24797 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIL 1 -L.: RI AL PERMITNO. '
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ^ 4 N�7
BUILDING PROJECT MEN T'IFICATION [ `�
BUILDING ADDRESS: < < SANITARY NO. APPLICA/T]OONSUBMITALDATE
K UNIT N LOT N
O NERSNAME: PHO CONTRACTOR'S NAME: LIC NO: J
O - NIC CONTROL N
i•A CHITECTENGINRE,: LIC NO: ADDRESS: F-1S
CONTACT: PHONE: H ILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ El
LIC D CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p K'Z Ihercb ffmtThat lirenxdunderpmvisions of Chvpta9(cmmmcncing with
0100 Section]000)of Division 3 ofthe Business and Professions Code,andmy license isin PANELS
full force and cffe 5
-U�ztV License C}��1'�,� Lisp UPT02WAMPS
DateComracmr 2111-IOW AMPS
FyFg 1 ARCHITECTS DF.CLA N FT �yEliA SISQ.
20 m OVER 10(10 AMPS ,6 J7
CZ-0 1 understand my plans shall h used a public tern a.
FsntJW SIGNSELECTRICAL • wP ?�
haa yy�J Licensed Rv(essionel M
gK��,j6 OWNER-BUILDERDECLARATIONhe CRATION SPECIAL CIRCUIT/MISC. Co �}/I
y t V 1 hereby v(fnn that I am exempt from the Conwanrs License Lew home / /f
uX134vFs following reason(Semion 90JL3,Business and Pmfeesions Cnde:Any citymcounty TEMP.MIeTER OR POLE[NST. 49 ✓/N
1❑❑❑❑"f5„� which require.,n perms to constfuet,alcor,improve,demolish,or repair any smucturc
prion.lu imume,alsorequbesmati,plim,forsuch Permit o flea quej,stemem POWER DEVICES ME.�.--�
Com'p 0 that he is licensed pursuant to The Provisions of rhe Contractors License Law(Chapter
o.X0�' 9(commencing with Section 7")of Division 3ofthe Business road Professions Coded SWIMMING POOL ELECTRIC VALUATION
W_H or that he is exempt herefrom and me basis for The alleged exemption.Any violation of
GSection]031.5 by any applicant fora permit mbjeem Theapplicant loo civil penalty of OUTLIIS-SWITCHES-FIXTURES O �0
p
not more than Bve hundred dollars($510f). NEW RESIDENTIAL ELECTR S .
cv ElI,mowneroltheproperty,ormyemployeeswiihwagesastheirsolecompensation, Q PI'. STORIES TYPE CONSTRUCTION
iy will dothe work,and the strocture,isnotlulmdedmoffmad forsule(Sec.Jf144,Business
and Professions Cade:The Contractor'a License Law does not apply to an owner of
propertywhobuildsor improves thereon,and whodocs such work hireaelforthmugh his -----6TC—GROUP RFS.UNITS
ownemployees,pmvidedthmsuchimprovementsa nwintendMwoffetedformic.If,
however,the buildingorimprovement is sold within oneyear ofeomphoion.the owner- TOTAL:
builder will have the burden of proving tom he did not build or improve far purpose of
asks.).
❑ I,nsownerofthcpropedy,amexclusivclycon(ractingwiihlicenudcontfactorsm QTY. PLUMHINGPERMIT FEE FLOODZONE APN
comma.,the project(Seo.704q Business and Professions Cada)The Contractor's
License Lawdoesnot apply toanownerofproperrywhobuilds or improves thereon,and PERMITISSUANCE
womontracuforsuch pmiectswithncommnut(s)Iiceresedpommutothe Contmctore ALTER FEE SUMMARY
License taw. (EA)
❑ 1 am exempt under Sec. ,B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
SANITARY Y N
• Owner Dora RECEIPTN
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMANCOMPENSATIONDECLARATION SCHOOL TAX YN
❑ Thereby uffnn shark have ecenifautc of ronsen[to self inmrc,orecertificate of R13CEIPTN
FIXTURES-PER TRAP
Wmrkeri COmpemmion lnsmrance oracenifed copy thereof(Sec.3tlW,is CJ which PARK FEE Y N
° 11 �pIpyge ypd°r NI�}�cmt t. GAS-PA.SYSTEM-I INC.40UTLLTS RECEIPTN
Policyp�INl�b-- 1/] t GK.Id. 1119� BUILDING DIVISION FEES
ar'so
GAS-FA.SYSTF.MAVER 4(FA) PIANCIiECK FEE
❑�Cenifird copy is hereby famished.
