S 3368 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull.DING-ELECTRICAL PEtIT NO, 3368
BUILDING DIVISION APPLICATION/PERMIT 1'LUMRING-M ECIIANICAI. \v
BUILDING PROJECT IDENTIFICATION
BUILDING ADDR[SS'. /, ^ SAN4NAON SUHMAL DATii
a 1LI\i„1 a�+�
OWNER'S NA T PHONE: ) I'1NA(,TI OR'S NA E: (` LIC Nin:, NMItOI.X
,�,AR ECf .NGIN ER: 1.1 NO:. 1 AUU EESSS:_ P.. y�CONIcr., HONF. T INFO
❑ Consultant Pecs Paid by Applicant(Initial) BM11MECHLICENSED CONTRACTOR'S DECLARAT ON QTY. ELECTRIC PERMIT FEE cJOB DESCRI PTTII,/ON
I herehy aRrm that Iran licensed under provisions cf Chapmr 9(commencing
"Z won SmtionloW)omivision Janne Busines,and rr�-s.' ev �de,a A mylaumsel, RES[DFNTIAL:
won IT ISSUANCE
F W lg in full force and once'. 7 ❑SFDWL ❑KITCHEN REMODEL
aU 1.icensc Class M APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F Z Dae Commcun
rn6 c ❑MUITI-UNIT ❑STRUCTURAL.
Deo (IIT.T'S D-CLA PANELS
ZO , I understand myplonsshall bcu%cd as publicrecords MODIFICATION
I UI'T02IXIAMPS
i OZ—, (_1 INTERIOR El CHIMNEY REPAIR
F�J�LL1 Licensed Professional 2111-1000ANIPS IMPROVEMENT []SWIMMING POOLS
a Y�� OWNER-BUILDER DECLARATION OVER 100D AMPS
❑BATH RF,MODEUREPAiR [I DEMOLITION
4K 1 hereby affirm that I am exempt from the Comractor'x License Low fm the
iqqi55 G d U following acaum.(Section 7031.5,Bosn,and professions Core:Any city ar county SIGNS ELF,CTRICAL ❑OTHER
n+'3NQ which requires a permit m constrod,ulmn improve,demolish nr.spec.any swem
O re
pain.u.its issuance,also requires the upplicam(or such permiuo lileasigneJ,mrement SPEC1ALCIRCUIDMI
that he islicenxui pursuant to the prevision%of the Contract nrvl,imnso Law(Chapmr9
I'd do�0 (commencing with Section oXXb or Division 3 of the Business and Pro@xsian.s Gude)or TEMP.ME'TF.R OR 1101-11CVpCOMMERCIAL
fL y m yv that tie is exempt thcnfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDOIADDITION ❑DEMOLITION
I+XI Y. Section 1031.5 by anyapplicam faro foluminuhjems theupPlicannoa.Wit penaltyof POWER DEVICES PNANT ❑FOOD SERVICE
F. re' mm�rc than Eve hundred dollars(ESW).
2 0 ❑I,as owner of the pmperty,nnny employee with wagesas lheinnlecnmpensainn, SWIMMING POOL ELECTRIC MPROVEMEN"I'
d will do dw.,ak,and the structure isnot intended to oferedfnr so le IS ec 70 Basin []OTHER
,ad Professions Cook:The Commmors License Law does
nal apply m an owner OUTLETS-SWITCHES-FIXTURIS N
6 3 property who builds or improves thereon,and who doss such work himself or through
his own employees,provided that such improvements ore nm intended or offered for NEW RESIDENTIAL F.LF.C'1"R SQ lel'.
sale.If,however,the building or improvement is sold within tine year ofeompldion,the SQ.II.FLOOR AREA 8ISQ.IT.
