10296 POST THIS CARD NEAR FRONT OF BUILDING eRMITNUMBER
�.. .: CITY OF CUPERTINO ,
} INSPECTION DIVISION
JOB INSPECTION RECORD.
iIts .PERMIT EXPIRATION
JOB ADDRESS UNIT# .LOT# •pERMIT.EXPIRES IF WORK
OWNER CONTRACTOR ft LOVFPpr. ' ' IS NOT STARTED WITHIN
INSP CTI N DATE INSPECTOR INSPECTION RECORD 180 DAYS of PERMIT ISSU,
FOUNDATION - , . J _5r6 7-AQA-/,V 7—A—/,V
ANCE OR '180 DAYS FROM
- ,
LASTCALLED INSPECTI
UFER ON.
PR EGUNITE
,PERMIT VALIDATION q
� � �
I
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ,{ ^ •/ -"
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL
I SUANCE GATE
MECHANICAL .BLDG. LEcr. PLG. MECR
O '
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED auILOING PERMIT
_ INFORMATION
WOOD-FLOOR V UATION slFr.
PLUMBING
MECHANICAL- +� '
ELECTRICAL _ a PE IT To
FRAMING •.
INSULATION STORIES I TYPE CONSTR."
' .00C.GROUP RES.UNITS,
P^.
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED \
_ ROOF SO,FT.FLOORAREA TOTALACREAGF,•
1
DIAPHRAGM
BUILDING USE
' NSIGNED
RES IND ,C,O�N/8 Omer11
APPLY NO ROOFING UNTIL ABOVE HAS BEP
. ASSESSORS PARCEL NO.
ROUGH
. PLUMBING '
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL -
ACC.DATEACC.FI LE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING, SAN # zoNlNc .ENc.srtE No.
INSULATION PLUMBING'
- GAS
`
FIRE SPRINK ENERGY T 24•e MECHANICAL Y* .N� Y E-] NE]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
LATH—INTERIOR ELECTRICAL •. FLOOD ZONE A.L.U.C..
. LATH—EXTERIOR FIRE DEPT. Y❑ N� Y I] N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR - - BUILDING
SHEAR EXTERIOR' 'TEMPORARY APPROVALS' BUILDING - r// .F, , •,
FIREWALLS ELECTRIC PLAN CHECK' .
IFEE
GAS,
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY — SEISMIC FEE'
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL_ISSIGNED.BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR-INSPECTION BY PHONING 252-4505, - ELECTRIC
�� ONE WORKING DAY BEFORE REQUIRED INSPECTION. , P:IUMeING' '
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
— SEE PERMIT FOR EXPIRATION.DATE, MECHANICAL
CONST.TAX
} IMPORTANT!
PLEASE READ REVERSE SIDE,BEFORE -TOTAL
CALLING FOR FINAL INSPECTION. .I
OFFICE COPY •' .. .. '
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT,PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
-� BUILDING APPLICATION & PERMIT 10296
ADDPE
.�. h IsXl- BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
�EI Z
�wNE s
NAME The GroLN/ el V�'WI��Q PLAN CHECK VALIDATION
/ ATV. ELECTRIC PERMIT FEE ,
PHONE
CONT CTOR'a
r UTLETS-SWITCHES-RECEP 10.00/1.00
M Coal uc tort
h uc.rvo. y� LIGHTING FIXTURES 10.00/1.00
04 f-ONTRACT R'S .(�
- DOREss J. �8 ��1s c�1 APPLIANCES-RESIDENTIAL 4.00
' PHONEPJ / PANELS 10.00 DATE OF APPLICATION
OR
PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENa. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESLICAS
AD MOTORS SEE FEE SCH.
` /
1,09(3oAI . OQ 2 lod GC SERVICE CHANGE 20.00 I/'3986
w o o
LICENSED CONTRACTORS DECLARATION TEMP.POLE D 30.00
ri w I hereby affirm that I am licensed under provisions of Chapter 9 I N
< . (commencing with Section 7000)of Division 3 of the Business and r BLDe. E CH.
D4 z Professions CoJ nJ my license is in full fpr I b 1 G �( ❑ ❑
Zo i m o to Class Con Not-
l-, XL_I�
F w J te Contra s
W S, w a OWNER-BUILDER DECLARATION UDQ'`IUO BUILDING PERMIT.
Ur INFORMATION
X 3:A y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
ea u O < Law for the following reason.(Sec.7031.5,Businessand Professions VALUATION $/FT.
- m PERMIT ISSUANCE '10.00
Fw> Code:Any city orcounly which requires a permit to construct,alter, iry.n
Q Q Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 9 1 V r'
n wO u requires the applicant for such permit to file a signed statement that TOTAL ��Fl PERMIT TO
$m he is licensed pursuant to the provisions bf the Contractor's,License ,
H i > Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe /n`zz•T��LQ,Q d��t
a o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE !
X I- $ the basis for the alleged exemption.Any violation ofSection.7031.5 - STORIES TYPE CONSTR.
by any applicant fora permit subjects the applicant to a civil penalty ' ALTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars($500).):
❑ 1,as owner of the properly,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their sale compensation,will do the work,and the structure is not
intended of offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 5,00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES=PER TRAP 5,00 BO.FT.FLOOR AREA TOTAL ACREAGE
• himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-i INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
huilder will have the burden of proving that he did not build or im- REB IND CON PB OtM1e,
move for purpose ofsaleJ' INDUSTRIAL WASTE INTER. 30.00 C3 0 ❑
❑ 1,as owner of the property,am exclusively contracting with El
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 - ASSESSORS PARCELNO.
and Professions Code:The Contractor's License Law does riot apply
to an owner of property who builds or improves thereon,and who LAWN SPRINLCLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM.EA.200ft/10.00 TRACT NO. -PARCEL NO.
❑ lam exempt under Sec.-,B.&P.C.for this
reason WATER HEATER WIVENT 6.00
Owner Date WATER SYSTEM 5.00 - ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00 ,
I hereby affirm that I have a certificate of consent In selbinsure, -
1 or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
-N copy thereoff5ec.3800,Lab.C.
