S0006 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 ") Ill cilia
BUILDING PROJECT IDEN'I'IYIC'ATIUN
BUILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATI
'S Lot q�
OWNER'S -7 f90 ^. FJ70 C ACTORS Ary _ � I.IC NIC CONTROLM
ARCHRECT/ENGINEER: LIC NO: S 7 ADDRESS: /M7/r'�Y�L ❑
CONTACT" PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I3L CCS ELECT PLUMB MECH
L1� r ❑ ❑
LICENSED CONTandordr DECLARATION QTY 'ELECTRIC PERMIT FEE
I hereby aRrm Lha I am licemed under previsions of Chapter 9(coenmeceming JOB DESCRIPTION
�U2, with 5cction]IxMllnc Busincaa and x' dmylicenae is RESIDENTIAL:
F O in fullfierce and eyes PERMITISSUANCE
�� ❑SIq)WL ❑KITCIiEN REMODEL
U U Liccme Lic.p
QL Dam t Cammctor APPLIANCES-RESIDENTIAL ❑ADDITION E)PLUMBING RE-PIPE
Dm ARCHITECTS DEC RATION PANELS ❑MULTI-UNIT ❑STRucTURAL
Zz l underared my plane shall he used as public records MODIFICATION
OZ C UPTO2WAMPS �/'
F-Nf'm Licensed Prefc,sionA '6NNTERIOR ❑CHIMNEY RHPAIR
HFI-IBBBAMPS 1�IMPROVEMENT WI 11NG POOLS
ctl" 4 OWNER-BUILDER DECLARATION ❑'
C C Q I hereby afro that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑RATH RE -LJ ❑ .ITION
X 34 F following reason.(Section 7831.5,Business and Professions Cede:Any city or county SIGNS ELIi01'RICAL ❑O�
YI u.y which requires a Permit to construct,alter,intprme,demolish,or mplia any structure
F�'Oa Puerto its komac.al.wrequirea Neappliconl forsuchpanni lofileosignt,il acream SPECIAL CIRCUITNISC.
SE"' Baal he is homestead pursuant the Provisions ofthe Contractor's License Law(Chapter 9
gty0_q (commencing with Section 701))of Division 3 tithe Business and Professions Code) TEMP.METIiR R EINST COMMERCIAL:
L C W Bhat he is exempt therefrom and the hasis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION [I DEMOLITION
m Section 7031.5 by any applicant fur a permit suhjeas the applicant is civil penalty of POWER DEV. '
F Z�• ail more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
C ❑I.as owner of the property,or my employees with wages as their sole compenmtion. SWIMMING LELE IMPROVEMENT
will do the work,and the statement,is not intended or offered Our sale(Sec.](K4,Rosiness ❑OTHER
Sand Professions Cimt The Continent's License Law docs not apply to an owner of OUTLETS-SW FS FIX
property who builds or improves thereon,and who does such work himself or through
his own employees,Invented that such improvements am nm intended or offered for NEW RESIDEN- R 1?.
sale.IL hosannVr.the building or improvement issold within one year ofcompletion,the SQ.Ff.ROORA12yA $/SQ,FI'.
err-builder will have the burden of proving that he did not build or improve for pun A '
poses eeleJ.
❑1,as owner of the property,am exclusively contracting with licensed contractors to ��
construct fee project(Sm.704,11,Business and Professions Code)The Conuacnr.c Li- Y
cense Low does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ` j /IBpI�
who commets for such projects with a contrecmr(s)licensed pursuant the Commctur's b s 6('
Liesuse
01 am exempt under See ,B&P C for this mason w. PERMIT ISSUANCE �IlY�fj- LurL
tu oil)
Owner hate
N M211-DRAIN&VENT-WATER(EA) VALUATION
J
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.UIiVICE SF/M
I hereby affirm under penalty of perjury one of the following decimations:kersCounted.
