28565 / APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. 28565
�ass r/�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL / X 5 M 5
BUILDING PROJECT IDENTIFICATION L.VVV VVV V VVV
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAP
7g"/If L/L IG Gr awozrm/0 t C,1 rcDiSG
OWNER'S p�t+AME:�e,L PHONE (�A ONTR C'I'O 'SN ML'd p ,( LIC NO:p l
,,U FS/Irlr✓� C//�r�yN PJG/13'1 D� L /a//N �/I T�O /�' ICVII
NIC CONTROLM
R HETECT/ENGINEF.R: LIC NO: ADDRESS: E ^ 1
D 9L A/� PArio. ��c / !.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fee.Paid by Applicant(Initial) ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑
1 hereby affirm Nat 1 am licensed under provisions of Chapter 9(commcncing JOB DESCRIPTION
cC) with SemimliY0)ofDivisinn 3 afthe Businessand Prof casi.m Cade.inad my Rom.is RFSIOPNTIeI.
in full forte and affect. PERMIT ISSUANCE
C IDC ❑SFDWL - ❑KITCHEN REMODEL
ac License Class Lic.Y
F a,a AT
Dam Cantmcmr - APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
p
gF. ARCHITECTSDECLARION PANELS ❑MULTI-UNIT []STRUCTURAL
Z r22 Z l understand my plans shall be used as public records MODIFICATION
pZ 0 UP T02W AMPS ❑INTERIOR - [I CHIMNEY REPAIR
W Licensed Pmfessionel 201-1000AMPS IMPROVEMENT -
a •aj OWNER-BUILDER DECLARATION OVER 11100 AA1P5 [I BATH REMODEUREPAIR 0DEMOLITION
y I hereby affirm that 1 am exempt from the Contractor's License Law for the
Sed aU fallowing reason(Section 7031.5,Business and Profaasi o , nyrcity m county SIGNS ELECTRICAL []OTHER
Y7�l O which nuadi s a permit m construct,ehcr,improve coolish, are t any atrucwre
Iwau
prionoim issuance,alai rcyuires the applicant fn chpetmnmfileas medsmament SPECIAL CIRCUIT/MISC.
yNat he is licensed pursuant to the provisions. eCtimarm ses License se(Chapmn9
Do SPECIAL
Section 7000)of Unions he Businesse dPmfus ns Cude)mr TEMP.ME IR OR POLE INST. L:
S C that he is exempt mammon and the b Torr the alleged exemption.Any aviation of ❑NEW BLDG/ADDITION ❑DEMOLITION
-,m Sectio ]031.5 by any applicant for emit subjects the applicant to a civi enaby of POWER DEVICES ❑TENANT ❑FOODSERVICE
x_ not name rise
ealacluninon doilar empl IMPROVEMENT,
Cj a 1savocofthdthest y myotinonee oroffegesastheirsolecom nsmiass SWIMMING POOL ELECTRIC
will ons and Nen tore isnotimm�ded Lw,does of apply to an, mass ❑OTHER
anderty who
Cole: coves thenco License Lawdoesnotapply himself
roof t OIITLEI'S-SWITCHES-FIXTURES
progeny who builds improves t such a and who does m n work himself offer mgr
his own employees provided trim such mentis old within arc not intended m ince¢ for NEW RESIDENTIAL ELECTR SQ PL ,
owner,hnwe,wilt builthe bu improvemengtatheadone wild or(completion, a SQ.PI'.FLOG A 5/SQ.FT.