Pnlicyy��!'o. Company Qle -
0 WCe if red copy rs here by furnished FIRESPRINK ENERGY T44
z ❑ C r Ie o filed v the city inspection division. MISC.- REFER TO ORD.
O Applic tt (j �-e V N V N
Fvi - PERMIT ISSUANCE 10.00.' FLooD zoNE A.L
O: - CFRTIFI F.OI'EXEMPTION FROM WORKERS' J.C.
LU - COMPENSATION INSURANCE PLG.CONTR. - LIC.NO. PLG.
d O (This Section need not be completed if the permit is for one TOTAL Y❑ N� Y❑ NQ
D Z hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
0 W Dam Applwant BUILDING Sa
a ALTER OR ADD TO MECH. 5.00
}
on NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F" 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK y
provisions of the Labor Code, you must forthwith comply with FEE .2O
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,000QF.M.) 6.00 SEISMIC FEE sa
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the
i
er performance of the work for which this permit is issued(Sec. MICROFILM
3097, HEATING UNIT ITU 100,000 B.T.U.) 8.00
Lender's Name H EATING UNIT(OV ER 100,000 B.T.U.)9.50 O`Z
Lender's Address �' ' ELECTRIC
I certify that I have read this application and ,are that the shove VENTILATION FAN (SINGLE) 4.00
information is street.1 agree to comply with all city and county - PLUMBING
ordinances and orate laws relating to comply
with all
city and c, and BOILER•COMP(3 H.P.or 100,0008.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Ova,100,000 BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and ezpenses which CONST.TAX
y in any wa accrue against said City in consequence n(the PERMIT ISSUANCE 10.00
g ti of this c U. MECH.CONT. LIC.NO. MECH.
L` t m . ' OVA E - TOTAL TOTAL 93 14
ignature Applicant/Contractor Date
' OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILIsNi- LLLCI'RICAL PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL g]Q e O C
BUILDING DIVISION BUILDING PROJECT'IDENJIFICA'I']ON LJ
/ILDING ADDRESS: �y ��f� �j SANITARY NO. A%'LICAT11ONSUB/MM1TTALDATE
- S a r T•.�� • D UNITM ,`� LOTp 6 �
WULR AME,: PH ACTOR'S NAME!: LIC NO�. J N
/`.CVL N2 CONTRDLp
A C h GINE LIC NO: DRESS: - ❑
r
rvTACT. QTY. ELECTRIC PERMIT FEEPHONE: �J� B ECT
BUILDING PERMIT INFO
.1;K `e .0 B MEC
PERMIT ISSUANCE atata
LICENSIiD CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIFnON
Oyez Ihereby affirm thalamliceueJ unJttprovisiouofChapmr9(commencingwiN
¢00 Section TWO)of Division 3 of Ne Business and Professions Code,and my license is in PANELS
FC UsO, full forectnd effect.
<z License Class Lue.M UP TO 200 AMPS
y<y Dae Contractor 201-1000 AMPS
FyOVER IOW AMPS
Z ARCHITECT"S DECLARATION SQ.FT.FLOOR AREA $/SQ.IT.
0 z m I undcrswnd my plans shall M used as puM1lic rtconcs. � �
4 �W,..11 SIGNS ELECTRICAL
y J Licensed Professional
�y0 U OWN[R-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�d0y I hereby affirm that I am exempt from the Contracmrs License Law for the
W 300r following crown.(Section 9031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE.INST.
k:rn<_1 which requims a permit m construct,alter,improve,demolish,or repair any somehow
f Wy2 poor o its issuance,also requires the applicant far such Permit to file a signed statement POWER DEVICES
<0 that he is licensed parmaafto the provisions of the Contractor's License Law(Chapter
yyo 9(cemmencing with Section 7000)nf Division 3ofthe Bmineasand Professions Cate) WIMMING POOL ELECTRIC VALUATION
y)�y or than he is exempt herefcan and door huts for the alleged nemplion.Any violation of ���
Y Section 7031.5 by any,applicant fora permit subjects the upplicam to a civil pcnWty of UTLETS-SWITCHES-VENTURES
Cnot more than five hundred dollars($50E.
KK ❑ I,uowncrof theproperry,mmyemplOyceswi@wagesuNeirsolecompcuation. NEW RFSIDENDALELECTR _SQ.FT. STORIES L TYPECONSTRUCTION
y3$ will do the work,undthestmcmre'nnot imandedoroffncedfor sale(See.7044.Business
and Prafeuions Code:The Commerce s License Law does oat apply to an owner of
properry who bui Ids or improves thcrecn,and who does such work hi mal f or through his
cmployces,provided that such improvememsare not intendedoroffered forsale.If, OCC.GROUP ENITS
however,the building or improvement is sold within one year ofcomplaion.the owner- L
builder will have the burden of proving that he did not build or improve for propose of
sale.).
❑ LasownerofthepraI,rr mexelusivelycontra wiN liceved<onweton to QTY. PLUMBING PERMIT FEE FLOOD ZONEN
construe the project(Sec.7044,Business and Ro asi Cade:)The Contractor's
Licerase lswdcesnotupply roan ownerofpmpen rebuilds impmveathenno.and P17RMIT ISSUANCE
whocomracm for such projects withawnuucto Fee
pureu umhe Contractor's ALTER-0RAIN&VENT-WATER FA
License Law. E- ) FEESUMMARY
❑ I am eaempr under Seo. ,B A P or this reason BACK FLOW PR01IFgtGICE
SANITARY Y N
Owner Dat° DRALNS-h100 OGF.AREA,CON RECIi1PfN
W MANCOMPFNSATLON DECLARATION SCHOOL TAX Y N
❑ Ihereby nf0r thmlhuveecenificam of conunno self-insure,or ace 'ficute of FlXTURIi. 'F.R TRAP RECI?I p
Workera'Compere ten lnaumere or acenified copy thereopSec.3800.Lab )which PARK FEE Y N
covers eOemployee ,lor!hispermit. GAS- A.SYSTEM-IINC.4OUTLEI'S RE .PTg
Policy M BUILDING VISION FEES
Company S-FA.SYSTf:M-OVER 4(EA) PLANCHECK FEE
❑ Cornified copy iso by famished.
