31096APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
PERMIT ND.. e] O�
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING - MECHANICAL
J
BUILDING PROJECT IDENTIFICATION
9UIL"NGADDRE55:
SANITARY NO.
APPLICATION SUBMITTAL DATE
DW F.R:S NAME. - IIQN� �'
CO R' N
2
- NIC
❑
a CONTROL p
A HIL C IT iCT N JNF.V J
�.g�i/�y .-��/%
ADDRESS:
CVo/-ryt�TTfrACI':�`rNF>,NayBUIL,
`.O�
4- Consultant Fees Paid by Applicant (Initial) s
)l RMIT INFO
BLDG ELECT PLUMB MECH
� `LU� X . ' .
1000
O O
�UV
yaul
0.0.ARCHITECI"S
Z p O Z
O
LICENSED CONTRACTOR'S DECLARATION
" 1 hereby,ffirm Net 1 am licersed undrr pm,o o w of Chirac, 9 (commencing'
with Section]00(ru'Division 3 upon, Busincomad Professions CWe,and my license is
in full force and cff__t.
License Class Lir. It
Dam Covert
DECLARATION
1 understood my plans shall Mu
vd M public records
QTY ELECTRIC PERMIT FEE'
-
' JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL El KITCHEN REMODEL
' ADDITION m E3 PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
h10DIPICATION- '
❑INTERIOR ❑CHIMNEY REPAIR -
IMPROVEMENT
❑ RATH REMODEURF:PAIR 0DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES - BESIDEN'DAL
��
PANELS
.UPTO 200 AMPS
�N,S]
p6�y
It. 0
V; E'
W 3
LiccrsWl'rofessimnal '-
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 um exempt from the Contractor's License Lnw I'nr the
7h, following reamn. (Serino ]OILS. Business and Rnfessiam CWe: Any city ar county
201tIOMAMPS
OVE AMPS
N':LECTRICAL
W
0
fLp'
.which requires a permit m construct, alter, improve, demolish, or repair any sat cmre
prior to its issuance, also requires the applicant for such permit lm fleusig nedslntemrm
that he is licensed putsuxnt to the provisions oflh, Contractors License Lxw(Chap¢r9
5 CIA .IRC( /MISC. -
-
'
_
TEM('. L'TE ORW IN$T.
COMMERCIAL:
gr. 0
(commencing wiN Section]INNOnfDlvlslon3of the l{uainesnunJ Dmfesaians Cal,)ar
a X n y
0.
W to
�G
0
that he is exempt Nerefmm and he basis for Nc alleged exemption. Any violation of
Section 911315 by any applicant for n permit subjects the applicant) a civil penalty of
not more III. five hundred dollars 1$500).
❑ I, as owner of the Prnpcny, ur my employees with wages as their sole cmmpensatian,
will da the work, and Ne structure is nal lntemdnl mothered fmsale 15__.044. Burincss
W BLDG/ADDITION Q DEMOLITION
ANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER D CES
SWIMMING POOL.
and Professions Cute: The Comractnr's License Law does not apply to un owner
property who ibudds or improves thereon, and who does such work himself or through
'1'S -S SWITCHES - FIXTURES
his awn employees, provided that such improvements re, not intended or offered for
NEW RBSIDENTIAI, LILECTR SQ FE
sale .If, however. the building or impnrvcmem is sold within one ycarof completion,the
owner-brEdee will have the burden al'prming that he did nm build car improve for put-
ar-
SQ. FT FLUOR AREA S/SQ. FT.
^l—((-�_�
you of sale..
potentials.).