owner-builder will ve the bunicn of proving that he did not build or improve for
pose of owner
/
❑s,esownuafshe Party.am.DexclusivelyN essitin 'en roman m
construct La the project p .]lana Rosiness and N eosin n c. The Cs this is l.i- -
hocontwdoesnouapp roan owner of pony n d. mpmves th a ,ers QTY. PLUMBING PERMIT PEE
who contracts for such p 'ens with. is se Put me ommmors
License law. PERMIT ISSUANCE -
El 1 am exempt under Su. ,R&P for Nis reason
ALTER-DRAIN&VENT-WATER MA) VALUATION
Owner - Oat '
WORKER'S MPjNIAN
ON C'', T N BACK FLOW PROTECT.DEVICE
I hereby mE_under pen y oone of Ne folio mg"N"an ono: V
❑Ihaveand will maintain a Cern aunuo-If-ins for Watters Compen- DRAINS-FLOOR,ROORARL'A,COND, STORIES TYPE CONSTRUCTION
safion,as provided for by Suridr 3 0Ishan Cale, or the performance of thework for which Nis permit is issual. FIXTURES-PER TRAP
❑1 have and will maintain Worker'sation Ina s required by Section
3710 ifthe Luhhr Cockafmtheperf.stli for which this gamut is ismed. GAS-EA.SYSTEM-I TNC.4OUTLETS OCC.GROUP AIN
MyWorker'sCompensationlnmmncend Pol' ynumheram:
Carrier. licy o.: GAS-EA.SYSTEM-OVER 4(EA)
CE•RTIFICATED,' ON OM WORKIiRS'
COMPENSN RANCE GREASFANDUSTRL WASTE INTER EI?OR
(This section need not Is,camplemd lfthe permit is name hundred it.]]..Di BUILDING DIV ION MUS
lesal GREASE TRAP L NCHECK FEE 0.I cenify Nat in the Performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STCIRM EA. WET.
not employ any personm any.. sons t.becomesubjutmNa Work,.C.mpen-- EN RGY FEE fV
z
no.Lava of Califomia.Data WATER HEATER WNENT/ELECTR
Applicant GRA ING
77In NOTICETO APPLICANT:If,ufrrmakin this Certificate of Exemption,
a7 ti gyoushauld WATER SYSTEM?BEATING SOIL
(••! ' biome subject to the Workers Compensation provisions of the tunlgr Code,you must
13p'lt forthwith comply with such provisions or Btix permit shill be deemed revoked. WATER SERVICE
Q
�zCONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL.PI,MB. SQ.FT. PAID
U I for whin thi thenherciised(Secm3097,lending agency for the performance or _ to ReceiptN
D. F the work for which this permit is issued(Sec.J(197,Civ.C.) _
O U Lenders Name - TOTAL:
Lenders Address TOTAL:
1 cenify that 1 have rent this application and store Net the ohwe information is - BUILD �
taVE co=i.1 agree m comply with all city and county ordinances and state laws relating n QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives of this city to enter upon the SEES IC FEE
'•'� above-nientiured property for inspection purposes. -
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE [ME
E IC FEE
Iiabilities,judgmerns,costs and expenses which may many way seeme aguinsisaid City ALTER OR ADD TO MECH.
a.comequcnee ofma granting canis gamut. MBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ETO IQWO CFM)
SOURCEREGULATI ANICAL FF.E
AIR HANDLING UNIT(OVER IBIXIIICFM) NS .TION TAX
Sina A am`ContrumrDate EXHAUST HOOD(W/DUCT)' USINGM ATION FEE
HAZARDOUS MATERIALSDIS OSURE
Will the applicant or future building occupant sr' m handle hazardous material HEATING UNIT(TO 100,000 BTU)
aide ed by the Cupertino Municipal Cade,Chapter 9.12,and the Health end Safay
Cade, ectian 25532(0)? HEATING UNIT(OVER I00,000 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID q
Will the applicant or future building occupant use equipment s devices which Data 0"' Rc t R
emit hismadmS air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP GHPOR 100,04)(1 �•
District? - BOILER-COMP(OVER IM."BTU)
❑Yes F1 No h
1 have read the harsNaus materials rryuiremems under Chapter 6.95 of the Cali- ALR CONDITIONER •r/ ISS D
fom &ia Health Safety Code,Sacunns 255115,25533 and 25534.I understand Nat if the NEW RESIDENTIAL MECH. SQ,FT. ~Lv kY
buildingdoes not currently have o mnam;than it is my responsibility mutant,the acupant
of therequirements wnian moat the met d.tmiaaaamee.racertifirate.raaa an H
p p cy.
Owner.,authnrimdogem Date. - TOTAL: ISSUEDBY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING-ELECTRICAL PF.R�11T NO,
IIUILDING DIVISION APPLICATWN/PF.RMIT• YI,UMNING-MRCHANICAI, l`7
BUILDING PROJECFIDENri b'ICA'f10N 3166
BUILDING ADDRESS: SANHARYNO. APPI.ICA ION SUBMITTAL DATE.