❑ Certified copy is fil with that lame, n vi, . GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
( CERTIFlCA EOPEX O OMR S' GREASETRAPnQ SOILS FEE -
C PUNS A [IRANCE
(Thnseaionneednotbe ompl r Ferranti. E$iti.for all drM dolhm ) S •R-S T - a ORM ENERGY FEE `
ones$.)
I cenifythut lathe ptdo reacAde for sine dhispermitis issued, :hall WATER /VF
not employ any person in any anner so m to E oma subject to the Wr kers' PAID
Compensation Lowe of Celifmmie. Dene T R S RF.9i5 Dam
O z Applicant
z NOTICE TOAPPLICANT:ILafter n ingt Cenifi<amofF:xemption,you a cold RFSID A\rLMB, SQ.F1'. AL:
h become subjecuo the Wail Compens evisiorts of the Labor Cwle,you mt
fvainvuh comply with such provisions or this permit shall he JeemeJrevoked. BUILDING FEGJn �.+
I" SEISMIC
CONSTRUCTION LENDING AGENCY
L) z I herebyaffirm that there is u construction lendingagency for the perfmmunce o ELF.CIRI
O the work for which this pcomt is issucd(Sea 3099,Civ_C.)
Lendeee Nnme
Ua P Leader's Address MEC! 0.1 PL PERMIT FEE Plu
O V 1 ccnify thar 1 have read this application and amte tom the above information is MEC! A Fli
Uj connect.l egrecm comply with all city and ceunry enclosures end slate laws relining to PERMIT!" ANCE OW
hbuildingconsuu<rien,and hereby aulhmrim rtpresentadives efthisciry reamer uponrhe CONSTRUCfIONT X
U z ahwr torch met p6ve,inderamiyarmikerpharroulasallue
oollchco n rposes. RCI'ER OR ADD TO MECH.
(We)agree a Ciry of Capmino againstliabilities,judgmennd expenses whichmey in any way accrue nguinst said Ciry AIR HANDLING UNIT(TO 10,000 CFM)
convey aceofng of t s pe
��ft
AIR HANDLING UNIT(OVER 10,(101!1 CFM)
rgnaure of Appl enVComm nr Dene EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CTO 100,000 BTU) Date Ramipta
Will theupplicam or future buildingoccupantstoreor handle hazurdum materia! HBATING UNIT(OVER 100,000 BTU) T -
n
as defined by the Colston.Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(8)7 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUJCEDA'M
Willthe applicmmrfmurc buildingcemcupenseeq (JHuipmentnrdevices whichemit BOILER-COMPPOR IW.000BTU)ma doses aicontaminants u defined by the Bay Arca Air Quality Management BOILER-COMP(OVER IN."BTU)
Mauldl
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.1 have read the haaancous materials mat iremems under Chapter 6.95 of the
California Health&Safety Cade,Sections 25505,25533 and 25534. 1 undcrsmnd that (�//a
if the building does not currently have a anent,that it is my responsibility to notify the I„H
Ocupunt of the reyuiremems which must be met prim w issuance of a Cenificam of y
rculwncy.
Owner or amhadeed agent Date ISSUED BY: f ,J
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PEIWfr No. �S O O
BUILDING DIVISION APPIdCAT10N/PERMIT PIA MB NG-MECHANICAL V\ J{ VX
BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADDRESS: )) SANITARY NO. APPLICATION SUBMITTAL DATE
b 20 c 13 A ' u lCAL v- ZK- 4
OWNERS NAME: PHONE: CO RACTOR'S NAM LIC NO: NAC CONTROL#
er l)!1 _ yaq�L ` /J2
AR HITECT/[NGINIiEN: LIC NO: Ap1)}{yJ 1�L/rwd jr l��a�+^LL I' ❑
CONTACT: PHONE: Yom%) BUILDING PERMIT INFO
El Fees Paid by Applicant(Initial) BLDG ELE❑CT PLUMB MECH
��
CU
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby i firm that I am licensed under provisions of Chapter 9(commencing
CizZ with Section]tN10pdUivision3ofthe easiness and desslons Code,andntyicemeis RESIDENTIAL:
W O O PERMIT ISSUANCE?
F1_ in full force and effect. ❑SPDWL ❑KITCHEN REMOD17L
<Zu Li _ se Cls Lie.# APPLIANCES-RESIDFMIAL []ADDITION ❑PLUMING RE-PIPE
F Z W Contmeoe
en6G [I MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECI,A ATION
Z O r.Z 1 understand my plans shall be used as public ra,md, Gym PANELS MODIFICATION
OZ4Q UPT0200AMPS El INTERIOR [I CHIMNEY REPAIR
F4`L,{A Licensed Pre
fewionel 201-1000 AMPS IMPROVEMENT E]SWIMMING POOUS
.scF, O
id '� OWNER-BUILDER DECLARATION OV17R 10110 AMPS [I BATH REMODEIJREPAIk El DEMOLITION
C 111 1 hereby stand(Second
11. exempt from the CnnlraalCoi license taw fur,the
yxO S V following reason ISemion]011.5,Business and Pml'evsinnu Calc:Any city nr coumY SIGNS CLECI'RICAL COTTER
W'3 i,F which requires a permit m cmadmor ,.:dtvr,improve,demolish,nr repair any someone
0 prior to it issuance,also requires the applicant for such pemrid to rileesigned stademend SPECIALCIRCt11TIMISC.
fEp��rr�N�Da]y ihul be is licensed pursuanuo the provisions of the Contractor's License Law(Chapter 9
Ia1000 (commencing with Section70uffof Division 3ofthe Bminessand Profusinnn Gsle)ar TEMP.ME]ER OR POLE INST, COMMERCIAL,
OL p� that he is exempt Nerefrotn and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicam for a permit subjects the applicant to a civil penalty of POWER DEVICES OTENANT El FWD SERVICE
FZY nrl more than rive hundred delta.3500). IMPROVEMENT
SQp ❑ I.ass owner of the property,or my employees with wages as throw,oleuom,,conion, SWIMMING POOL ELECTRIC
p.
will do the weak,and the structure is not intended oreffcred I...le(See.]0,W.Desires, ❑GTIIIiR
mnil trnfevsiuns Celle:The Commcmrr License Law Aucs not apply to an owner of OUTLETS-SWITCHES-FIXTURES
3.. prnpeny who builds m improves thereon and who does such work himself,uthrough 'n..