.rfiLV
❑Laws pinvidl marry eCcrti3caw7W of Con sent self-Code,for the
sce of the URAINS-tLIXIR,ROOF,AREA.COND.
tion,este provided for by Section J]W of the Veer Code,for the perfnnnance of me STORIES TYI'li CONSTRUCTION
as for which this permit is issued 171X'I'URES-PER TRAP
ve and will maintain Worker's Compensation Insurance,as required by Section
700of the labor Code,for the pedon:Iance of the wmkfor which thisp Bis issuM. GAS-EA.SYSTEb1-I INC.4011TLLT5 OCC GROUP ANN
M Work m t,y�y.u� tie rand Pudic ala that(���z^^^
Cli nerd in " IJcarrie Policy No.: -��(/ ,J— GAS-EA.SYSTHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASEBNDUSTRL WASTE INTERCEPTOR
(This section need Brat becumpleted if the pemul is for onehundmd duffers($100) BUILDING DIVISION FEES
m less.) GREASE TRAP PLANCHECK FEE
I certify that this,meed is issued,i shall 517 W ER-SANITARY-STORM EA. 17.
not employ any perum in any manner so as to become subject to the Workers'Compen- ENERGY FEE
0 Z within Laws of Date WATER HEATER WNENT/ELF,CTR
Z Applicant GRADING FEE
h NOTICIi TOILAPPLICANT: after making this Certificate of Exemption,you should WAITER SYST EM/TREA'I'ING
a ; become subject to the Worker's Cmer,acaum Provisions of the Labor Cude,yue..,at SOILS FEE
foMwith comply with such provisions or thio permit shall M deemed revoked. WATER SERVICE
CONSTRUCTION ONLENDINGAGENCY NGW RESIDENTIAL PLMB. SQ.FT. PAID
V 0 l fare which foe that ski isacedSce.30 len ding agency for the performancc of D eceiptN
tr
the work far which this pcmul is issued(Sec.J(19].Civ.C.)
0 fs Letter's Name TOTAL:
Lendcr' AJdress TOTAL:
I' Z) certify o c I have read this application and stem tam the arm
information dining is RUILUIN r
Z coered.lagree toaemply withallordinances insmlatingm QTY. MECHANICAL PERMIT FEE
V Z building nmawclion.and hereby emhoeiss rephsematives n(this city to enter upon the SEISMIC
above-mentional xmparty for inspection purposes. PERMIT ISSUANCE
(We)agree to wive,imlemnily,and keep harmless the City of Cupertino agaiml ELECTRIC FEE
fiabildice.judgmem,custsand expenses which ren y way attmeaguimlaaid City ALTER OR ADDTO MECH.
me onsequence of the grenting of this permit anPLUMBING FEE
APPLICANT ON �)iRST/yVDS WICALL NON-POIMI' AIR HANDLING UNIT(TO IU,0100 CPM)
SOURCE RE 'I
55 MECHANICAL iG
AIR HANDLING UNIT(OVER 10.10x)CFM) CONSTRUCTI TAX
Signa hof A,pIaamA` B ate EXIIAUST HOOD(WMUCO
HAZAR .'MATERIALS DISCLOSU HOUSING MIT FEE
Willmeapplicvm orN m building occupant stertor handle hicadous material H17ATING UNI'1'(TOIW.(NX)BTU7
as defined by the Cupcnin unicipol Code,Chapter 9.12,and the Health and Safety
Code,Station 25532m)? H17ATING UNIT(OVER 110.000 BTU)
❑Yes ❑Nn PAID
VENtILATION FAN(SINGLI3 RESID) Dam RcccipBp
Wtionsll the applicamcrfuture defined occupby
Buyse Area
AirQntotyiManage ichant, BOILER-COMP(3HP OR 1(X1,(01)BTUI
mit hazardous sir comaninants as defined by the Buy Areu Air Quality Management,
Dianct] TOTAL:
❑Yes LJ No BOILER-COMP(OVER 110.W0 RTU)
I have read the hnzardons materials mgnimmems under Cheerier 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code,Sections 25505,M533 ort 25534.1 understand cut if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a moan tit it is my responsibility mainly the occupant
of dee mquihmana which most be,mel prior m issuance Ufa Certificam of Occupancy.
