20658 APPLICANT IU FILL IN INFUHMAI IU14 VVI I HIN HtU LIIatS — USt BALL NUIIV 11-ctu UigLI
11.11dIng rrnocl Identification PERMIT NO.
Building Address: �s 0 Wz AS 20658
QCF}t�g�1 one. CITY OF CUPERTINO-BUILDINGDIVISION
C.ntracto'a Na
Lie.No: APPLICATION / PERMIT ^3 Lo
'a$ �?A 293rt L-T"/dam p�/ FP_ BUILDING-ELDCTRICALPLUMBINC-MECHAMCAL CA7ECARY CONTROL 4/! „Oa
I rchltect/Ggineer. LIc.N.
N'v d a I1 'r�r ppyy����yyy�y(��.o � I( y� vyr+t+� }i1�3:j?�J.BUILDINQP,ERMIT,INFO I,;.'�f(;.
/QTY„YtI�rI'a t .ELECT
Addrme: EYwEItR,1lTFL,',�pt14�. .
PEMITISSUANCE i.0 (U( ❑ O
LICENSED CONTRACTOR'S DECLARATION r)-
Ihrrehy affirm lh+l lam licensed under pmwlslnnacfCM...Co e,.rd m- AI'I'LIANCFSRESTDENML JOU RT'
Ingwlth Section 7000).!Dlvi@lon3 ofthe Ousineuand Profeulons Coda and my
Ilnnx b In tali(9{,and Mfect. PANELS
DateClass]] LION 7
Dale idntna0r l/l'TO ZWA
ARCHITECT ECLARATION 701•I000 AMPS
M7- I understand my plana shall be use aspubllcrecords OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
Llmnxd Professhm.1 SIGNS ELECTRICAL I'1 (• �'I'1 ��c�,Z
W OWNER-BUILDER DECLARATION
rn Gi SPECIAL CEtMT/MISE sa W
L., Z owing reason.(Section
7031mp..ir,.eConlra,.l Llcenx Law fmthe
•O q county following
req ire..p permit
to gudnex and PImprove, Codr.Any dtyor
•��qcounty which requlnsaperMllowmiruct,aller,lmpmve,demolbh,orrepalr, TEMP'MET[R ORIOLE INST.
E any strunun prlortolts Issuance,also requires the applicant for such permit to
I� < POWER DEVICES
U 01e a signed statement that he ls licensed pursuant to the provIslons of the
Contractors License Law(Chapter 9(mmmendcg with healon 7000).(Dlvl- SWIMMING POOL ELECTRIC
ROJ s]on 3.fthe 0uslnnaand PmfxxoIonaCode)orlhat he Is exempt lherefromand VALUATION
t x'•]] the Mals for the alleged exemption. Any violation of Section 7011.5 by any
applicant fora permit aubkaa lheappllcanl to a civil penalty of no more than U OIf13.EiS5WHCIIFSIgglUR6 (
five hundred delta.($SM. NEW RA DENIAL ELECTR SQJ7. STORES TYPECONSTRUCTION
c j 9.1 ❑I,as owner of Ibe property,or my employees with wages as Ihelr sole
< compensation,will dothe work and lheslructure Isnot intended or offered for
q xlc&e.7014,Bminess and Prefeselom Code:The Contractor's Llnnsc Law
E7$$ dace not apply to an owner o/property who Wilds or Improvesthenor,and OCC.GROUP RES.UNITS
who does@uchw.rkhlnuelf or through hisawnemployees,provided that such
Improvements am not Intended oroffered forsale.If,however,thebulWing or TOTAL t
improvement Is sold wllhlnoneyearofcomplctlogt1ba..ar-bWlder Wlllhave _ 1
thr„Jprrdenof pmving that be did not build or Improve for purposeofsale.). Q7y, .Qq PLIJM 71(N IT �y� �, 1, TY FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed pp(MIT LSSU NCE
Mtnclon to construct the project(Sec 7044,Business and Profrmlom Code:
Contractor's License Taw does not apply to an owner of property who
W ALTER-DRAIN h 7ER ffA)
lids or Improves thereon, and who contracts for such p( m -
ojewith a SUM11•MARY Vkii?{e.ia'`1it .