, 1
his own employee,provided that such imtrovemermrc anod intended u offered for NEW RISIDEN9'IAL ELECIR SQ Ff.
role.IL however,the building or improvement is sold within onewarofconutdcaun.the SQ,1-7.FLOOR AREA 5/SQ.FT.
owner-builder will haw me burden of proving that he did not build or improve forpar-
of sale.).
h m owner of the property,am exclusively contractingcontracting with IicenveJ contractors m TOTAL
L]
construct the project(See 7846,Business and Potassium Code:)Me Conlmcmfs Li-
c se Lawdoes nod apply oanoommofpmpeny who mddcor lmpovw thereon,and Q•1'V. PLUMBING PERMIT FEF. /JD/
who contracts forsuch projects with a uvowctor(s7 lieenud pursuant to the Communes 11//
License law. PERMS"r ISSUANCE.
❑ I on.exempt..our Sec. .If&P C for thin rcaan
ALTER-DRAIN&vuNT-WATER(EA) HON
Owner Data /�
WORKER'S COMPENSATION DF.CIARA'1'ION If ACK FLOW PROTECT.DEVICE 1 ,y
I hereby affirm under penuhy ef,rimy nue of rhe following declarations. i
t ❑ Ihave vnJwillmaintainsCenifica¢ofCnmenuoself-annum for Worker's Cooper. DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
secant,as provided for by Section 3700 of Ne labor Code:for the performance of the
work for which Ibis permit is issued. PUG GRES-PER TRAP
1 have and will random Worker's C9nrpcnsation Insurance,as required by Section
for which this permilis issued. GAS-EA.SYSTEM-I INC.6 OUT LETS OCC.GROUP APN
]IXl of the Labor Cada,for the perlormanee of the work
Worker's Compenxalion Inwmnce carjer amt Policy number are:
r. Policy No; GAS-EA.SYSTEM-OVER 6(EA)
CF.RTULCATE OP EXEMPTION MOM WORKERS' GRE,ASI%INDUSTRI.WAS9'E INL'[RCF.ITOR
m COMP'ENSA'TION INSURANCE B UILDING DIVISION FEES
(Thuseetion need nodbecomplemidd the permit ishmonehundrcddollon Slg) GRIASETRAP
or less.) PLANCHECK PEE
Itonn ythut in the perfnnnuneeofmc,,kier which thispennid isiodded,Isbell SEWER-SAND'A ORM .2W
urn employ any laces n in an�#^ander sues I come su 'ea m dori Cnmpen. ENERGY FEE
O ,Z odium law.v orcehf. w` WATER HEATER T
1 licml ....��Q✓/..��Q/ xRc' _ GRADING PEE
(� h OTIC,.TG AP I NT,If er uta a This m sam of Exemption,you should WATER SYSTEM/ -TING
a ; become subject to the Workers Compensation provisions of the Labor Cale,you must SOILS PEE
forthwith comply with such provisions or this penned shall be deemed revoked WATER SERVICE
Q PAID
CONSTNUC'f10N LENDING AGENCY NEW RESIDPMI P,of
ffDade Receipt#
V 0 I hereby afford that
hem is a construction lending agency fur the janforman
",— he work for which Nis permit is issued(Sea 3099,Ci,C.)
TOTAL
OU Lender's Name
W Lender's Address )OTAL.
ly 1 cenify that 1 have read this application and state dhw the above infnmarlon is BUILDING FEF,
Hh correct.)agree mconrply with all city and county nNinancas and smile laws relaiingm QTY. MECHANICAL PERMIT FEE SEISMIC FGF.
(.) Z building construction,and hereby amhmiae representatives of this city to on enter upthe
above-mentioned property for inspection purposes. 4NN
PERMITISSUANCE ELECTRIC PEI?
(We)agree a save,indemnify and keep handles me City of ainst
liabilities,judgments,costs and expenses which may in any way dameCity ALTER OR ADDTO MECH. PLUMBING FEE
in consequence of the granting of thin permit.
APPLICANT UN 'RSTANDS AND WILL COMP WITH ALINT AER HANDLING UNIT(TO 10,000CPM) MECHANICALFEE
SOURCIt RE ATIONS.
AIR HANDLING UNIT(OVER 10,ICMICFM) CONSTRUCTION TAX
Igo auf cn NConwetoeI'XIIAUSTHWD(W/DUCT) HOUSING MITIGATION PT:E
HAZARDOUS MATERIALS DISCLOSUREWill the applieanl o future building occupant sore or handle merial BEATING UNIT(TO 100.00(1 BTU)
as defined by the Cupertino Municipal GWeChaotic,9.12,anddhe afety
Coda.Section 25532(v)Y HEATING UNIT(OVER 100,000 BTU)
0 Yet 0N VENTILATION FAN(SINGLE RESIDE PAID
Date Roo,min#
Will the applied,or future building occupant use equipment or devices which BOILER-COMPOHPOR 100,000111U)
us
emit twom air contaminants as defined by the Bay Amor Air Quality Management
Violent? BOILER-COMP(OVF,R 1(70,0(0 BTU)
El Yes ❑NO
I have read the hur.adom materials en,iremems under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE, ayy
funds Health&Safety Cute,Sections 25505,25513 and 355Xt.1 unslenland am,If the NEW RESIDENHAL MUCH, SQ.FT.
building does not curenlly have a tenant,that it is my responsibility to notify the Occupant
of the reyuiremems which must be net prior to issuance of v Certificate of Occupancy.
