24060 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT"24060
Q, 4060
Building Address: '
a1q'-15 H Qnn l a i� �i, ✓L
n hone: p
�. �✓i�ZZ�'- 3—�/3 CITY OF CUPERTINO-BUILDING DIVISION
. qf
r° '^x° 1)b2(bi �_ % APPLICATION /PERMIT
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY COMROL N
Architect/En n Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmaa:l ozog)fti, &rPE4h9TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLAAATION
I hereby affirm that l am licensed under provisions o(Chapter9(comment. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwithSMbn7 )of DlWsion3otihe BusinessandlsrolessionsCode,andmy,
license PANELS -
Dan
amassContnctor i / '/��J. CO
ARCHITECTS DECLARATION / MI'I000 AMPS
G50 7r) I understand my plans shaft W used u pubec records OVER l OD0 AMPS SQ.17.FLODR AREA $/SQ.FT.
eed CC U Licensed Pro(emtoml SIGNS ELECTRICAL a ,I
6. OWNER.BUILDER DECLARATION
y, 7 Iherebya(firmthatlam exempt fromthe Contractors License law fou the
SPECIAL CIEtCU1T/M]SC aYG •1
2 0..'qq��( followingn.(Section 7031,5,Business and Profession.Code:An city -
PLF'❑ countywichrequlresaper ttommtmd,Oteyimpmve,demoltsh,ornalr TEMP.METERORPOLEINST.
ImS ❑ anystmetueprice toIts kswance,alsornryirestheapplicant for such pemdtto 7,q
K 15 file a signed statement that he he licensed pursuant to the provisions of the R]WER DEVICES `Or *
3�G Contractors License Law(Chapter 9(commenWg with Section 7000)of Divi- S4y��NG A70L ELECTRIC
~' V
F�O< slon3ofthe Busmessand ProfestioneCode)orthat hale exempttherommand 'pVALUATION
Q y.'.1 the basis for the alleged exemption. Any violation of Section 7MI5 by any •'3'U
ay< appilantfo s permitsubjectstheapplicanttoa Mvilpensltyofnat morethan OUTLE7SSWITCHISFDTURES -
g five hundred dollars($SM.
1,asownerofthe property, _ NEW RESIDENTIAL ELFCTR SQF T. STORIES TYPE CONSBICTION
k�6 0 nsation,w ldothew rk ndth my
ed or offelrM for
5 O sale(Sec.7044,Business and Professions Code:The Contractors License law
does not apply to an owner of property who builds or improves thereon,and
who domauch work himself orthrough his own employees,provided that such OCC GROUP RFS.UNRS
Improvements are not intended aroffered for sale.I(however,thebuilding sir TOTAL:
improvement issold withlnoneyearofcomplMioNtheowner-builderwlll have
UIL.Iiurden of proving that he did not build or improve for purpose ofsale3. QTy. PLUMB N ERMIT FEE R,OOD7DNE APN
Lj 1,as owner of the property,am exclusively contracting with licensed PFRMl7ISSUANC
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN& ATER(EA)
Wilds or Improves thereon, and who contracts for such ptajects with e
OTT,
hcensed pursuant to the Contractors License Law. BACK FLOW PROTECT.D FEE SUMMARY
IJ I am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA, SANITARY Y_ IN
• WORKMAN COM SATION DECLARATION RECEIPT
hereby affirm that I have a certificate of consent to self-Insure or a FIXTURES.PER TRAP SCHOOL TAX Y N
rti0atea(Worken Compensation Wura ceora certified ropy thereof(Sec. RECEIPT#
Polis Lab CJ '1C� Q2 140 GAS EA.SYS'IFA1-I INCA PARK FEE Y_ N_
1'o1lry M .P� (/7 GJ RECEIPT#
m any _ sat ni GAS FA.SYSlFT4.OVERd BUILDING DIVISION FEES
rtlfied copy Is hereby the cid.
MCertlOed tepybfiled withh the city inspection division. GREASE/INDUSTRL WASTE INTERC PLANCI-lECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(7hlsseMlonneed not becompieted gibe period b(oone hundreddollara SEWER-SANTTARY-STORM EA.20OFT. Date RCCCI [#
($100)orlen.)