1, as owner of the am exclusively contracting with licenced emtr9cmry to
' I PA D
7T�
5 V
Seml'erty,
ono, the (Sec. ]fano Business and Professions Co.,., Tho Com
cents,La es not
c se tact__Jcesnos applymun owner of propcny who builds or improves Corson,and
hereon,
RsrsuchprojectswiNuronwetor(s)Iiamrsedpursuantmtha Cmmnmmr's
Q'FY. PLUMBING PERMIT FEE
�^�
r 215%CV
PERMIT ISSUANCE
LicenseI.w.
exempt
❑ lam exempt unJer Sec. ,B&PC for this reumn
0
ALTER- DRAIN & VENT - THR(EA)
HACK PLOW PROTECT.' DEVICE
-
r17V Is -
N
`J
� /nl
Owner Dan,-
•
WORKER'S COMPENSA'T'ION DECLARATION
Thereby affirm undo penalty of perjury one of be following declemtions:
DRAINS -FLOOR, ROOF, AREA, C D.
El I have and will maintain a Cirafcate of Consent o self -insure for Workers Coogan-
action, as presided for by Section 371X1 of the Labor Cosh.for Ore performance of the
STORIES -
TYPE CONSTRUCDUN
FIXTURES - PER TRAP
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, vs espaicd by Section
37)Oof �ttI�he�¢lln�c�hrap CCpS5W��e,yymr Ne perfonnanceof Newark fmavl ich Nispermit is issued.
=1/-1
C m�em:KY�Fl117NCin sum, q$e carne andy Nv.: nup�C5'6S _Py
GAS -EA. SYSTEM.) INC, 40 1'LEl'S
OCC.GRO
APN '
_r
q GAS - EA. SYSTEM-OVL'R 4(EA)
I
CERTIFICATE OF P,XEh1PtbN(EOM WORKERS'
COMPENSATION INSURANCE
(Thissection neWnot be completed if the permit is forme hundred dollars ($100)
less.)
GREASFANDIJSTRI, WASTIi 1NTF.RCEMR
U ODIVISION FEES
GREASE TRAP
PLANCHECK
SEWER -SANITARY -STORM RA. 2010 IT.
0
77 O
A�
a,
0.Q
�:)z
V
W Ir
(unify that in the performance ofthe work for which Nispermitls issued, lstood
not employ any person in any manner, 1Jkxr�nrlaM� m he Workers' Cooper-
svtimm Luws iI(j' I/u ua: Dam },, II ��YY
Applicant ri✓ LY. 7—� -
ENERGY rE.F.
WATER HEATER W/VENT/ELF.CTR
GRADING IEEE
NOl'ICF.T' AI� ILuncrmuking this Cenifiwte of Exemption, yoashauld
become subject Io one Worker's Compensation provision of the labor Code, you most
forthwith comply with such provisions Illp.i,,h.11 be deemed revoked.
CONSTRUCTION LENDING AGENCY
Thereby affirm Nat there isanmswction lending agency for the performance of
Dr
the work for which this pc Iran is hold (Sec. 3097, Civ. C.)
WAIERSYS'TEM?RF,ATING
WATER SERVICE
SOILS lit
PAID
Date Receiptp
NEWRESIDIINTIALI'LMR. SQ FT.
-
- TOTAL:
Q E"
Lenders Name
Lenders Address -
- is W,
A.
LFi to
vZ
certify that 1 lyse mad this application and state that the above information is
rnrecct.l agree to comply with all city and County ordinances and state laws relatingm
building consuuctlonanl herehyatuhsrisamPosemativesof his city tm eme, upon the
,
BUILDING FEE
SEISMIC FEE
I �O
QTY. MECHANICAL PERMIT FEF,
PERMIT ISSUANCE
above-mentioned property for inspection proposes.
'(We) agree m save, indemnify unit keep harmless the City of Cupertino against
ELECTRIC FEE
LTER ORADDTOMECil:Ir.
liubilitia,judgmcros, costs and expenus which may in any way accrue egxinsl said City
in consequence of the granting of Nis permit.