Oward,m authoimitagent Date TOTAL: ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bu-Ildlitit Project Identification PERMIT N22571
Building Address:
3a oS
ams:
/'�;c DIDS-
One. CITY OF CUPERTINO-BUILDING DIVISION
Con etor'.N. Lie,No: APPLICATION / PERMIT �L
09 1 0je449<PDA BUILDING0,KTRICAL-PLUMBINGMFCHAMCAL CATEGORY, CONTROL M
Itect/Englnse. Lk.Na - .
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I her Beensed oftheerines.aonOfCha fesslaer9(mmmen AI'I'LIANCESRE9DENML JOB DESCRIPTION
ingwitliorme I.I.Fullf roe ofdeffecn3 ofthe BusinessandprofesslonaCode,and my
license Is In Tull _ and effect. PANELS `T.G��
Llcen lam LUP TO 2DO AhTS
..tmct r_ 0� � TD'�xa�.� 6 l v�
Date Contractor L S 2011000AMPS
ARCHITECTS ECIARATION
Fppp++re0 O I understand my plans ehaB be used as public records. OVER 1000 AMP5 SQ.FT.FLOOR AREA $M..FT.
E Licensed Professional SIGNSELECTRICAL / d D D \
add¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/1119C I herebyafBrm that I m.xampt from the Contractors Llrenae Lw(orthe
following reason.(Section AIDS,Business and Professions Code:Any city or
O TEMP.METER OR POLE INST.
P� countywhkh requires penNttocoratruat,alter,improve,demolish,orrepair,
< anystrocture pectin let bauance,also requirestheapplicant for such perodtto POWER DEVICES
file a V Contracttoole Lkerse Law(Cha statement that he tsri9(cmumncin wlthed pumouset to 9ectWmn�1ons 000)offDlvl-
�Og slan3 ofthe Butressand ProfembnCode)orthathets eaemptthererromanct SWPfMING POOL ELECTRIC ALUAUON
y1.1 the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the applicant to a civil peealty of net more OI11LE7SSWITCHE.SFIk'rURES than
five hundred delta.($500). NEW RESIDENTIAL ELECTRSQ.Ff. CON ION
0 I,as owner or the property,or my employees with wages as their sole
compensation,willdo the work andthestructure is not intended or offered for
5 O sale(Sec.7044,Business and Proressloru Code:The Contractoes License law
Lys$ does notapply to an owner of property who bulMsorimprovesthemon,and G R
E whodansuchworkhlnself orthroughhl•ownemployees,providedthatmch OCC, I
Improvements arc not Intended oroffered forests.If,however,the buildingor TOTAL. DATE 73
Improvement issuld wlthlnoneycarofcompletian,theowner-buBderwlll have v
ttlLkurden of proving that he did net build or impmve for purpose ofsaleJ. QTY, PLUMBING PERMIT FE - FLOOD ZONE A
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contrectma to cmatruet the project(Sec.7044,Businessand Profession Code:
The Contractors License law don not apply to an owner of property who ALTER-DRAW A VENT WATER ffN
behl. or improves re
theon, and who comment for such p(okeb - •with a FEE SUMMARY
egN�actm(•)Ecensed pursuant to the Comracrors License Law. BACK FIAWPROTECT.DEVICE
LJ I am exempt under Sec B A P C for this recon
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
RECEIPT
a
s,,/ WORKMAN COMPENSATION DECLARATION VON
lI hereby affirm su
that I have a mutlBcate of consent to self-Insure,or a FIXNRES I'ER TRAP SCI{OOL TA% RECEIPT X
rtl ote ofWorkers'Compewtlonlnsurencemacertifled copythereof(sec. GAS EA.SYSPEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.7
Poliry P_ RECEIPTM
Cam anv GAS EA.SYSTEM-OVER 4(RA) BUILDING DIVISION FEES
Certifted copyls hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
( G Ki ied copy b filed with the city Inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF-ASETRAP PAID ( J
COMPENSATION INSURANCESEWER-SANgr.NiY-b1ORM EA.2WFl. - Date Recei tq
(Thissection need net becompleted if the permit b Lorene hundred dollars
(510(ftorlese) WATER HEATER W/VENT/ELECIR ENERGYFEE Y_ N_
I certify that In the performance of mework forwhkh this permit Is issued.
I shall not employ any person in any manner se m to become subject to the WAT[•R SYSTEM/TREA1ING
Workers'COmpaaatlonlawa Of Ca Wor ia.Date PAID
Z Z Applicant NEW RFSIDENTSAL PLMB. SQFr. Date Recel tic
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould become subset to the Workers'Compensation provisions of the Labor T TAC: 3
N Cede,you=at forthwith comply with such provisions erthls permit shall be BUILDING
W j deemed rooked.
CONSTRUCTION LENDING AGENCY SEISMIC E O
CL Ihe.byar0rm that them Is a corswctice 1crling agency for the perform TOr ELECTRI ' E
Z •rare of the work for which this permit b Iswed(Sec.3097,Civ.Q
U O Lendel•Name PLUMBINGIEE X
LL ~ Lender's Address QTY. MECHANICAL PERMIT FEE MECH LFEB
O111 lmdlfythatlhavereadthbappBce00namlrtatethattheabovelnfornstlon
IL isconect.7 aliment,comply with ail city and county ordlnancea and slatelaws PERMIT LSSUANCE FEE
} N relating to building coralmction,and hereby authorles representatives of this
Z city,to enter u pan the above-menflned property for Inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recei tN
1..1 agaimt liabilities,judgments,cons and expenses which may in anyway same AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
againtseld Cl in con a mqqI the gra nR ofthl it
8 s?Ws X91163. PSS /}JCs / AIRHANDLING UNIT(OVER 10,000CFM) CON T ON,TAX'
signatu or not/ a Y1��A '_ill. I��EY'1l•/a MIAUST HOOD(W/DUCT) UCTI N TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Notre building occupant store or handle hasardous HEATING UNIT(M 100,030 BTU) Date Receipt
material as defined by the Cupertino Munlcipal Code,Chapler9.17,and the -
IleilthandSafetyCede Section25532(a)7 BEATING UNIT(OVER 100,000 BTLB OTA .
