S 1289 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEISITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 1289
IlUIL.DIN, R F:CT IDENTIF'ICAI'[ON
HIIILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2M �.� Vi�Ul9t i1� COVFN� 2.Z2,q
OW ER NAM rte✓ PI II INE: CONTRACTOR:S NAME: LIC NO'.
NIC CONTROL#
CHITECT/PNGINCER: LIC NO: ADDRESS: S 1\
COONEAACCST: PHONE' I31111,IJINC PGRI INFO
�r--✓'iN`l...LI+V�C QO
Y 2S2 S77a ❑ Consultant Fees Paid by Applicant(Initial) BLOCt ELECT PLUME MECH
5S3 3633
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OWOZ with Section]IXXB of Division J of the Bninessand Professions Core,and my license a TUE
F1_ in full fame and elect. PERMIT'ISSUANCE ,'1'DWI. ❑KI'fCI11iN kF.MOUIiI.
IAL-
�UU Llane Clasv _ Lic.M
HZW pate Comedemr APPLIANCES—RESIDIiN'I'IAI, 1 ADDITION El PLUMBING RE-PIPE
ARCHITECT'S DECLARATION PANELS [I MULTI-UNIT CSIRUCTURAL
ZOyZ Iunderstand myplan shall heusWaspublic records MODIFICATION
O Z�QUPIC 2(X1 AMPS
F I:'YWl IJacmul Professumal ❑INTERIOR 13 CHIMNEY REPAIR
G O
201.1000AMPS IMPROVEMENT SWIMMING POOLS
�."..4I/ morIII➢LDERDECLARATIONuntp
W 6 I hereby uftimt thaatt Ium exl from the Coo
nuutor'x License Law for Om OVER thou AMPS El BATH RE UP 2� _ lih OLITION
x 3 L I.VF.., fallowing rcnson.(Salina 7031 5,(tonnes.and Prof r..inns Coale:Any city err cnwny SIGNS E71-FM RICAL C OTHER
W LL N myuires a m amino,oliva improve,demolish,or repair ct
any, metu e
E'�� which prior to its issuance.alParton so armada,applicant for such permit la file a signed etatemam
NSPECIALCIRCI/IT/MISC.
sxa� that heisEan.Jpursuant mm.pmvistansarNeetintamrau.en aw(enamm9
WCOO (commencing with Saeon AMIE)of Division 3 oftbe Business and Profession CoM)or TEMP.M1.1 IR OR POLE:INST. COMMERCIAL:
6 y o y IM1at he is exempt theteGom and the hnsis for the allege)ucmption.Any viulminn of ❑NEW BLDG/ADDITION C DEMOLITION
LLXl WN
Serino 70)15 by nny applicant Earn permit the applicant m a civil penally of POWER DEVICES
til more than Evchundreddolbus($5110). CTENANT CIrOOD SERVICE
~ Q El 1,as neonatal the propcit or my caliloyeas with wages as theirsole ntmpenalion, SWIMMING POOL ELECT RIC IMPROVEMENT'
`o will du the work,and theawdure is ntn irmndedmoli'eredfmsulc(SecJIW.Business El OTHER
W 3 m and Professions Code:The Conlmnor's License Law dors oat apply to an(owner of OUTLETS—SWITCHES—FIXTURES
propeny who builds or improves themon,and who does such work himself or through
his awn employers,provided that such improvements am not immrded or offered for NEW REMDF,NTIAL ELEC!R SQ PI'.
sale.If,however.the building orimprovement is sold within one yamrdoampaetinn,the SQ.PT.FLOOIAREA $/SQ.FT.
er
r-buildwill have the harden ol'prnvingvt thhe JlJ urn build or improve for
n
p �lufale, (\�� (F�JT'
JS
El 1,as owner of p
the ropenm y,aexclusively convecting with licensed amenscanm
s
.nsntn the pmjeat(Sec.70UU Business and Profession,Ged.t)'_C.nlm.........