'
per-builder will have the huNco of proving that he did not build car improve for pur-
leafITA
sole.). l/((TIIAII I F
I,as owner of the property,am exclusively contracting with Iicmrwe l contractors to
E] a
u sl uct the project(Sec.70DL Business and Pndession,Codc:)The Contractor's LI-
mLa.deesnntapplyto anownerof property who builds or improvcx themon,and QT)'. PLUMBING PERMIT FEE I
whn:.m lrmis for such projects with a contractor(&)licensed pursuant to the Contractors
License law. PERMIT ISSUANCE
I am exempt under Sec. ,B&1'C for this pos:m
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION rjuryon DECLARATION efolloing BACK FLOW PROTECT.DEVICE Y1 AOO
1 hereby off rat under Certificate
of perjury one of the followingWdeductions!kerV
❑Those and will mninminaCeniOcmmfCnnsem to alb-insure for Workers Comper" DRAINS-IIAOR,RTRIF.AREA.CON0. gyORDgg I 1'YPIi CONSTRUCTION
saussm as provided for by Seetian 3100 of the Labor Cade,for the perfonnanca of the1
ark for which this permit is issued PIXTURES-PER TRAP �1v/
C I have and will maintain Worker's Compensation Insurance,as required by Section /
310K)of the Labor Cade,far the pubmencneeof the work far which this permit is issued GAS-EA.SYSTEM-I INC.a OUTLETS OCC.GROUT' - APIN C
C Worker's amine eatio ran Iatric Palmy Noy nut M 351k�Ub f
Cortico GAS-PA.SYSTEM-OVRR4(F.A ✓1 UV
CE 'IPICA F,OFEXEMPTION FROM ItKERS' GREAS[IINUUSTRI.WASTE IN PIY)R '
COMPENSATION INSURANCE BUILDING DIVISION FEES
(this section reed oat completed ifthe pemrit is for one hmrdred dollars fElOB) GREASETRAP -
oat less.) PL iCK PEE I
lecnifyth: ' eine as idhewmkforwto t armritisissuW,lshall SEWER-SANITARY-STORM . 300 FT
nm employ. persnnt !m srysm d the Wnrkeri Cam IiNR FEIi )�
Z &oboe lasso Califon I WATER HEATER WNENTMLE G GFEE
O Applicant
Z NOTICE TO AP a eIs g this CertIM.¢of ' you should WATER SYS'TEMGTGE TING
,tet VJ SOILS EE
F-t become,nbjcct
,it,
the War "Co •nx tion provisions a' ho
Calc,you must
WF> forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE /
0PAID T
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.PIL Date !1op,If �1
Uz I hereby afirm that there is a construction lending agency forte performance of
F+ the work for which this permit Miscued(sec.3091.Civ.C.) All TOTAL:
ULender's Name
BJ Lender,Address
y 1 certify that 1 have read this application and state put he abase information is BU11, iE
N correct.l agree to comply with all city and county ordinances and suite laws relating to QTY. MFCHANICAI.PERMITFEE gel L sE rC
U Z buildingeonswdit n and hereby amhadne represented esof this city m enter upon the —C
above-mremianedp pony for inspection proposes. _ PERMO ISSUANCE Zr
(We)agree save,indere ify and keep harmless the City of Cuponinn ngains Eh. IC FEE
liabilities,'udgmen .cost,and pease, nay in any way accmea Co ATTER OR ADD TO MECH. - O PIA RING PLP. Q
in sold a g m n tnhi: it.
PLIC U. iR DWILL COM('). LTH ALL .-POINT AIR HANDLING UNIT(TO RI,INN)CFM) MIANANICAL FEE ze 190
OUR L'.
� _ AIR HANDLING UNIT(OVER IQ(NNI CFM) CON51 UCf10N TAX cr
4SlgnmmenfApplicaMC mmctor Done 1 EXHAUST HOLD OMMUC) HOUSING MITIGATION FEF.
HA
"I'm 1ATE IsCLOSURE
Wlltbeapplicad,or but d rgoccupant store or handle huoudommmarid HEATING UNIT D 0 I TNI,"BTU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Heulth and Safety
Code.Section 25532(0'! 1IIIATING UNIT(OVER 100,000 BTU)
❑Yes VEM'ILATION FAN(SINGLE RFSID) (AID Dam RecciptX
Will the appii.re or future building occupant use equipment or devices which BOILER-COM('(3HP OR Esso ll B'TO)
emit hazallows air emumninarts as defined by the Ray Area Air Quality Mamagemcm TO'
District! �`' BOILER-COMP(OVER I W(1(N)B
, TU)
0Yes V
Iha read the mountains camomilsquiremen is under Chapter 6.95 of the Cali AIRCONDITIONER ISSUANCE.DATE
I, to &S or Core,Sceaonal.ISI,'_5533and2S53J.I .ranheoccuant NEW RESIDENTIALh1EC11. SQ.Fr.