n
Y. r]NO
Ill theappllont or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ` ISSUANCE DATE
which emit haus rdous air contaminants as defined by the Bay Arca Air, a
Iu�lity Management District? BOILER-COMP OHP OR 100,000 R1'N AI®
�You oNo asYv
Ihaveread Health
Safety
moria,Lemon,255nh5533 and 2554.1 of BOILER-COMP(OVER 100,000 BTU) u"' 'T lag,
the unde2rd t Health buildinghe Suety Code,neaiOv 7550x,ve a t and 75534.I 1 .R"tlM
resp nand that n tifytheoccupoes net orrequiremetly encs which
that it be et NEW RESIDENTIAL MEIN. SQ.FT
responsibility to of.Cehe occupant of thecupa requirements which must be met � _•Cu
prior to lmuame ofa Certltlate o(Ocmpanry. ' Q( /�ai.��
Owner or aulhodud agent Date ISSUED RY'•�U
TOTAL:
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pl7tl r NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. `v
BUILDING PROJECT'IDF.N'1'IRIL'ATION 1831
BUILDINGADDRESS: TSANITARYO. APPLICATIONSUBMIn ALDA'Z'E/03 _v � 0 QZfl -BLV laa
OWNERS NAME. PHONE: CONT7:1RACTOR'S Af F.: " /-•b/'1•W� IC NO IlSO CON CaARCHITECf/ENGINEI!R: LIC ND', ADI RT•SS�I — �/ 1 �4$ DO
CONTACT`. ,PHONE ����••IIfU1I/AA�� �fl JC-� S,fN BUILDING PERMIT INFO
it �n 9to — 662 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE PLUMB MECH
EJ ov
LICENSED COM'RAC'IOR:S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hen•M1y affirm NS 1 am licensed under S DELLA el Clepter 9(commencing
Q Z withSection Il1)(Bu Division3ofthe Business and Professions Code,unit my l lcenreis RESIDENTIAL,
DENTIAL,
1+100 wt �t-��'/ PF.NMI'I'ISSUANCE
in full Bsne am IT I( y G 4�D / ❑SFI WL ❑KITCHEN REMODEL.
�UU License Clggg N y APPLIANCES-RESIDENTIAL ❑ADDITION E]PLUMBING RF.-PIPE
CS'DEln[
mQly ❑MULTI-UNIT ❑STRUCTURAL
AR,lmll bCI-S IIECmfic ret ON
Z O m Z I understand my plans shall be used vs public rcennls PANELS CHIMNEY
REPAIR
ty13a UP TO 200AMPS [I INTERIOR ❑CHIMNEY RIiPA1R
Li,mwd Pnsfensional 701-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNIiR-BUILDER DECLARATION
C� OVER IMOAMPS ❑BATH REMODEIIREPAIR DEMOLITION
y I hereby affirm that I.m exempt Bonn the Contuse License Law for the
x O 6 U following mann.(Section 9031.5,Bu.aine<s and Professions Cody.Any city m county SIGNS F.LECfRICAI. ❑OTHER
W;
which reyoirts a permit to construct,alter,improve,demolish,or repair any s mems,
OQ prior to its issuance,also requires the upplicenl for such period to file a signed tenement SPECIAL CIRCU IDM LSC dr
}•]
that he is licenced pursuant ns the previsions nl the Contractor's License Law lChader9
H�p0 Bourencing with Section W00)of Di vision Sof the Business and Pndesnions Carle)or TEMP.MITER OR POLE INST. COMMERCIAL:
d G e� that be is exempt therefrom and the haais for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^H
Section 7031.5 by any applicant fare perminwbjeets the applicant o v civil picashl of POWER DEVICES []TENANT FOOD SERVICE
t marc Than live hundred doll....0$511). IMPROVEMENT
�56 I,ax owner of the property, bees with woes as their sole compensator, SWIMMING POOL ELECTRIC
❑ prose y YcmP Y 6 penssi MOTHER
will do the work,and the he mrd is fors tendedLivens Ls.ed does mint apply to m a Business -
L a�
and Professions Calc:The Comrncurzs License War mea not apply a un owner of OU'fLFTS-SWITCHES-Is1X'IVRES
pmpenY who bullJs or Improves thereon,and who Jam Hoch work himself nr Through p A
his own employers,provided that such improvements are not intended or offered for NEW RESIDENTAI.ELECI'R 4.
sale.IL however,the building or improvement it sold within one year ofcompletion,Ihe SQ,FT.FLUOR AREA SISQ.FT.
cosect,lboadder will have the burden of pining that he did not build or improve baton, JU11LW�
poreofeale.l u
3 3 /
ED 1.an owner of the popery,ran exclusively contracting with licensed matractms e TOTAL:
construct the pmjeet(Sec 7044,Business and Professions Codc)'Ihe Cmnlrmcne's Li-
cense law does not apply to an owner of property who builds(It improves thereon.and QTY. PLUMBING PERMIT FEE CITY OF i:urenunU
,he ermines for tach pmjema with a mrarr mast licensed porsuam to the Comracrors
License Law, PERMIT ISSUANCE
❑I It.exempt under Sec. ,B&P C for this rcasnn
AhTIiR-DRAIN&VENT-WATI3R(EA) VALUATION
Owner Dee
WORKER'S COMPENSATION DECLARA'T'ION HACK PLOW PROTECT.DGVICI?