Icertify that In the performance lithe work forwhlch this permit is Issue, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I aha8 not employ any person N any manner n ns to become subject to the
Workers'Compensationlawaof California. Data WATER SYSTEM/TREATING PAID
z Z Applicant
Z O NOTICETOAPPLICANT:If,after making this Certificate of Exemption,you NET RESIDENTIAL PLMB. SQ.FT. Data Revel t#
Fshould become subject to thmue Workeri Compensation provillavofthe Labor
W Cade,you=at forthwith romply TOTAL:
with such proWlons orthh perrNt shall be
W > decreed revoked. BUILDING FEE_
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby affirm that there is a construction lending agency for the perform- TOTAL: SEISMIC
FEE
once of the work for which this permit N issued(Sec.3097,Clv.C.)
U O Lenders Nacos PLUMBING FEE
LLI— LenaersAddren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedl(ythatl have read thhappBatbnand satethatthe above info noted
CL Vtermct.lagrecto complywdh all Mtyand county ordinance and state I= PERMITISSUANCE FEESPAID:
} N relating to build ing construction,and h ,by authorize representatives of this
F Z city to enter upon the aWw,memioned property for Inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to nave,Indemnify an d keep harmless the City of Cupertino Data Receipt#
against liabilities,p1gernms,ro s and expenses which may In any way..e AIR HANDLING UNU(To 10,000 CFM) SUBTOTAL:
ag/alym)t/a�aid CityIn enseque of the antfng�j thi `�enit. /
//l7LC/L c1� AIR HANOWNG UNIT(OVER IofsoCFM) CONSTRUCTION TAX
Slgnaw.&Applicant ntra.or Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA7 RDO US MATER]ALS DI SCLOSURE
Will the applicant or future building occupant store or handle hazardousHEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Reeal [#
He.nth and Safety Code Section 25532(a)2 HEATING UNIT(OVER IW D00 BTU)
MY. . t]No TOTAL:
Will the applicant or future building rampant use equipment o devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardin
hazardous air tents mors as dell ned by the Bay Area Air
. Quality Mawgemenf District? BOILER-COMP PFI'OR 100000 BTUML
Yet II��II No
have read the h.wr`Iious.turlals requirements a nder Cha pter 6.95 of BOILER-COMP
the California Health k Safety Coda Sections 25505,25$73 and 25534.I
understand that if the building d s not currently have a ten ant,that it is myNEW "
raponsibil fly to notify theaceu tof the ntswwKh/ t
prlort anccofa.C. (Oc an . 3
Owner or authorf nt Date
: ISSUED BY:
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT"24060
Q, 4060
Building Address: '
a1q'-15 H Qnn l a i� �i, ✓L
n hone: p
�. �✓i�ZZ�'- 3—�/3 CITY OF CUPERTINO-BUILDING DIVISION
. qf
r° '^x° 1)b2(bi �_ % APPLICATION /PERMIT
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY COMROL N
Architect/En n Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addmaa:l ozog)fti, &rPE4h9TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLAAATION
I hereby affirm that l am licensed under provisions o(Chapter9(comment. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwithSMbn7 )of DlWsion3otihe BusinessandlsrolessionsCode,andmy,
license PANELS -
Dan
amassContnctor i / '/��J. CO
ARCHITECTS DECLARATION / MI'I000 AMPS
G50 7r) I understand my plans shaft W used u pubec records OVER l OD0 AMPS SQ.17.FLODR AREA $/SQ.FT.
eed CC U Licensed Pro(emtoml SIGNS ELECTRICAL a ,I
6. OWNER.BUILDER DECLARATION
y, 7 Iherebya(firmthatlam exempt fromthe Contractors License law fou the
SPECIAL CIEtCU1T/M]SC aYG •1
2 0..'qq��( followingn.(Section 7031,5,Business and Profession.Code:An city -
PLF'❑ countywichrequlresaper ttommtmd,Oteyimpmve,demoltsh,ornalr TEMP.METERORPOLEINST.
ImS ❑ anystmetueprice toIts kswance,alsornryirestheapplicant for such pemdtto 7,q
K 15 file a signed statement that he he licensed pursuant to the provisions of the R]WER DEVICES `Or *
3�G Contractors License Law(Chapter 9(commenWg with Section 7000)of Divi- S4y��NG A70L ELECTRIC
~' V
F�O< slon3ofthe Busmessand ProfestioneCode)orthat hale exempttherommand 'pVALUATION
Q y.'.1 the basis for the alleged exemption. Any violation of Section 7MI5 by any •'3'U
ay< appilantfo s permitsubjectstheapplicanttoa Mvilpensltyofnat morethan OUTLE7SSWITCHISFDTURES -
g five hundred dollars($SM.