uildi nm city tenant,that it i,myresPr mnotify the occupant
ofto i must mono ixsn CertlOcat f ryO
ro eche agent Dam AL ISSUED BY: O
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull.DING-ELECTRICAL PEtIT NO, 3368
BUILDING DIVISION APPLICATION/PERMIT 1'LUMRING-M ECIIANICAI. \v
BUILDING PROJECT IDENTIFICATION
BUILDING ADDR[SS'. /, ^ SAN4NAON SUHMAL DATii
a 1LI\i„1 a�+�
OWNER'S NA T PHONE: ) I'1NA(,TI OR'S NA E: (` LIC Nin:, NMItOI.X
,�,AR ECf .NGIN ER: 1.1 NO:. 1 AUU EESSS:_ P.. y�CONIcr., HONF. T INFO
❑ Consultant Pecs Paid by Applicant(Initial) BM11MECHLICENSED CONTRACTOR'S DECLARAT ON QTY. ELECTRIC PERMIT FEE cJOB DESCRI PTTII,/ON
I herehy aRrm that Iran licensed under provisions cf Chapmr 9(commencing
"Z won SmtionloW)omivision Janne Busines,and rr�-s.' ev �de,a A mylaumsel, RES[DFNTIAL:
won IT ISSUANCE
F W lg in full force and once'. 7 ❑SFDWL ❑KITCHEN REMODEL
aU 1.icensc Class M APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
F Z Dae Commcun
rn6 c ❑MUITI-UNIT ❑STRUCTURAL.
Deo (IIT.T'S D-CLA PANELS
ZO , I understand myplonsshall bcu%cd as publicrecords MODIFICATION
I UI'T02IXIAMPS
i OZ—, (_1 INTERIOR El CHIMNEY REPAIR
F�J�LL1 Licensed Professional 2111-1000ANIPS IMPROVEMENT []SWIMMING POOLS
a Y�� OWNER-BUILDER DECLARATION OVER 100D AMPS
❑BATH RF,MODEUREPAiR [I DEMOLITION
4K 1 hereby affirm that I am exempt from the Comractor'x License Low fm the
iqqi55 G d U following acaum.(Section 7031.5,Bosn,and professions Core:Any city ar county SIGNS ELF,CTRICAL ❑OTHER
n+'3NQ which requires a permit m constrod,ulmn improve,demolish nr.spec.any swem
O re
pain.u.its issuance,also requires the upplicam(or such permiuo lileasigneJ,mrement SPEC1ALCIRCUIDMI
that he islicenxui pursuant to the prevision%of the Contract nrvl,imnso Law(Chapmr9
I'd do�0 (commencing with Section oXXb or Division 3 of the Business and Pro@xsian.s Gude)or TEMP.ME'TF.R OR 1101-11CVpCOMMERCIAL
fL y m yv that tie is exempt thcnfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDOIADDITION ❑DEMOLITION
I+XI Y. Section 1031.5 by anyapplicam faro foluminuhjems theupPlicannoa.Wit penaltyof POWER DEVICES PNANT ❑FOOD SERVICE
F. re' mm�rc than Eve hundred dollars(ESW).
2 0 ❑I,as owner of the pmperty,nnny employee with wagesas lheinnlecnmpensainn, SWIMMING POOL ELECTRIC MPROVEMEN"I'
d will do dw.,ak,and the structure isnot intended to oferedfnr so le IS ec 70 Basin []OTHER
,ad Professions Cook:The Commmors License Law does
nal apply m an owner OUTLETS-SWITCHES-FIXTURIS N
6 3 property who builds or improves thereon,and who doss such work himself or through
his own employees,provided that such improvements ore nm intended or offered for NEW RESIDENTIAL F.LF.C'1"R SQ lel'.
sale.If,however,the building or improvement is sold within tine year ofeompldion,the SQ.II.FLOOR AREA 8ISQ.IT.