I hereby affirm under Penalty of perjury one ofthe following declaration,
❑Ihave and will maintains CertiOcete of Conttmto self-insure for Workers Comlero DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONS'fRUCT10N
mica,as provided for by Section 374 of the Lahmr Cale,for he performance of the
for which this pemut is issued. FIXTURES-PER TRAP
Q'1 have and will maintain Worker's Compensation Insurance,as required by Section
37M ofthe labs Cade,for the performance at the work for which this permit is issued. GAS-EA.SYSTEMA INC.40VrLITS OCC GROUT' APN
My Wor'et" lion m�r9mucaricr and Policy nmmher re:
Caries " �lZiY�a_Policy No. OAS-IIA SYSTEM"OV8R4fEA)
CE IFICATEOFLXEMITION FROM WORK17RS' GRIiA51%INDUS fRL WASTE IN fERCEITOR
COMPENSAI ION INSURANCE BUILDING DIVISION FEES
(Thly section need not do amtpleted i[thepennil is fnrnnehundred dollars(b10111 GRF.ASETRAI'
tar less b PLANCHECK FEE
Icer that lithe pe,fnmariamcifthe work buwhich this permit is issued,l shall SEWER-SANITARY-S'I ORM IRA.4011IT.
not employ any Person In any marine so as to become subject to the Workers'Comp rn- ENERGY PER
0� cation Laws of California Dom WATER HEATER WNF.NT/ELECfR GRADING FEE
z 0 Applicant
y NOTICE TO APPLICAN'n If,utter maks.,this Cenifcete of Exemption,you should WATER SVSTEMORHAT'ING
a; txubmc ml rat m the Worker',Compto,ubion provisions of Thr Lahm Code,you must SOILS FT!G
Lk1 forthwith comply with such provisions tr this permit shall be deemed revoked. WATER SERVICE
Q
=' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.14. PAID para Receipt
V 0 l herebyaflirm that thercls a construction Ituddrgagency bathe performance of
[I. . Ihe work for which this permit isissued Eim,3099,Civ.C)
0 Lenders Name
U 'f(YfAL:
U tenders Address TOTAL:
6 1 certify mm 1 have read this application and scam ohm the.hove information is BUILDING IT!F.
wF-t to correct.I agree m comply with all city and county oNinnnces and scute laws relating to QTY. MECHANICAL PERMIT FEF.
V a building construction,and hereby immunize representatives ofthln city m enter upon the SEISMIC FEB
above-mentioned property for inspection purposes. I PERMIT ISSUANCE
(We)agree m save,indanmfy and keep hnmdess the City of Cupertino against ELECTRIC FEE
Iishilltics,judgments,costs and expenses which may in any stay accrue against said City ALTER OR ADD'IV MECU PLUMBING FEF!
in consequence of me granting of this permit.
APPLICAB UNDFRS ANDS NDW .L COMPLY WITH ALL NONPOINTAIR HANDLING UNIT(TO 10,(10CFM) MECHANICAL FEE
S(JUR F ril". I S.
/ AIR HANDLING UNIT(OVER 0,000CFM) CONSTRUCTION TAX
CSC_/' -7„ P)
Si mtercof Apph'an onitacmr 7Sajj” EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occumamslore or handle hazardous material HFAI'INC,UNI"1'(TO 0(10.010 BTU)
as Jef nN by the Coltman.Municipal Code.Chapter 9.12,and the Health and Safety
J HEATING UNIT(OVER I(gl,(XXI ETU)
Cade.Section 25532(u)9
❑Yes LKNn VENTILATION PAN(SINGLE RESID) PAID Date Receipt p -"
Will the applicant or future building tempead use cquiptned or dellen which BOILER-COMP(3HP OR 100,000 BTU)
emit hwurdous air commi
mnsm,a dclined by the flay Arca Air Quality Management TOTAL:
District? / BOILER-COMP(OVER 101,11(00 BTU)
[JAN /3-9 T
I]Yes L'
I have read Ne mcmdou.s materials requirementsunder Chapter 695 of the Cali- AIR CONDITIONER 7 ISSUANCE DATE
fords Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that VIhe NEW RESIDENTIAL M CH. SQ.Fr. "
huildiugd ' nntcu tl m-lir my re"nodility et notify the evcupam
of me ine is musts w pr s anceof a Ceriticmeof Germano,
5T., r...intized a gent - Oute TOTAL: SSUED BY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO a
E LEcrRICAh rEB.1Clr"°. 1320
i BUILDING DIVISION APPLICATION/PERMIT -AIHCIIANICAL \V
LT IUI!N'1'IFICATI(1N
BUILDING ADDRESS: SANITARY NO.
APPLICATION SUBMITTAL DATE
io 3o0 5. �� /%vd
O N"SNAME:
HONE: C&�� L i-. L11 fy0: NIC 'ONTIiO1,N
�A CIIITECT/.NGT Rlili: VLAC NO: ADU!{E � a5`J(/ 1791 ❑
CONTACT. PHONE: �( 'L,.iV`s' BUILDING PERMIT INTO
•!/ir 1) i //f / j L AA� ❑ Consultant Fees Paid by Applicant(Initial) qLU iLE PLUMB MECH
El 13
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB IJESCRIPTION
PIiRAtIT ISSUANCE
I hereby affirm that 1.m licensed under provisions of Chapter 9(commencing
W06 with section'Tan)ofnivision 3 onbe Business and professions Cole.and my license it RESIDENTIAL'
�w in full force and SJfyt _ ❑M'DWL ❑KITCHEN REMODEL
QU I'ens,Class Lae.R gPPLIANCE$-RESIDENTRAI. ❑ADDITION [I PLUMBING Rid-PIPE
FZ arc—Jori NLGComrucmr
mQ I7�'(�� ❑MULTI-UNIT ❑MODIFI RAL
MODIFICATION F.Dm ARCHITECTS DECLARATION PANELS
Z p H Z` I understand my plans shall he used.s public records MODIFICATION
pZ�Q UPT02IMAMPS El INTERIOR ❑CHIMNEY REPAIR
Licensed Prnfessiamal 201-IaMAMPS IMPROVfiMENT E3 SWIMMING POOLS
s1 J OWNER-BUILDER DECLARATION OVER 1000 AMPS
El BATH REMODELREPMR El DEMOLITION
a Q I hereby affirm That I um exempt front the Contractors License Law for the
0.x p d U following reams.(Section 7031.5,Business and Professinns Cod,:Any city or eoudy SIGNS ELECTRICAL OTHER
W 3 LL F' which requires a permit to construct.alter impmve,demolish,or repair any structure