PLUMBING IEE
AIR HANDLING UNIT LTO IO,gMICFM)
-
MECHANICAL
APPLICANT I NDERS' .SNDS'AND WILL COMPLY WITH ALI. NON -POINT
SOURCE G LATH IS. _
AIR HANDLING UNIT 10,00(CFM).
�I
Q5' 1 /
CONSTRUL X
Signature. ApPli /Conuacmr Date
- ALAR IMUS MATERIALS DISCLOSURE
'EXHAUST F{OOD(W/DUCT')
sist
HOUSING MILT ON FE
HEATING UNI'I'(fO 100.000 BTU)
Will Nc app( ant or future building Occupant store or handle hazardous material
its defined by the Cupertino Municipal CW, Chapter 9.12, unit the Ileulth and Safety
CWe, Section 25532(x)?
HEATING ON[ r(OVER IInoosI BTU)E]
yes, No
Will the applicant or future building Occupant nor equipment or devices w'bich
cnmit hazardous air comeminnnts as relined by the My Area Air Costly Management
Dinner?
❑Yes No
PAID
Date Re
VEM'ILATION FAN(SINGLE RES ID)
BOILER -COMP (3HP OR ILO,WO BTU) ;
T i.upo
BOILER- COMP (OVER I00.000 HIM
AIR CONDITIONER-
I have read one h,zvdous =[costs requirements under Chapter 6.95 of Be Cali-
(nmia I{calN & Sufery Code Sections 255115 25533 and 25334 1 u mderst vmd N.n If the
building does mol currently have a tenant, TUBI n is my responambJny, to notify the Mcupaml
ISSUANCIi DAT('
NEW RESIIIENTIAI. MSCI I. SQ. IT.
of the requirements which must be met prior 10 issuance of a Cenifcate ul Occupancy.
�-
-
ISSUED BY:
Owner ornuNmrizedagent - Date
OFFICE
AYYLIUAN 1 IU PILL IN INFUHMAI IUN VVI I MIN NtU LINtb - U,t MALL YUIN I YtIN UNLS
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJR(7r IDENTIFICATION
PERMIT ND. 31096
BURMINGADURF.SS:
SANIGRYNO.
API'LICATIONSIJIIMl1'1'ALDAIIi
OW ER'SNAMR:
COT ( H'.'N
G l�_I
NI('
❑
CONIHOL4
r (TCI' 9NGINCI'R:
G .
ADDRESS:
SSSo. i\� E S -St
D�IrA_CAs `
�ll
1 1 "E]Crngullanl
V�
Fces Pail by Applicant (initial)
BUILDIN RMI'f INFO
Il.1iC I' I'17LI111 �M1'�MliCll
LICENSED I a CONTRA under S DECLARATION
I hereby v04nn That l am licensed under provisions of Chnpmr, 9 Rumn¢ncing
with Suction 7103) of Division 3 of The Business and professions Cale. and my license in
in hill force and effect.
Loeuc Cho, Lie.M
Date Connector
QTY ELECTRIC PERMIT ; -' EEE
JOB DESCRIITf10N
RFs�JI)_:NT�L:
❑SPDW'I. ❑KI'ICIIIiN REMODEL
❑ADDITION ❑ PLUMBING BE PIPE
❑SIRUCIURM.
MODIFICATION
❑INTERIOR ❑ CIIIMNHY REPAIR
IMPROVEMENT
❑BAI'II RFMODNJRII'AIR ❑DFMOLTIION
ED Or
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
ARCHITECT'S DECLARATION
I umbrium t my plans shall he u.serl vs public recoNs
PANELS❑MULTIUNIT
Oil TO NDAMPS
Licensed Professional
flstNEHI BUILDIiH IlEC1.ARAI'ION
1 hereby anion non 1 am aentpt (span the Contract.,., Utmost, Law hn The
following reason. (Sano.. 71315. Business and Professions Ca re: Any city or earn',
which requires a Permit m connate, alley, improve, demolish, a repair any salt:%
prior To in issuance. also requires the applicant for such pepnisto rile a signed statement
That he is licensed purseannm the pmvisiom of the Commctrn's License Low (Chanter 9
(coounencinR with Scelun Ban)) of Division 3 of the Business and Paires.sinns Code) or
the[ be is exempt Tbeefmnt and The basis for the alleged calcul ion. Any violation of
Section 7031.5 by may applicant lore pernh objects the applicmo Tato civil termly o!