nsc Law does net apply to an nwner of property who builds or improves themon.and QTY PLU ING PERMIT FEE
who contracts forsuch pmjmo withacontngears)licensed pursuammthe Cnntrecior's WAY
q �
License Law. PERMIT 1.' WA a
C I am exempt tinder Sec. n PQI15 P C for this reason
ACfER-DItA1N& -WRTIiR(EA)
wfaer D:I O — Ur yt,rrrl� �V�°O
ORnder P COMI9: SATION❑ECLARA [ONmoving BACK PLOW PR ;Cf. li
1 hereby lRnm under penalty of perjury one of the following deflections:
a
❑Ihave and will maintainer Cen3700 of the sent toLabor
Costa,to,suare
Workers C(ompen- DRAINS-Fh00 .ARG,C STORIES TYPE CONSTRUCTION
isti kf r provided for by Section 3]1X1 of the IaMr Cale,far IM1c perrnemance of the
work for which Nis p.tmil is Ione). PI%'TllRliS-PER TRAP
❑ 1 have and wall mountain W'orker's Contpcnsntion Insurance,as required by Section
3700.f the Luhar Cn le,or, performm�ceof the work fm'wbicb Ibis'trial la isaucd. GAS-L'A.SYS'IEM-1 INC.401f1'.' OCC GROUP APN
My Worker's Compensation Insurance anicT and Policy number arc:
Carol Policy No.: GAS-IA.SYSTEM-OVER J(IA)
CERTIFICATE OI:EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASHIINDUSTRL WASTE INTERCEPTOR
(This.section fared not becnmplened if the permit is(oronc hundred dollars is[do) BU . Ii MPS _ _ -
nrlevs) GREASE TRAP PLANCHECKF.
Ioyany(polio the perany manneeoltire is k ron,xlobemee,hiuh lt,o0a,W.,k,,'ix Cond. ahnR SEWER-SANI'T'ARY-:'
Lkq
oaten to a STORM EA.200FT. �+
employ any parson in any manner m ns la heron w:hjed 1.IM1e WnrkecJ Cotnpen- ENERGY FEB
O 2 Alli Lnws nl'Culil'omia.pure WATER HEATER WATI'D11I.ECTR
Z Applicant GRADING FF.F:
NOTICE TO subject
to the Wma IL alter making this Certificate at e Loop,tio dyou u a mJ WATER SYSTEAVIREATING
a > bccham wih Comte,the Wurh ro Compensation or
is provision aVde rralr code,. must SOILS FEE
W
forthwith comply with such provisions far Nis permit shall MJmtned revoked. WATI7R SERVICE
0. Q
CONS]hem iso ION LENDING AGENCY
ii,mmy NIiW ItliSlpi?NTIAL PLMB. SV.PI', PAID
L) O (for whi hthi ihauM1erc issued(Svctiomlendie.agency for the perfnnn;m.e of Date k�'PTGIAI
Hthe work for which Nis permit is issue)(Sec.409],Civ.C.)
0U Lenders Num.Lenders Address1 certify that 1 have real this application andsale that the above information is BUII,DING .E
N tueen.I agree to comply with al city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEEZ building construction.tmJ hereby authorize representatives al(his city memer uponNe SHISMid,o,mealin Mi pmpeny for......lin i parptisec PIBMI'f ISSUANCE(We)agree m save,matetnNfy and keep harmless the City of Cupertino against HL IC FEIiabilities,judgmenu,costs and expenses which may in any way aceme against said City AUTER OR ADD TO MECH.in consequence of the granting of this permit PLUMBING M
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,Bq)CFM)SOURCE REGULATIONS. MECHANI ALFM
AIR HANDLING UNIT(OVER 10,00 CFM1 CONS'I'RUL 'I'A%
Signnmre u pplinnConua Uv e EXHAUSTHOOD OV/DUC1) f{OfJSiNG MITIGA'ION FB
HAZARDOUS MATERIAL S DISCLOSURii
Will the applicant or forum building occupant store or handle hazardous material HEATING UNIT(TO 100,000 RTIO
as defined by the C.loompn Municipal Core,Chapter 9.12,and the Health and Safety
Core,Section 25532pro? HEATING UNIT(OVER 100,000 BTU)
Eyes CNc PAID
IV
VGfILAI PAN(SINGLERISID) Ilene Receipt to
Will the upplleanl or future holding occupant use clfl nrent or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER—COMP CHP OR 100INNI BTU)
tri
Disct? TOTAL:
❑Yes E]No BOILER—COMP(OVER 100,0011 BTU)
I have mail the hazardous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomia Health A Safety Core,Sections 25505.25533 and 25534.1 understand Nut if the NEW RI?SIDENTIAL MECH. i+, '�� A
building dnexnat enmemly have a late oth:n it is my resrymsihi lity at utility the oceufnot L
of the reyuirelocal,wbinth must to,ofvprior In il.suarecuE a Cao-al tem(OCcuminey.