cgB�(a tort@)licensed pursuant to the Contractor's License Law. la `:� I::t 1'• e'
Nam exempt under Sec. B k P C for this ..on BACK FLAW PROTECT.D CE
DRAINS OOF,AREA,COND. SANITARY Y N
Tuner Dale RECEI T N
WORKMAN COMPENSATION DECLARATION TTX PPR SCIIWLTAX Y_ N_
❑1 hereby affirm that I have•certificate of consent to self-Insure,ora RECEIPTNN
cenlflcaleo(Worker.Compemationlmunnmoracertl(led copy ihereo(we. GAS EA.SYSTEM-1 IN EIS PNtKIV Y N
3BA,I037/�G -Yi
I'ollry N RECEIPT
GAS.EA.SYSITM-OVER 4
th
Com T —r1N0 BUILDING DIVISION PF:CS
CertlOed copy b filed with
hthe cit. CREASE/INDUSIBL WASTE INTERCE'TO PLANCHECK FEE
❑CetilOed copy b flied with the Aly Inspectlan dlvlalon. (�
CERTIFICATE OF TA EM PTION FROM WO R K ERS' GREASE TRAP PAID7�� 7b�_
COMPENSATION INSURANCE
SEWER-SANITARY-STORM EA.2IXIFT. Dale Reed IN {�(�S
(Fhb section need not be completed if(he permit Is(.mane hundred dollars
($l Ofd or lea.) _ WATER II[ATER W/VENT/ELFATR ENERGY FEE Y N
I certify that In the performance of the work for which this permit b Issued,
I shall not employ any person In any manner x as to become @object to the WATER SYSTEM/TREATING r-T r�.�,, S �'-JA
I hallo not
any Laws of any
alifornia.Brie PAID I�TLca �aro-
z Z Applicant NEW RESIDENTIALPIMB._SQ]7. Date Recel tq So4�
z O NOulCETome.ubAPPLICANT.e orken'kingthlssation caleolo"ofthe Lyou
—
should 6emme subject to the Workers'Compensallon provblom of the Labor TOTAL:
N
Code,you=&I forthwith comply with such pmvIslom orlM1b permit shall be
L j deemedrevoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 'ClO
1 I hemby affirm that there b a combuction lending agency for the perform ELECTRIC FEE
Z occ.((he work(.r which this permit Is Issued(See 3097,C1v.C.) TOTAL:
;) O I<ndcr'eNamn ,.. .,.5, h I ,. PLUMBING FEE
F I<ndcr'aAddrcm QTti:ir;l>tiIVI �IiANI TIL 6
If ;Tr, .'�,iFEM4
D W Iced lfy that l have read t his application a rad gate(hal lheabove Information - MECHANICAL FEE
11 cornet.l agree to comply with a 11 city arad county mdlnanms and Asia laws PERMIT ISSUANCE FEES PAID:
t• N relnting lobullding conslsudlon,and harcby mtharize reprcxntallvee o(thb
U) city to enter upon the above-mentloned propemty(or Inspection purposes. ALTERORADDTOMECH. Date RCCCI IN
_ (We)agree to save,Indemnify an d keep harmless the CIIy of uped Ino
•&.lost llablllilm,judgmenb,coslund expenses which may Ir.ryw.y.c.x AIR HANDLING UNIT(T010,ODOCFM) SUBTOTAL:
agabnloid City In consequence ofthe granting ofthlspermlt. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Appllant/Contna.r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will Iheappll"m or future building occupentatore or handle hazardous HEATING UNIT(PO 10D,ODD BTU) Date a
noterlalasdefinedl, the CupyyylllI na Munlet pd Code,Chapter9.IZandthe -
IlrallhandSafetyCede Z553Z(a)7 HEATING UNIT(OVER 100,000 BTU) A .