78 1 L I LAC C-7 N ' 3S9 -D3 -Oaf l� �l 1 5 `�
OWNERS NAME: � PHONE: ..yO y CONTRACT'OR'S NAML:
Ll
ENGINEER^:fL C LIC NNEO: T4^U'( 7 LIC NI:
WL)L '- / N/C
CONTROL
D )�„ S• IAIP/ rWL �L✓o ❑
CONTACTPHONERMITINFO
vWhr,r Lo$ N
Consultant Fres Paid by Applicant(Initial) BLDG EI.ECf PLUMB MEC
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that Ica licensed under provieinn,of Chapter 9(commencing JOB DESCRIPTION
OW aOGwith Seciion700(gof Division 3 ofthe B.Irmevsaad Plufiussum,Cod rdmylicerre is pERMI'1'ISSUANCE RESIDENTIAL,
�W_ in full force an do If L/ ❑SFDWL ❑KITCHEN REMODEL
�UZ1- ense Class L.;'n?ci APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE:
Don It ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
z 'in I undersand my plans shall he used as public records MODIFICATION
OZ-0 UPT0200AMPS ❑IM'ER[OR ❑CHIMNEY REPAIR
r�F❑w Licensed Professional 201-10X0AMPS IMPROVEMENT C]SWIMMING POOLS
;y2; OWNER-BUILDER DECLARATION OVER IlNX1AMl'S ❑BATH REMODELIREPAIR ❑DEMOLITION
S ka Q 1 hereby atErm that I um exempt from the Contractor's rrt6e Law for the 7q
iq$O L Q following reason.(Section]071.5,Business nod Professions Je:Any city or county SIGNS ELECTRICAL XOTHI.R
u10 O y which rtquires a permit m cnnswn,ober,imprnvc.Jc tsu m repair any,mr,rure �'v ea J S
PPr
1qqrr ��nn prior,.its issuance,a0ore,one,heapplicantfors pemtinofilea ogneAsmtement SPECIAL CIRCUIT/MISC.
that he is licensed pursuant,.(lie provisions of l numcmtrs Licerme Law(Chapmr9
cal00 (commencing with sec LionaRCE,fDivisio of Ne nosiness and Professions Cnle)or TFMR METER OR POLE INCOMMERCIAL;
Il y e IY thin he is exempt therefrom and the be for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
liil 1i• Section 7031.5 by any applicant for rmit subjects the applicant m a civil penakyof POWER DEVICES ❑TENANT El FOOD SERVICE
y not more than Five hundred doll (5500).
Y IMPROVEMENT
Q ❑9,as owner the prnpen army employees with wages as their sale compensation. SWIMMING POOL HLLCfRIC
_W will do the w.rk.md the. One is
not intended oroRered for wle lSec.]1W4,Business El OTHER
W and Professions Cod fie Contractor's License Law does not apply to an owner of OUTLRfS-SWITCHES-FIXTURES
property who buil or improves Ihernm,and who does such work hlmsdl'..through
his own emplo •s,pmvidcd thin such impnrvemenix arc not intended or nfiemJ fur NEW RIEdDENTIAL ELECT'R SQ FT
sole.H h.,we aInch
anding or improvement is solA within one year nfcomplati.n,,M1e SQ.FI'.FLOOR AREA &SQ.FT.
owner-hail r will have the burden of proving that he did not ootid or improve for pur-
iwsenf- e.). AL
❑I, ow er of the property,am exclusively contracting with la,maled svnlrucmrs t.
a the project(tire.]1114,Business and Profcs,ions Code:)The Nnlrenor s Li-
n:a Law does notapply m an uwnerof property who builds or improves thereon,and QTY P IN ERMIT FEE
who contracts for such projects with a commaor(s)licensed pursuant to the Contractors
License Law. PERMIT ISSUAN
1 am exempt under Sec. .B h P C for this reason
Owner Dam ALTER-DRAIN E -WATER(EA) VALUATION
DECL
WOR KER'S COM I'FNSjo,m ofthic RATION
rain, BACK('LOW 1'ROTIiCf. .VICE.