Owner at authorized agent Dae 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 ") Ill cilia
BUILDING PROJECT IDEN'I'IYIC'ATIUN
BUILDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DATI
'S Lot q�
OWNER'S -7 f90 ^. FJ70 C ACTORS Ary _ � I.IC NIC CONTROLM
ARCHRECT/ENGINEER: LIC NO: S 7 ADDRESS: /M7/r'�Y�L ❑
CONTACT" PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) I3L CCS ELECT PLUMB MECH
L1� r ❑ ❑
LICENSED CONTandordr DECLARATION QTY 'ELECTRIC PERMIT FEE
I hereby aRrm Lha I am licemed under previsions of Chapter 9(coenmeceming JOB DESCRIPTION
�U2, with 5cction]IxMllnc Busincaa and x' dmylicenae is RESIDENTIAL:
F O in fullfierce and eyes PERMITISSUANCE
�� ❑SIq)WL ❑KITCIiEN REMODEL
U U Liccme Lic.p
QL Dam t Cammctor APPLIANCES-RESIDENTIAL ❑ADDITION E)PLUMBING RE-PIPE
Dm ARCHITECTS DEC RATION PANELS ❑MULTI-UNIT ❑STRucTURAL
Zz l underared my plane shall he used as public records MODIFICATION
OZ C UPTO2WAMPS �/'
F-Nf'm Licensed Prefc,sionA '6NNTERIOR ❑CHIMNEY RHPAIR
HFI-IBBBAMPS 1�IMPROVEMENT WI 11NG POOLS
ctl" 4 OWNER-BUILDER DECLARATION ❑'
C C Q I hereby afro that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑RATH RE -LJ ❑ .ITION
X 34 F following reason.(Section 7831.5,Business and Professions Cede:Any city or county SIGNS ELIi01'RICAL ❑O�
YI u.y which requires a Permit to construct,alter,intprme,demolish,or mplia any structure
F�'Oa Puerto its komac.al.wrequirea Neappliconl forsuchpanni lofileosignt,il acream SPECIAL CIRCUITNISC.
SE"' Baal he is homestead pursuant the Provisions ofthe Contractor's License Law(Chapter 9
gty0_q (commencing with Section 701))of Division 3 tithe Business and Professions Code) TEMP.METIiR R EINST COMMERCIAL:
L C W Bhat he is exempt therefrom and the hasis for the alleged exemption.Any violation of ElNEW BLDG/ADDITION [I DEMOLITION
m Section 7031.5 by any applicant fur a permit suhjeas the applicant is civil penalty of POWER DEV. '
F Z�• ail more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
C ❑I.as owner of the property,or my employees with wages as their sole compenmtion. SWIMMING LELE IMPROVEMENT
will do the work,and the statement,is not intended or offered Our sale(Sec.](K4,Rosiness ❑OTHER
Sand Professions Cimt The Continent's License Law docs not apply to an owner of OUTLETS-SW FS FIX
property who builds or improves thereon,and who does such work himself or through
his own employees,Invented that such improvements am nm intended or offered for NEW RESIDEN- R 1?.
sale.IL hosannVr.the building or improvement issold within one year ofcompletion,the SQ.Ff.ROORA12yA $/SQ,FI'.
err-builder will have the burden of proving that he did not build or improve for pun A '
poses eeleJ.
❑1,as owner of the property,am exclusively contracting with licensed contractors to ��
construct fee project(Sm.704,11,Business and Professions Code)The Conuacnr.c Li- Y
cense Low does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE ` j /IBpI�
who commets for such projects with a contrecmr(s)licensed pursuant the Commctur's b s 6('
Liesuse
01 am exempt under See ,B&P C for this mason w. PERMIT ISSUANCE �IlY�fj- LurL
tu oil)
Owner hate
N M211-DRAIN&VENT-WATER(EA) VALUATION
J
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.UIiVICE SF/M
I hereby affirm under penalty of perjury one of the following decimations:kersCounted.
