBING PE I who contracts for such Projects with a contracrogs)licensed mustand d to the Contractor's License Luw. PERMIT ISSUANCE ❑Ian exempt on Sec. .9&PC for on,reason n �� nr- ALTER-DRAIN&VENT-WATER(EA) VALUATION G , Date� /p�� U jWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �0 V O O 1 hereby affirm under SPenaltyCOM of perjury One of the fallowing declarations:: .dvesnd will maintain a Cenificatn of Comm to self-insure for Workers Courtlier- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRUCTION sation,as provided for by Section 3]00 of the Labor Cade,for the performance of the work for which this permir is issued. FIXTURES-PER TRAP ❑1 have and will trminmin Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for Be performance afdre work for which this pemdt is issued Z GAS-EA.SYS OCC.GROUP My Workers Compensation Insurance carinand Policy numberan: e) 3b Cornier: Policy NO.: GAS-EA.SYS - ) O CERTIFICATE OF EXEMPTION FROM WORKERS' Z COMPENSATION INSURANCE GRIiASFJINDU WASTE INTERCEPTORBUILDING DIVISION FEES (This section need not W Completed ifthe Perot is income hundred dollars(SIM) GREASE TRA p orless) O PLANCHECK FEB Ioyany that in the Performance The as for subject ich jetttio arms is Me uCompell SEWER-SANTARY-STORM EA.200 FT. not employ any person in any manner so as r0 become mbjeeuo the Workers'Cnmpcn- ENERGY FEE OZ sation Laws of Califumia.Date ' WATER HEATJ�VIENTMLEMR Z O Applicam GRADING rN. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMUREA'FI (-' became subjeet to the Workerh Workers Compensation provisions of the Lar Cade,you most SOILS FEE a forthwith comply with such Provisions.,,his permit shall be deemed revoked WATER SERVICE Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PT. PAID L)O l hereby affirm that Nem is a construction lending agency fortbe performance of Dat RecciprM H the work for which this permit ii issued(Sec.3097,Civ.C.) u" Lender's Name TOTAL: 0 U Lenders Address TOTAL. BUILDING FEE 1 eerify thre at 1 have au)this application and nate that the shove information is rF. h correct.l agree to comply with all city and county ordinances and state laws miming to QTY, MECHANICAL PERMIT FEE (.) Z building conwuction,and herchy authorize representatives of this city to enter upon the SEISMICFEE above-mentioned property for inspection purposes PERMIT ISSUANCE (We)agree to save,indemnify and keep hafmless the City of Cupertino against ELECTRIC E Iiebilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the gmatiag of mix perm,, PLUMBIN APPLICANT UNDERS WPLILWITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(i MECHA F SOURCEREGUL HIS 9/vyI AIR HANDLING UNIT(OVER 1O."CFM) CONST'RU TAX Signore of A,,branVCommaor Dam EXHAUST'HDGD(W/UUCP) HOUSING MIT ATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicum ar Treace building mcupanurnrc.,handle Warcdaus ma.dal HEATING UNIT(TO 100,000 BTU) as defined by Be Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade,Section 25532(x)'! HEATING UNIT(OVER 100.000 BI II) ❑Yes Fl No VENTILA'r1GN PAN(SINGLE RESID) PAID "- Date Receipt Will the it contaminants or tutu.handing by the bay y A equipment or devices which emit hezallous sir comaminanrs a defined 0y the Buy Area Air Quality Management BOILER-COMP(JHP OR 1 W,qq BTU) TOT L: District? BOILER-COMP(OVER 100,00s)BTU) ❑Yes F7 No s I have reed the hezvdous materials.quirements uMer Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE fomis Health&Safety Caere.Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.PT. buildingd n'..tcutrent num,that it is my rcxPmsibility mn.tify the scupam / '— Z 3^Y� of the require m ich moa rssuancc ofa CC Owner or authe a to TOTAL ISSUED By. OFFICE APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION By1L6N4TD5ERr SANITARY NO. MMO&MM 1 «� s>;¢,-Sou ��. Ow-ER'S NAME: PHONE: CONTRACTOR'S NAME LIC NO: u'L Al ET 3215-621 - / T N/C CONTROLp IITECVENGINEQR. LIC NO: ADDRESS: N G ❑ ��� 7r5AV r—PN'�t C'21-)76 CONTACT: �p PHONE: BUILDING PERMIT INFO T*v ID CT c6—;?a Cr` ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH l P Y" LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE affirm that I am licensed under provisions.f Clearer 9(commencing JOB DESCRIPTION �0C with Section](100)Of Division 3ofthe Business and Pmfex,ens Code,and my license is PERMIT ISSUANCE RESIDENTIAL: Fq F in full force and effect. ❑SFDWL ❑KITCHEN REMODEL 6Vw License Class Contractor APPLIANCES-RESIDENTIAL DDITION C1 PLUMBING RE-PIPE F.^�a Uete TS DELL On ARCHITECTS DECLARATION ❑MULThUNIT ❑STRUCNRAL Fy Z lundersmnd my plans shell be usedmepublic records PATOIS ���� MODIFICATION 0Z�JQ I UP TO 200 AMPS Il7INTERIOR [I CHIMNEY REPAIR NaW Licensed Professional 201-10 N..F. N10AMPS IMPROVEMENT ❑SWIMMING POOLS OWNER-BUILDER DECLARATION OVER I000 AMPS [I BATH REMODEUREPAIR [I DEMOLITION yy tY Q I hereby affirm that I am exempt from the Contractor's License Law far the following reason.(Section 7031.5,Business and Professions Code,Any city or county SIGNS ELECTRICAL []OTHER VLL71 so,na which requires issuance.permit ac uirnwd,niter,improve,demolish, repair any ewemre Aof 4 mJ priori.slcensedpursuant acquires the theapions o thefor such Contractors Licefile. Law(ical chapter SPECIAL CIRCUIT/MISC. S 'T� �F, } thinio islicensedpurtion7 the provisions of the,Business License Inw(Chaps) 9 Qp (commencing with Section 7")of Division 3nf the Business and Pmlessi.nsCWe)or TEMP.METER OR POLE INST. COMMERCIAL, 6 ce yy that he is exempt therefrom and the basis for the alleged exemption Any violation of EW BLDG/ADDITION ❑DEMOLITION iC cols. Section 7031.5 by any applicant for a permit xubje<u the applicant I..civil penalty of POWER DEVICES ANT ❑FOOD SERVICE ey il F. not more Nan five hundred dollars(SSW). �4 ROV ENT F Q I,us owner of the norm to ees with wa csnstheir sole core nsution. SWIMMING POOL ELECTRIC ❑ ln, Y Y. Y g M1 Itis d dotheime Cade:The o.,isnot.Licensnrtieso,ot apply 1.im Nosiness ❑OT 1 u1 aroerlywhoh Cade:The Contmctuo License Law dodoesoat work hi toll ownergh 17 OVI'LETS-SWITCHES-FlXTURES 6 3^ his o Properly who builds or improves thereon, pr who does such work himself or through his own employees.provided that vao improvements arc one intended or plcrcd for NEW RESIDENTIAL ELECfR SQ FT. sale.ILhowever,the building or improvement is sold within ane year of completion,the SQ.PT.FLOOR AREA LSQ.FT. t o ner-builder will have the burden of praying that he did not build or improve for pur- a Q Pose ns len), \'�8 r of the pmpery,um exclusively countering with licensed earousue,t. L' consumer the finical(Sec.]014,Business and Professions Code:)The Contractor's Li- cameLawdoesnotapplytoanownerofpmpTywhobuildsorimprovesdamogaM QTY. PLUMBING PE I who contracts for such Projects with a contracrogs)licensed mustand d to the Contractor's License Luw. PERMIT ISSUANCE ❑Ian exempt on Sec. .9&PC for on,reason n �� nr- ALTER-DRAIN&VENT-WATER(EA) VALUATION G , Date� /p�� U jWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �0 V O O 1 hereby affirm under SPenaltyCOM of perjury One of the fallowing declarations:: .dvesnd will maintain a Cenificatn of Comm to self-insure for Workers Courtlier- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYPECONSTRUCTION sation,as provided for by Section 3]00 of the Labor Cade,for the performance of the work for which this permir is issued. FIXTURES-PER TRAP ❑1 have and will trminmin Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for Be performance afdre work for which this pemdt is issued Z GAS-EA.SYS OCC.GROUP My Workers Compensation Insurance carinand Policy numberan: e) 3b Cornier: Policy NO.: GAS-EA.SYS - ) O CERTIFICATE OF EXEMPTION FROM WORKERS' Z COMPENSATION INSURANCE GRIiASFJINDU WASTE INTERCEPTORBUILDING DIVISION FEES (This section need not W Completed ifthe Perot is income hundred dollars(SIM) GREASE TRA p orless) O PLANCHECK FEB Ioyany that in the Performance The as for subject ich jetttio arms is Me uCompell SEWER-SANTARY-STORM EA.200 FT. not employ any person in any manner so as r0 become mbjeeuo the Workers'Cnmpcn- ENERGY FEE OZ sation Laws of Califumia.Date ' WATER HEATJ�VIENTMLEMR Z O Applicam GRADING rN. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMUREA'FI (-' became subjeet to the Workerh Workers Compensation provisions of the Lar Cade,you most SOILS FEE a forthwith comply with such Provisions.,,his permit shall be deemed revoked WATER SERVICE Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PT. PAID L)O l hereby affirm that Nem is a construction lending agency fortbe performance of Dat RecciprM H the work for which this permit ii issued(Sec.3097,Civ.C.) u" Lender's Name TOTAL: 0 U Lenders Address TOTAL. BUILDING FEE 1 eerify thre at 1 have au)this application and nate that the shove information is rF. h correct.l agree to comply with all city and county ordinances and state laws miming to QTY, MECHANICAL PERMIT FEE (.) Z building conwuction,and herchy authorize representatives of this city to enter upon the SEISMICFEE above-mentioned property for inspection purposes PERMIT ISSUANCE (We)agree to save,indemnify and keep hafmless the City of Cupertino against ELECTRIC E Iiebilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the gmatiag of mix perm,, PLUMBIN APPLICANT UNDERS WPLILWITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00(i MECHA F SOURCEREGUL HIS 9/vyI AIR HANDLING UNIT(OVER 1O."CFM) CONST'RU TAX Signore of A,,branVCommaor Dam EXHAUST'HDGD(W/UUCP) HOUSING MIT ATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicum ar Treace building mcupanurnrc.,handle Warcdaus ma.dal HEATING UNIT(TO 100,000 BTU) as defined by Be Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade,Section 25532(x)'! HEATING UNIT(OVER 100.000 BI II) ❑Yes Fl No VENTILA'r1GN PAN(SINGLE RESID) PAID "- Date Receipt Will the it contaminants or tutu.handing by the bay y A equipment or devices which emit hezallous sir comaminanrs a defined 0y the Buy Area Air Quality Management BOILER-COMP(JHP OR 1 W,qq BTU) TOT L: District? BOILER-COMP(OVER 100,00s)BTU) ❑Yes F7 No s I have reed the hezvdous materials.quirements uMer Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE fomis Health&Safety Caere.Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.PT. buildingd n'..tcutrent num,that it is my rcxPmsibility mn.tify the scupam / '— Z 3^Y� of the require m ich moa rssuancc ofa CC Owner or authe a to TOTAL ISSUED By. OFFICE