'
per-builder will have the huNco of proving that he did not build car improve for pur-
leafITA
sole.). l/((TIIAII I F
I,as owner of the property,am exclusively contracting with Iicmrwe l contractors to
E] a
u sl uct the project(Sec.70DL Business and Pndession,Codc:)The Contractor's LI-
mLa.deesnntapplyto anownerof property who builds or improvcx themon,and QT)'. PLUMBING PERMIT FEE I
whn:.m lrmis for such projects with a contractor(&)licensed pursuant to the Contractors
License law. PERMIT ISSUANCE
I am exempt under Sec. ,B&1'C for this pos:m
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION rjuryon DECLARATION efolloing BACK FLOW PROTECT.DEVICE Y1 AOO
1 hereby off rat under Certificate
of perjury one of the followingWdeductions!kerV
❑Those and will mninminaCeniOcmmfCnnsem to alb-insure for Workers Comper" DRAINS-IIAOR,RTRIF.AREA.CON0. gyORDgg I 1'YPIi CONSTRUCTION
saussm as provided for by Seetian 3100 of the Labor Cade,for the perfonnanca of the1
ark for which this permit is issued PIXTURES-PER TRAP �1v/
C I have and will maintain Worker's Compensation Insurance,as required by Section /
310K)of the Labor Cade,far the pubmencneeof the work far which this permit is issued GAS-EA.SYSTEM-I INC.a OUTLETS OCC.GROUT' - APIN C
C Worker's amine eatio ran Iatric Palmy Noy nut M 351k�Ub f
Cortico GAS-PA.SYSTEM-OVRR4(F.A ✓1 UV
CE 'IPICA F,OFEXEMPTION FROM ItKERS' GREAS[IINUUSTRI.WASTE IN PIY)R '
COMPENSATION INSURANCE BUILDING DIVISION FEES
(this section reed oat completed ifthe pemrit is for one hmrdred dollars fElOB) GREASETRAP -
oat less.) PL iCK PEE I
lecnifyth: ' eine as idhewmkforwto t armritisissuW,lshall SEWER-SANITARY-STORM . 300 FT
nm employ. persnnt !m srysm d the Wnrkeri Cam IiNR FEIi )�
Z &oboe lasso Califon I WATER HEATER WNENTMLE G GFEE
O Applicant
Z NOTICE TO AP a eIs g this CertIM.¢of ' you should WATER SYS'TEMGTGE TING
,tet VJ SOILS EE
F-t become,nbjcct
,it,
the War "Co •nx tion provisions a' ho
Calc,you must
WF> forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE /
0PAID T
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ.PIL Date !1op,If �1
Uz I hereby afirm that there is a construction lending agency forte performance of
F+ the work for which this permit Miscued(sec.3091.Civ.C.) All TOTAL:
ULender's Name
BJ Lender,Address
y 1 certify that 1 have read this application and state put he abase information is BU11, iE
N correct.l agree to comply with all city and county ordinances and suite laws relating to QTY. MFCHANICAI.PERMITFEE gel L sE rC
U Z buildingeonswdit n and hereby amhadne represented esof this city m enter upon the —C
above-mremianedp pony for inspection proposes. _ PERMO ISSUANCE Zr
(We)agree save,indere ify and keep harmless the City of Cuponinn ngains Eh. IC FEE
liabilities,'udgmen .cost,and pease, nay in any way accmea Co ATTER OR ADD TO MECH. - O PIA RING PLP. Q
in sold a g m n tnhi: it.
PLIC U. iR DWILL COM('). LTH ALL .-POINT AIR HANDLING UNIT(TO RI,INN)CFM) MIANANICAL FEE ze 190
OUR L'.
� _ AIR HANDLING UNIT(OVER IQ(NNI CFM) CON51 UCf10N TAX cr
4SlgnmmenfApplicaMC mmctor Done 1 EXHAUST HOLD OMMUC) HOUSING MITIGATION FEF.
HA
"I'm 1ATE IsCLOSURE
Wlltbeapplicad,or but d rgoccupant store or handle huoudommmarid HEATING UNIT D 0 I TNI,"BTU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Heulth and Safety
Code.Section 25532(0'! 1IIIATING UNIT(OVER 100,000 BTU)
❑Yes VEM'ILATION FAN(SINGLE RFSID) (AID Dam RecciptX
Will the appii.re or future building occupant use equipment or devices which BOILER-COM('(3HP OR Esso ll B'TO)
emit hazallows air emumninarts as defined by the Ray Area Air Quality Mamagemcm TO'
District! �`' BOILER-COMP(OVER I W(1(N)B
, TU)
0Yes V
Iha read the mountains camomilsquiremen is under Chapter 6.95 of the Cali AIRCONDITIONER ISSUANCE.DATE
I, to &S or Core,Sceaonal.ISI,'_5533and2S53J.I .ranheoccuant NEW RESIDENTIALh1EC11. SQ.Fr.
uildi nm city tenant,that it i,myresPr mnotify the occupant
ofto i must mono ixsn CertlOcat f ryO
ro eche agent Dam AL ISSUED BY: O
OFFICE