Yea Noxj
III the applicant or ulure bullding occupant use equlpmnnl or devises VPNTILATION PAN(SINGLE RESID) ISSUAI]ICE ISA
�•hkheMtharard.us air coma nanlaude0ned by the Oay Area Alr -`
ally Management Dista BOILER-COMP OM'OR ID0,WO RTU)
4Yea o
have read the Faza ons rruiarhb requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,000 OTU)
I la Ide.11h k Safety C.de,SMlom 75505,25533 and 75534. 1
undenlan I the building does not currently have a lcnani that It 1.my NEW RESIDENTIAL MECIi. SQ.17.
ropomlb yl I eocarpanl Wthe requirements which court be mel ,
riorit m m Atfi�es(m�.lompancy.
.Whminedagen �Da J TOTAL I SS LIE.D 9
(Writ C(InDv
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add(.0-30lb LOS o wD Fla 20658
OwnersName: rz one: q
(3Ca k(8t�1 CITY OF CUPERTINO-BUILDING DIVISION r-
Con.114 .a LIe.No: APPLICATION I PERMIT I N
cl� 'Jacr. BLIILDINGELECTRICA PLUMBINC.MECHAMCAL CATEGORY CONTROL p� �O1
Architect green Lk No:
QTY ELECTRIC PERMIT FEa,Eys BUILDING/PERMIT INFO
Address: PERMITISSUANCE J��' ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthal l am licenaed under provisions of Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRI'TION
Ingwlth Se ion7000)of Dlvfsion3oflhe Busineuand PmfeskmsCode,and my
license is In fulf and effect. PANELS ,es'_ \
LlccmeCl�m� a 7 C)\
Date id /-ase Contractor
—UP TO 20DAMPS
ARCHITECT DECLARATION 201-1000AMP5
9
0 2C0 I understand my plans shelf be u. .public records OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Licensed Professional SIGNS ELECTRICAL
<�6 OWNER-BUILDER DECLARATION SPECIAL C)RCNT/M1SC Ss CXR L
Zt.., 5 (hereby affirmlhat lamexemptfrom the Contractor's License Law for the
QQ following reason.(Section 7031.5,Business and Professions Code:Any city or
f'ty cmntywhichrequlrcsapermitlocomtruct,alter,impm ,demolish,orrepair TEMP.MEM OR POLE INST.
wa•`'�BC 33< anystmMmprlortoitalemancealwrequlmlheappBantfmauchper tto POWER DEVICES
K U Ole a signed statement that he is Bernard pursuant to the provisions of the
04 Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi-SVALUATION
OS sion 3 ofthe Budnessand ProfeuforsCode)orlhat he is exempttherefromand SWIMMING POOL ELECTRIC
the Wait for the alleged exemption. Anyviolationtolacon of t o 7m1.5 re any L 9
<� the bans fora permiged exe anon.the pAnyviaation ofpenalty Section
of not 31.5 by henany 1U OUTLETSSWITCHESH%'1'URFS "I YI G
five hundred dollars(f500). `
❑I, NEWR as owner of the property,or my employees with wages as their sole DENTIAL ELECIR SQFr. STORIES TYPE CONSTRUCTION .
compensation,will do the work and the structure is not intended or offered for
O .Is(Sec.7044,Business.ral Professions Code:The Cmdrectols License Law
$$ does not apply to an owner of property who builds or improves therco,and OCC.GROUP RES AMTS
EE whodoeaeuchworkhim Harthmughhisownemployees,pr idedlhatach
improvements are not Intended oroffered(mmle.If,however thebulWingor TOTAL:
Improvement issold mthlnomyearofcompletb tMo ner-bulfderwW have
tlalZurden ofproving that he did not build or improve forpurposeofuleJ. QTY. PLUMBIN IT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed pEgMlT lggU NCE.