mmore than Rvt haandreJ Jnllars (k$IMIL
❑1, asowner of the property or my enapinyms with wages as their sure compensation,
will Ju the work, and the structure in not mended or offered formic (See.11H4, Business
and Ppnosions Calc: 104 Contractor's License Law docs not triply m an owner
psnpeny who builds or improves thereon• and who does suet, wad himself or through
his own employees, provided that such imrimm
veems am nut inended nr offered an
art, If, loilellr• the looking or improvement !avoid withinone ym...t o a eica,The
ouncT-builder will have The burden of proving That he did not huild or l aprove it par
arse of sole, c.
I, us own r nl the pmpeny, vat esdmivdy conrnning with IicenaJ mnvacv... to
construct The project (Sec. 7044, Rusineas and Profusions Code:)The Contrartm a IA,
crnsc lawdtes nm appy nun owner of pn+peny wan huildsm improms thcruut. otd
who contracts such projects with a ctmtrano(O licensed purswat m The Contract...
License Law.
❑ I am exempt under Sec. ,B& P C fur thin,coma
2111 1000 AMPS
OVE IAMPS
:I FUI RICAL
NX
S 'CIA :IRC 1'IMISC. 17
I'EMI', lifts 0JN •INST.
COMME-IiQIAL
7W BI.DGIADDITION O DHMULII ION
ANT 0To IDSERVICC
OTTER F,MIiNI'
OI'i1F:H
POWER DIST
SWIMMING POOL. I'I
TS -SWITCHES -FIXTURES
NEW RISIDENTIAL ELECI'R SQ FT.
SQ. fT. ITOOR AREA VSQ. FT.
gs J4 f'a
iJ
APR
Mr` 25'REC D
VITV
J q IN
-�upt� 1
�I `� a
a/�,s.
l \kfJs
Q'fY. PLUMBINOPERMIT FEE
PIiRMI'f ISSUANCE
ALTER - DRAIN&VENT- Tf:RBEAT)
Owner Umc
WORKER'S COhI ofiN rj., IN DECLARATION
Iherchy affirm nada penalty of perjury one ofd¢following Jedamtiuns:
haveaml will msinaina Cenifiene of Conttnuo self-amre for Wakec'n Compcm
o To n. as pmvidcd for by Section 371() of the Inhsn Calc• for the performance of ase
work for which this permit !s issued
Ej I have and will rntinmin Worker's Compemm�nn Insurance, as required by Section
3700 of the Labor Gale, for the Performance of The work for vshidt Ili s repair is iwua1,
MY WorFkf`s�CmN Jpr3't)o4onA-V ecvjc Niocym^mMyaryk .3 G1 s(IO
Copier. Ibl.l(i }� x-1 `-s V S V -I
CEROFICATF,OPEXEMfTI NPROM WORKIifl5'
COMPI3NSATION INSURANCE
This section need not hecnmpRTed iOhe permit is failure hundreddullar, IS 11X0
less.)
Trott rhm in The perfornmm<of1hewmk lar vbkh Thislernlr is issued. Ishall
nm entrloy any peoon in any nmnncr soy T�p� �,ti� to the Wmkeri Cnmpcm
Amino ant s(,(':J/n/Tiv. Uat� J /7_7 a[
Applicant fAr
BACK ROW PROTECT. DEVICE
DRAINS- FLOOR. ROOF. AREA. C U.