1,asownerofthe property, _ NEW RESIDENTIAL ELFCTR SQF T. STORIES TYPE CONSBICTION
k�6 0 nsation,w ldothew rk ndth my
ed or offelrM for
5 O sale(Sec.7044,Business and Professions Code:The Contractors License law
does not apply to an owner of property who builds or improves thereon,and
who domauch work himself orthrough his own employees,provided that such OCC GROUP RFS.UNRS
Improvements are not intended aroffered for sale.I(however,thebuilding sir TOTAL:
improvement issold withlnoneyearofcomplMioNtheowner-builderwlll have
UIL.Iiurden of proving that he did not build or improve for purpose ofsale3. QTy. PLUMB N ERMIT FEE R,OOD7DNE APN
Lj 1,as owner of the property,am exclusively contracting with licensed PFRMl7ISSUANC
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does out apply to an owner of property who ALTER-DRAIN& ATER(EA)
Wilds or Improves thereon, and who contracts for such ptajects with e
OTT,
hcensed pursuant to the Contractors License Law. BACK FLOW PROTECT.D FEE SUMMARY
IJ I am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA, SANITARY Y_ IN
• WORKMAN COM SATION DECLARATION RECEIPT
hereby affirm that I have a certificate of consent to self-Insure or a FIXTURES.PER TRAP SCHOOL TAX Y N
rti0atea(Worken Compensation Wura ceora certified ropy thereof(Sec. RECEIPT#
Polis Lab CJ '1C� Q2 140 GAS EA.SYS'IFA1-I INCA PARK FEE Y_ N_
1'o1lry M .P� (/7 GJ RECEIPT#
m any _ sat ni GAS FA.SYSlFT4.OVERd BUILDING DIVISION FEES
rtlfied copy Is hereby the cid.
MCertlOed tepybfiled withh the city inspection division. GREASE/INDUSTRL WASTE INTERC PLANCI-lECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(7hlsseMlonneed not becompieted gibe period b(oone hundreddollara SEWER-SANTTARY-STORM EA.20OFT. Date RCCCI [#
($100)orlen.)
Icertify that In the performance lithe work forwhlch this permit is Issue, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I aha8 not employ any person N any manner n ns to become subject to the
Workers'Compensationlawaof California. Data WATER SYSTEM/TREATING PAID
z Z Applicant
Z O NOTICETOAPPLICANT:If,after making this Certificate of Exemption,you NET RESIDENTIAL PLMB. SQ.FT. Data Revel t#
Fshould become subject to thmue Workeri Compensation provillavofthe Labor
W Cade,you=at forthwith romply TOTAL:
with such proWlons orthh perrNt shall be
W > decreed revoked. BUILDING FEE_
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z I hereby affirm that there is a construction lending agency for the perform- TOTAL: SEISMIC
FEE
once of the work for which this permit N issued(Sec.3097,Clv.C.)
U O Lenders Nacos PLUMBING FEE
LLI— LenaersAddren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedl(ythatl have read thhappBatbnand satethatthe above info noted
CL Vtermct.lagrecto complywdh all Mtyand county ordinance and state I= PERMITISSUANCE FEESPAID:
} N relating to build ing construction,and h ,by authorize representatives of this
F Z city to enter upon the aWw,memioned property for Inspection purposes. ALTER OR ADD TO MUCH.
(We)agree to nave,Indemnify an d keep harmless the City of Cupertino Data Receipt#
against liabilities,p1gernms,ro s and expenses which may In any way..e AIR HANDLING UNU(To 10,000 CFM) SUBTOTAL:
ag/alym)t/a�aid CityIn enseque of the antfng�j thi `�enit. /
//l7LC/L c1� AIR HANOWNG UNIT(OVER IofsoCFM) CONSTRUCTION TAX
Slgnaw.&Applicant ntra.or Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA7 RDO US MATER]ALS DI SCLOSURE
Will the applicant or future building occupant store or handle hazardousHEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Reeal [#
He.nth and Safety Code Section 25532(a)2 HEATING UNIT(OVER IW D00 BTU)
MY. . t]No TOTAL:
Will the applicant or future building rampant use equipment o devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardin
hazardous air tents mors as dell ned by the Bay Area Air
. Quality Mawgemenf District? BOILER-COMP PFI'OR 100000 BTUML
Yet II��II No
have read the h.wr`Iious.turlals requirements a nder Cha pter 6.95 of BOILER-COMP
the California Health k Safety Coda Sections 25505,25$73 and 25534.I
understand that if the building d s not currently have a ten ant,that it is myNEW "
raponsibil fly to notify theaceu tof the ntswwKh/ t
prlort anccofa.C. (Oc an . 3
Owner or authorf nt Date
: ISSUED BY:
OFFICE COPY