0 Morto its issuance,also requiresthcapplicant for such permit o file a signedsunc...at SPECIAL CIRCUIT/MISC.
Iru"Iy that he is licensed momma,,the provisions ofthe Contractor's License Law(Chapter 9
ayp0 (commencingwiih Section 901001o1'Di,kion 3ofihe Business.nd Professions Code)., TEMP.MITER OR POLE INST COMMERCIAL:
d L ey that he Is exmnpt therefrom and the basis for the alleged exemption.Any vichuimn of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmLL, Section 70315 by any applicantfor.permit subjects lheit,di,cal m a civil penalty of POWER DEVICES ❑TEryANT ❑FOOD SERVICE
W m not mote than fee hundred dollars(SSRD
E � C]I,as owner of the pmpeny.nr my employees with wages as lhcir snlecnntprn,nima, SWIMMING POOL ELECTRIC OFHER EMF
xr
will do the work,and the structure is unl hnended or offered far sale(Sec.7044.Business ❑ THER
mand Prnfcsions Code '[he Contractors License Law does not apply m an owner of OU'rLITS-SWITCHES-FIXTURES
Property who builds or improves thereon,and who does such work himself m through
his own employees,provided that such improvements are not intended or ogerer for NEW RESIDENTIAL ELECIR SQ
sale lL hawamr,the building or intm
proveeal issold widbi.orc ycm of completion,the SQFT FLOOR AREA SJSQ.FT.
.
owner-huilder will have the burden of proving that he did not bond nr improve for,me of of sale.). TOTAL:
❑ 1,as owner of the property,atm exclaeively contracting with licensed contractors In -
construct rheTorso(Sce.71 ,Business.,and Professions CMeJTheCuoloiamr'sLi-
seLawdoesnotapplytoanownerofpropertywhobuildsorimprovesllerear.and QTY, PLUMBING PERMIT FEE
who comosels for such projects with a contracumd licensed pursuant to Ilene Contractors
License Law. PERMIT ISSUANCE
❑ I oro exempt trader See. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER IF VALUATION
Owner Date
WORKER'S COMPENSATION DECLARAq'ION RACK FLOW PROTECT.DEVICE
1 hereby affiran under Penalty of perjury one of the following declenllions:
❑I have and will maintain a Cenllicate of Cousem to self-in.som for Worker's Crimper. DRAINS-FLOOR,ROOF,AREA,GOND, p, STORIES TYPE CONSTRUCTION
ration,as position for by Section 3900 of the Labor Code,robe performance of the
work for which this perms is Issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurers,as required by Section
370dmfthe lah...Code,for the perhamancccaftM work for which this permit is•i-ssu�ed, GAS-IiA.SYSTEM-1 INC.4 OUTLL•'f5 OCC.GROUT' APN
my war- mmpm.e sa mNran,Tmi
ae, Policy vutWear. -s/4�V GAS-FA.SYSTEM-OVER 4(RAT root slater :RTIFICA'1'r OFL kF: r FROM WORKERS'
I J
COMPENSATION INSURANCE. GRIiASUINDl15TRl.WASTE INTLRCF.�(1R1 UI NO DIVISION o
frbissection need ambecantpletedifoulsemtit is forms,hundreddollan(SIM) GRf;ASETRAP
,it less.) PfAN'iii
I certify that in the performance ofthe work for which lhispermit is Issued,l shall SEWER-SANITARY-STORM CA.100 F1'.
nm employ any persom in anY manner so asmbecome suhjecuolhe WnrkerS Compere L :RGY
,Z satin.Luwsuf California.Data WATER HEATER WNF.NTMLECTR GRADIN FEE
C) Applicant
N
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption.you should WATER SYSLE.Mn BEATING
(� become subjectthe Worker's Compensation previsions of the Labor Cale,you nor, SUITS Eo
a( ..t forthwith comply withsuch provisions or this permit shall he dremesim,okcd. WAI'FR SERVICE
WQ
a' C'ONSTItUCTION LENDING AGENCY NEW RESIDT:N'I'IAL PLMB. SQ,FT. PAI Date Receipt a
0 I hereby ufOrnt that there is it construction lending agency forthe performance of
V
U F the work for which this permit is issued(Sac 3091,Civ.C.) TOTAL:
O U Lenders Name
Lendres Address TOTAL
�s 0. 1 certify that 1 have read this application and sone then the above information is 1 G FEE
V) correct 1 agree to comply with all city and county ordinances and state laws relatingm QTY. MECHANICAL.PERMIT FEE I.MI FEF
V Z buildingcons0umion,and harsh,aulhorim representatives ofihis anymenterupon the
^-t above-mentioned Property for inspection purpn>es, PERMIT ISSUANCE : Ii UC FEF.
(We)agree m save,indemnify and keep hamdcss the City N'Cupcnim ngain.a
liabilities,judgments.costs and expenus which may in any way acerae against said City ALTIiR OR ADD TO M ECH. PLUM HNGFEE
in consequence of the staining of this permit. e
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT TF010.(")CFM) MECH FEE:
SOURCIiyppfll��IGUL!!AyWWI((OIINS,
AIRHANDLINGUNI'I'(OVIiRIQ(MOCFM) CONSTRUCTION TA
Signature cdApplcdA,ficicamfCom/mch" - EXHAUST HOOD(W/DUCI I fOUSINGMDIGATIONI' ?
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or bandit haaafduus material HEATING ON IT(TO 109.0(X1 BN)
os dice eer by the Cupertino Mmoripal Code,Chapter 9.12,vad the Health and Safety
Code.Section 25532017 HEATING UNIT(OVER IabO(M PTU)
❑Yes E]No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt a
Will Ne applicant or future building occupant use eqllpment or devices which BOILER-COMP(311P OR I(M."BTU)
emit humanism,air cmnumiann,as relined by the Nay Are.Air Quality Man.gemenl TOTAL: pj
District' BOILER-COMP(OVER 100.000BTU)
El Yet Fl No
I have rod the lemNuuv materials requirements order Chapter605af We Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Ce e.Sections 25505,25533 trod 25534.1 undershot!that tithe NEW RESIDENTIAL MECH. SQ.FT. 3
building dons not currently have a tenant,that it is my nespmsibilhy to notify Be occupant
of the requirements which must he net prior to issuance of a Cenifcate of Occupancy. _
Owner or untCFO
agent Use TOTAL: ISSUED BY: O'�C • 0
OFFICE