thereby affirm underpenalty u,pe Juryoneoftheileure far
declarations: O
❑Ihnvc and will maintain nCcnifcuu of Cnnscnuoself-insure for Workers Compcn- DRAINS-FLOOR,ROOF,AREA,GOND, ST RIES TYPE.CONSTRUCTION
Billion,us provided for by Section 3400 of the Lim,Code,for the performance of the
work for which this perm,is issued. FIXTURES-PER TRAP
❑I Iuve and will maintain Worker's C insteutimi Insurance'as tequircd by Section
3700of the Libra Cwle,Penh,performance ofthewak forwhicbbis pcmtit is issu<<edVV. GAS-EA.SYSTEM-1 INC.4 OUT - I LI C.GROUP I APN
Carticrder'sG O CXE PTION NOMRKERS' (1 'k g GREASFANDUSTRI.WASTE INTF: V
COMPENSATION INSl1RANCli NC BUILDING DIVISION Ilifs
01i.,when need no he completed tithe Permit is forone hundred Jolim,(5100) GREASETRAP
ur law.) PLANCHEC FEE e
I cenily that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STT)RM GA. IN rf.
not employ any person in any manner so as to become subject o the Worked Capers- / D
rZ Bation Laws of California.Data WATER HEATER WNENTELECfR
O Applicant I GRAD P i
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATINC
(-'? become subject,.the Worker's Cnmpemation provisions of the Labor Codo,you out SOI
Lakl forthwith...Id,with such provisi.nx.,this paran.shall he deemedrev.ked. WAT RR SERVICE
Q
CONS'1'RDCI'ION/NG AGENCY NEW RESIDINTIAI.PLM({, SQ.FT. P
V ti I hereby affirm lhauherc isaconnding agency far the perf.rmunce of Date Receiptp
IZ F.t the work for which thi,pennillslxsncJ( Civ.C.) [
O U Lenders Name
Lender',Address
�r W0. B ) G FEE f.
[r 1 cenily that I have rcaJ tl' application and rule tha and nMwe iws.dation is
(A Bet l agree to comply with any and county ordinances and emte laws relating ro QTY. MECHANICAL PERMIT FEE
U� building con.mruction,unJ he ynnlbovc rcpre>emmives nfthis city,.annn:pon the MIST FEE
a bovcmrntionWpmpeny ,inspection purposes. PERMIT ISSUANCE �o
(We)agree m saw,indemnify and keep bamticas the Cit,of Cupenino against ;To—
(We)
`-' EL 'TRIC PEE
liabilities,judgment.s,c ts'nnd exPenseswitub mayin any way namocagainst said City- ALTERORADDTOMECH. PL MI{INGFF.E
Q
in cons, apfine ibrang of this permit. r
APP( 'ANT U_DER.TryRQS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 IQgXI CFM(
SOUR .GULAT'ION'y. M ANICAL FEE.
1A14 4 AIR HANDLING UNIT(OVER HI,00)CFM) CONST Cf10N TAX
Signature of ApplicanVComucmr L m EXHAUST HOOD IW/DUCT) f{OUSING ITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE.
Wlllheap,Iwml erfmum haildingoccupantsmre m moolehaaardou,mmen.1 1()M
NIT('1'0 IW,BW BTU)
as defined by the Cupertino Municipal Gyle,Chapter 9.12,and the Health and Safety D
Code,Section 25532(x)4 NIT(OVER 100,000 BTU)
�Ym (IN FAN(SINGLE RISID) PAID Uate Receiptp
. WIII the applicant or future building occupant use equipment or devices which OMP(3HP ) W,fNO BTU)
emit haeardnus air c.mantinants as defined by the Bay Area Air Quality Management
District? OMP(DYHR I(IB,(XX)BTU)❑Yes NaI have read the hnmr us dials rcyuiremen,s under Chapter fi95 of the Cali TIONER ISSUANCE tDATE
fomia Health&Safety Cal, Sectionsand 25534.I ualertmnd that if the3F.NTIAL MEC1t. SQ.FP. // 9_T
building does not currently a ve a tannin,that i,is my responsibility m notify the occupant
of the lryuirenrents which must be me,poor in of Cenilica,e.I Occupancy.
Owner or umhoired agent Date L: ISSUED BY: n
OFFICE