.rfiLV
❑Laws pinvidl marry eCcrti3caw7W of Con sent self-Code,for the
sce of the URAINS-tLIXIR,ROOF,AREA.COND.
tion,este provided for by Section J]W of the Veer Code,for the perfnnnance of me STORIES TYI'li CONSTRUCTION
as for which this permit is issued 171X'I'URES-PER TRAP
ve and will maintain Worker's Compensation Insurance,as required by Section
700of the labor Code,for the pedon:Iance of the wmkfor which thisp Bis issuM. GAS-EA.SYSTEb1-I INC.4011TLLT5 OCC GROUP ANN
M Work m t,y�y.u� tie rand Pudic ala that(���z^^^
Cli nerd in " IJcarrie Policy No.: -��(/ ,J— GAS-EA.SYSTHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE OREASEBNDUSTRL WASTE INTERCEPTOR
(This section need Brat becumpleted if the pemul is for onehundmd duffers($100) BUILDING DIVISION FEES
m less.) GREASE TRAP PLANCHECK FEE
I certify that this,meed is issued,i shall 517 W ER-SANITARY-STORM EA. 17.
not employ any perum in any manner so as to become subject to the Workers'Compen- ENERGY FEE
0 Z within Laws of Date WATER HEATER WNENT/ELF,CTR
Z Applicant GRADING FEE
h NOTICIi TOILAPPLICANT: after making this Certificate of Exemption,you should WAITER SYST EM/TREA'I'ING
a ; become subject to the Worker's Cmer,acaum Provisions of the Labor Cude,yue..,at SOILS FEE
foMwith comply with such provisions or thio permit shall M deemed revoked. WATER SERVICE
CONSTRUCTION ONLENDINGAGENCY NGW RESIDENTIAL PLMB. SQ.FT. PAID
V 0 l fare which foe that ski isacedSce.30 len ding agency for the performancc of D eceiptN
tr
the work far which this pcmul is issued(Sec.J(19].Civ.C.)
0 fs Letter's Name TOTAL:
Lendcr' AJdress TOTAL:
I' Z) certify o c I have read this application and stem tam the arm
information dining is RUILUIN r
Z coered.lagree toaemply withallordinances insmlatingm QTY. MECHANICAL PERMIT FEE
V Z building nmawclion.and hereby emhoeiss rephsematives n(this city to enter upon the SEISMIC
above-mentional xmparty for inspection purposes. PERMIT ISSUANCE
(We)agree to wive,imlemnily,and keep harmless the City of Cupertino agaiml ELECTRIC FEE
fiabildice.judgmem,custsand expenses which ren y way attmeaguimlaaid City ALTER OR ADDTO MECH.
me onsequence of the grenting of this permit anPLUMBING FEE
APPLICANT ON �)iRST/yVDS WICALL NON-POIMI' AIR HANDLING UNIT(TO IU,0100 CPM)
SOURCE RE 'I
55 MECHANICAL iG
AIR HANDLING UNIT(OVER 10.10x)CFM) CONSTRUCTI TAX
Signa hof A,pIaamA` B ate EXIIAUST HOOD(WMUCO
HAZAR .'MATERIALS DISCLOSU HOUSING MIT FEE
Willmeapplicvm orN m building occupant stertor handle hicadous material H17ATING UNI'1'(TOIW.(NX)BTU7
as defined by the Cupcnin unicipol Code,Chapter 9.12,and the Health and Safety
Code,Station 25532m)? H17ATING UNIT(OVER 110.000 BTU)
❑Yes ❑Nn PAID
VENtILATION FAN(SINGLI3 RESID) Dam RcccipBp
Wtionsll the applicamcrfuture defined occupby
Buyse Area
AirQntotyiManage ichant, BOILER-COMP(3HP OR 1(X1,(01)BTUI
mit hazardous sir comaninants as defined by the Buy Areu Air Quality Management,
Dianct] TOTAL:
❑Yes LJ No BOILER-COMP(OVER 110.W0 RTU)
I have read the hnzardons materials mgnimmems under Cheerier 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&Safety Code,Sections 25505,M533 ort 25534.1 understand cut if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a moan tit it is my responsibility mainly the occupant
of dee mquihmana which most be,mel prior m issuance Ufa Certificam of Occupancy.
Owner at authorized agent Dae TOTAL: ISSUED BY:
OFFICE