STORIES
OCC GRD
'1'YI'Ii CONS'TRUCT'ION
AIN
FIXTU RF -5 - PER I'RAI'
CAS-IiA. SVS'TIiM-I INC.40 ILFiTS
q GAS -IiA. SYS'ICM-0VCR 41EA1
GREASMNDIJST RL WASTE INT FRCEPTOR
O O DIVISION I717FS
GREASETHAI'
PLANCfIECK Lk
SEWER - SANITARY - STORM CA. 200 FT.
CNIiHGY ITE
WATER IIEATIiR WNF.NT/IiLECI'R
GRADINGPEF.
NOTICE TO API(' 11� Tf. after making this Cenificam of EaentNion. you ehnu:it
become subject Fs the Workers Compensation provisions of The Labor Code, you must
loohwith comply with such provisions or this varrill shall be deemed revoked.
CONSTRUCTION LENUINGAGF.NCY
I hereby aflirn that is acunnruction lenfirgageney forthe penopnancel
the work for which This penplt is issued (Sec, 3097, Co, C.)
Lcialels Name
lender's Address
I cenify the 1 hove mad,hie npplicntimt and .nate native above information is
correct. I agree In a.utply with all clay and canary ordimmcee aced mne lnws relating m
InailJing cnnsmadinn, and hereby solitaire rcprcammives of this city To enter
e, uMsn The
nbove-rtenrioned poi or y for inspection purposes
Wo) agree to save, indemnify and keep hepates. the City of Cupemnr against
Iinhil itics, judgmenss,cast, and espouses whichmay In any way amroeagaiml said City
in consequence of the granting or this permit.
AI'I'hICANT UIiRS' ANUS AND WILL COMPLY WITT I ALL NON POINT
SOURCE 7 ,AtI S.
Q5 ,'�
WATER SYSTCMO-REATING
SOUS PEI!
WATER SERVICE
PAID
Date Receipts
NEW RESIUT:N IALPI.MB. SQ. IT.
r MI.TOTAL:
IT O
BUILDING ITE
SEISMIC FEE.
CI.ECI RIC PEI.
PLUMBING tLC
1 `♦ pO
_'il
l
QTY, MECHANICAL PERMITFEE
PERMITISSUANCE
LTER Oil ADD TO MECII.
AIR HANDLING UNIT (TO Iq(XD CPM(
MECIIAMCAh
AIR HANDLING UNIT (OVER I0.013CFM)
CONSTRuc ralftpx
Signature o ATinih IContracmr Data
AZARDOUS MATERIA( S DISCLOSURE;
Will the appl'am home he hupa
ir,occunsn.nom handle hararJpus material
nn defined by the Cupertino Municipal Cale. Chapter 9.12, end the Health and Safety
Code, Section 255321a1'.'
❑Yes 0 N
i future huildng occupant use equipment nr devices which
Writhe Pit contaminants
hnzardnm air mnmminvn0 as de0nal by the )lay Area Air Quality MenaRmntnt
. it,
❑Vcs 0Nu
I have mad rho Meal us ramcmdsagahcoems under Chnpmr(.91 of the Cal!-
final, Health & Spray C de, Section, 25511.5. 2553) and 29534. 11 &,,load That it rhe
building does not cunmnly have v (nam, that it is nay respmsibility m norily the oecuponl
of the requirements which must he met Prue to issuance of a Ceniftcate of Occupancy.
EXHAUSF BODO WIDUC)
HOUSING MITI ION i'li.
HEATING UNIT (10113,1X3 BTU)
HEATING UNIT (OVER Harrah I) I'U)
PAID
Date
VENTILATION PAN (SINGLE RESID)
0(IILCR -C(IMP t711P OR 104.1X3 (ITU)
I I
RAILER -COM(' (OVER 113.1X10 B'TO)
AIR CONDITIONER
ISSUANCE DA7T
ISSUED BY: n 51P
NEW RESIDENTIAL MECIL SQ. FT.
Ow at, or authorised .,or Dam
OFFICE