Owner or eulM1nnrsA agent pate ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEg`WIT NO 1 Q
BUILDINGDIVISION APPLICATION/PERMIT PLUMPING-MECHANICAL. v y Z pJ O
BUILDING PROJECTLDENTIPICATION
SANITARY NO. APPLICATION SUBMITTAL DATE
BUILDING ADIlRE55'. V��c�a
O FIRS AMG:Cw/L� PHONE: CONT'RACTOR'S NAME: LIC NO:
NIC (/`�J�I�]CONTROLM
CHIT ECT/ENGINEGR: LIC NO'. ADDRESS: ❑ v / 1 1
CONTACT: /� PHONE: BUILDING PERMIT INFO
�`�A/kl— �'LaV FOy '�S- 57� ❑ Consultant Fees Paid by Applicant(Initial) B E PLu MGCII
v / u95-3.363
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby afforded 1 am Ilcenned under p...rei es of Chapter 9(commencing
A a'Z in full
of"andNfect. vision3ofNC BusineR and Pmressions Code,and my license is 2.$( FLNT1�L'
WOO PERMIT ISSUANCR
f- in full form and effect. FOWL [I KI REMODEL
V� License Class IJc.a
Q U APPLIANCES ADDITION ❑PLUMBING RE-PIPE
FZ Dam Contractor
rn6 ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
P.❑w PANELS MODIFICATION
Z O y z I understood my plane,hull be used as public records
OZ-, Up'PO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Limnsed Professional 201-1000AMPS IMPROVEMENT (]SWIMMING FOCUS
OWNER-BUILDER DECLARATION OVER 1003 AMPS ❑BATH REMODIr PAIR ❑DEMOLITION
a a 1 hereby oflirm that I an exempt from the Contractor's License Low I'.,the lu A
a W [-1 OFFER �!' '{ M
xx O G U following reas.m(Section 7031.5,Dienes,and Professions Code.Any city m county SIGNS ELECTRICAL —
W 3 W y whian requires a permit t.construct,alter,improve,demolish,ur rcpoir any aruaurc
�NONJ prior to ts issuance,also requires thppl t for suchPermit file a ingred statement SPFCIALCIRCUIT/MISC.
F, }
hat he is licensed ptT The fact isions ofth Contractor's Licente L (Chapter9 MMER�d 1 pc ,
and T LIMP. OR POLE INST. D0 (ru gThSt ]fal@ fIY _ T ftBusiness T ❑ Q
LITTON
The,1 pt Therefrom d N b f the.11 lid pt Any violation f I
�� Secton]In1.5bya ,lit, cant far a tiomnsthleds the applicant te 'l penalty of POWER DEVICES ❑TENANT' Vl' (,U/C�FOOD SERVICE
not mare man rr.bttna,ee d.fam(asoH). ITV
F Q [] hmowncr.f Nc Property,n,my employeenwith wages as,hci,ple crmpcnrarme SW I MMING POOL ELECTRIC IMPROVEMENT V
❑OTHER
will it,,the work,and the structure is not intended or offered far sale(Sec.9044,Business
W and Professions Cafe:The Contractors License Low does not apply In an owner of OUTLETS-$WITCHES-PIXTIIRES
property who hands or improves thereon,and who does such work hirewil or through
his own employees,provided that such improvements ere not in¢nded m offcrul for NEW RESIDENTIAL ELECT R SQ PT
sale.If,however,the building or improvement Lv sold within ane year of amtplmioq Ne 0 SQ.FT.FLOOR AREA $/SQ.FT.