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Low does not apply to an owner of property who ALTER-DRAIN& TELL
(EN -
builds or Improves thereon,and who contracts for s such plajacwith a
cFEE SUMMARY
ga[factor(s)Ilrenrd pursuant to the Contractolo License Law. BACK FLOW PROTECT.D CE
LI I am exempt under Sec B k P C for this reuonOUTSIDE"no
DRAINS OOF,AREA,COND.
SANITARY Y N
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑I hereby affirm that 1.have a certificate of consent to self-Imum,or RFOER'f N
cedlfirateofWorken'Compematimlre mncemaccAified copythereof(Sec. CAS EA.SYSTEM-1 IN E15 PARK FEE Y N
38W,Ieb C.) >> ��( RECEIPT If
YdIryM �QJ7��� " i I .
Com T—�JnaO GAS G.SYSTEM-0VERd BUILDING DIVISION FEES
CertNed mpylahercby I ed. GREASE/INDUSIAL WASTE INTFRCEPTO PLANCHHCK PEE
❑CertJed ropylaflled withthe eitylupectiondivision. `'') f�F L^y
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID l� `^ 3tcM
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA.XIOFI'. Qz
Date Recef f#
(Chis section need not be completed If the permit is forone hundred dollars
O51W)or leu.) _"- WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I rertify that In the performance of the work for which this permit is fumed,
I shall not employ any person In any manner n u to become subject to the WATER gySTEM/TREATING ,ry^••_
Workers'Compensation Tawe of CaB(omla.Date PAID L—Tt ' {p-
Z Z Applicant NEW RESIDFNTTAL PLMB. SQFT. DBI¢ R¢C¢1 [#
O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor - TOTAL:
'i N Code,you most forthwith comply with such provisions orthb permit shall be
LU
LU > deemed revoked. .
CONSTRUCTION LENDING AGENCY , SEISMIC FEE Q
CL (hereby affirm that there la a mmtmdlw lending agency for the perform ELECTRIC FEE
7 Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: CRl
V O Lender'shame PLUMBING FEE
F- I.endcr.Add.x - QTy.J MECHANICAL PERMIT FEE
O W 1artily that l have read this application and Yate that the above intomutIon
MECHANICAL FEE
iscorrect.l agree to comply with all city and county ordhommand Yat.laws PERMIT ISSUANCE FEES PAID:
>- relating to building construction,and hereby authorize representatives of this
N city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MECH.
? (We)agree to save,Ind emNfy an d keep harndeu the City of Cu portion Date Receipt#
V against liabilities,Judgments,coats and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit AIR HANDLI NG UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data IXHAUSTHOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WW the applicant orfumm building oaupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupppppp��y��yrrttttlno Mun1dpel Cod,Chapter9.IZ..dthe Date R
Health and Safety Cod. ; 32(a)7 HEATING UNIT(OVER 100,000 BTU) c A L
❑ Yes No
Will the applicant or future building occupant use equipment or devices VFNDLATION FAN(SINGLE RESID) ISSUANCE MATE'a`+
which emit hazardous air roma nano as defined by the Bay Area Air �s
� Q�iality Managemehe nt DlYr1 BOILER-COMP ptE'ORIW,OW BTIn
4 Yes
have read Health
oety Cedefalarcons requirements and 25534.
of BOILER-COMP(OVER I00,000 BTU)
t islaHefth kSafety Cods Sttctim7t y have a tenant,
that
nderstan fthe ulldingdces nm mrtenOy have atenanL slut ltlamy NEW RES DLNIIAL MEIN. SQFr.
raponYbPytPar ape occupant of the requirements which moat be met
Mort rn rtifiateof Occupancy. �7
authorized agerDate J ISSUEDBIV'll'T�/���`^^'cA'
TOTAL:
OFFICE COPY