p rve.r'neder,will hava the bnNen of proving mut he did not build or improve fico par-
e of solo.). O
❑ I,its owner of the property,,B exclu,a and contracting with Ii the cou—n., m
construct the project(Sec 944,owner
(if and ry who ar,builds
C.dap TM1eC,other tar LI-
e se Law does nmapply man ownend'propany whosedanrmtt to
ourracand QTY. PLUMBING PERMIT - PEE ^�
wincontracts forsuch projects with o contramortc)licensed pursumm to Ne Comrndorx
License law. PERISH r ISS NCE
El Impunder Sec. .B&P C for this rens.n
ALTS RAI &VENT-WAT'HR(PM) VALUATION
S'S'314
WORKERS CO ENSA'ITON DECLARA'T'ION HACK FLO .DEVICE
1 hereby affirm under penalty of perjury ane nl'the lalnwing declarations
I haveandwill maintain a Cenifesecof Cnmommself-insure ror Work.r's Compen- DRAINS- ,O ,ROO , .A,GOND. STORIES TY PE CONSTRUCTION
,rdon,as provided for by Seeuon 3900 of the LNM1e,Cade for the po,fommnec of the
work for which his permit is issued. FIXTURES Ayb
1 have and will maintain Workers Compensation Insurance,as required by Section
37M(it the Lebo,Code,far the performance of the work for which this permit is Issued. GAS-IIA.SYSTEM-]I fLETS OCG GROUP APN
My Workers Compensation Insurance cortin and Policy number are:
Carrier: Policy Ne: GAS-F.A.SYSTEM-OVER 4(F.A
CERTIPICAd I.OF EXEMPTION FROM WORKERSGREASETNDUSTRL WASTE IMfERCEPfOR
COMPENSATION INSURANCE IVISION FF.&S
(This swoon need not baeempleted if Neporntit is fsrnne hundrat dolhtrsisBar GREASITTRAI'
nr Ices) PLANCIIEC 0�
I certify that in the pedinma ice of The wnrkfo,whldt mhpermii,liksued,Isha1l SEWER-SANITARY-STORM EA.210 FT.
not employ any parson many manners.as to become arldect to the WorkersCompen- ENERGY FEE
Z arionlawsof Colifoure Date WATER HEATER W/VENTIF.LECTR
O 2 GRADING FEE
Applicant t
NOTICE TO APPLICANT:If,afking This Cenific nc of Exemption,yoWAFER u should R SYSTBM/TREATING
h far,maSOILS FEE
become subject the Worker's Compensationaorthis permit
b Ned Labor Coca,you most
forthwith unnply with such Provisions or lh'ro punnit sMJI be themed revoked. WATER SERVICE _11
Q �S
CONSTRUCTION LENDING AGENCY NEW RESIDEMf1AL PLMB. SQ.FT me a tpt#
'7 Z' Ihomhy affirm that the,c iso construction lending agency fo,the perrnrmanm of
Wtho work far which this permit is issued(Sec.3099,Civ.C.) TOTAL:
QLender's Name
W Lender's Address T( �•
1 certify that I have read this eppllemon iand ,are that The above information is BUILDIN
.F. y calrwl.l agreem comply with nu coy and county oNlnences and shoe laws mmtingm QTY MECHANICAL PERMIT FEE
L) Z building commactime and hereby authorize representatives of this city it)enter upon the SEISM ' :E
above-mentioned pmpeny for inspection pmpns.s. PERMIT ISSUANCE ELECTRIC �E
(Wc)agree1.,ave,Inti expenses
keep may
in an the Cityor Cupertinoid City
tobimidijudgntanls,costs anti hissesmit. may in any way nmmeagainst said City gI:PER OR ADDTO MECH. PLUMB] PE8
requNT of Nc RSTA Sof thisp WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(IMU
INNI CPM) MECIIA ICAL PGE
SOURCE REGULATIONS.
!-' ING UNIT(OVER It1,OfNI CFM) CONSTRUCfI 'A%
Signalurc of liwnl/Com,ncmv PM/kJ\}J�+V J DNte` IOOD(WIWCTJ HOUSING MITIGATI NP.E
HAZARDOUS MATERIALS DISCLOSURE
Wil ma appllwnl nr ruwrc building omupam store or handle M1nzalloun TalenNI'1'('r011%I,IIINI H'I'U)as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and SafetCode,Section 25532m)7 NIT(OVER 100,000 BTU)❑Yen ❑Nu ION FAN(SINGLE RESID) PAID Date ReceiptWill the applicant or rume building occupant use equipment or devlms whicOMPf3HP OR 100,0008"fU)mit hazardous air cumaminants as defined by the Bay Area Air Quality ManagemeT'O AL:
UistrinP ROILGR-COMPIOVEk ITERM 8'I'l17
L-]Yes ❑Nn
I hovered the bazardeus material,requirements under Chapter 6.95 of the Call- AIRCONDITIONER ISSUANCED E
boom Health&Safety Code,Swoons 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.PP.
building does not currently Mortician,that it only responsibility to notify the occupant
.find requiemente which mel beret prier In ie,uunee of a Cemifilealett Occupancy.
Owner or....ma ized agent Date ISSUED PY:
OFFICE