�Gasified copy is file)with the city inspection division. GRFASIyINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(flus section meednot be completed Hire permit is for onehondred dollars P$100) SEWER-SANITARY-STORM EA.20l ENERGY FEE
or less.)
I mnify that in the performance of the work for which this permit is issued,l shall WATER HEATER WIVENT/F.LECTR
not employ any Person in any manner so as to become subject to the Workers' PAID
Compensation Lowaof Califomia. Data WATER SYSTEM/IREATING Dme Receipt#
OC) Applicant
NOTICE TO APPLICANT:If,after making this Cerificam of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FL TOTAL.:
(•-' V) become subject to the Workers Cmmpurroulon Provisions of the Labor Cade,you most
,
� forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION[.ENDING AGENCY SEISMIC FEE
=) Z I hereby afBTm that him is a construction lending agency for the performance of TOTAL: ELECTRIC ME
O the work for which this permit is issued(Sec.3097,Civ.CJ
LJ. E Lender's Name
[.ender s Address Q'I'Y. MECHANICAL PERMIT FEE PLUMBING FEE
I terrify that 1 have read this application and stare that the above information is
correct.I ripemo comply with all city and county ordinances and scuta laws relating in PERMIT ISSUANCE MECHANICAL FEE
E-' building construetion,and hereby authorize representatives ofthiscity toemerupmn the CONSTRUCTION TAX
V above mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cuperinm against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO HUM CFM)
in emete,core of The granting ofjhia per, i
% ,.= AIR HANDLING UNIT(OVER IO,OW CFM)
-� Jia
Signature of APPlimut/Contianor m I EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10J.”BTU) —Date Receipt#
Will the applicant or furore building occupant em.or handle hazardous mend.]
as de0ned by the Cupertino Municipal Code,Chapter 9.12,and The Ilomth and Safety HEATING UNIT(OVER 1 W,M BTU) TOTAL:
Code,Section 25532(u)P
Cl Yea 11 No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will Neapplicantnrfuturebuildingmcupmtus equipmentordeviceswhichemit I BOILER-COMP CHP OR I00,000 HIM
• enormous air cmntammarro.as defined by the Bay Area At,Quality Management BOILER-COMP(OVER I W,WB BTU) p ' D
District' ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 0'4
1 have read The hazardous materials requirements under Chapter 6.95 of the fJu� 151993
Californiaa ia Health As Safety CoSections 25505,23533 sad 25534. 1 understand shot
if the building Aoeanotmants yhaveatenantthat Itis mymuance ofI enotify the
pant of g d"moes not come which m t ns met prior m issuance of CerTat he /�
icy' V�IVUj%1
oma, A"-,. 1-i L1Ise9�
O ramhorizeJ ugem "Dem TOTAL: ISSUED BY:
OFFICE /
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIL 1 -L.: RI AL PERMITNO. '
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ^ 4 N�7
BUILDING PROJECT MEN T'IFICATION [ `�
BUILDING ADDRESS: < < SANITARY NO. APPLICA/T]OONSUBMITALDATE
K UNIT N LOT N
O NERSNAME: PHO CONTRACTOR'S NAME: LIC NO: J
O - NIC CONTROL N
i•A CHITECTENGINRE,: LIC NO: ADDRESS: F-1S
CONTACT: PHONE: H ILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ El
LIC D CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p K'Z Ihercb ffmtThat lirenxdunderpmvisions of Chvpta9(cmmmcncing with
0100 Section]000)of Division 3 ofthe Business and Professions Code,andmy license isin PANELS
full force and cffe 5
-U�ztV License C}��1'�,� Lisp UPT02WAMPS
DateComracmr 2111-IOW AMPS
FyFg 1 ARCHITECTS DF.CLA N FT �yEliA SISQ.
20 m OVER 10(10 AMPS ,6 J7
CZ-0 1 understand my plans shall h used a public tern a.
FsntJW SIGNSELECTRICAL • wP ?�
haa yy�J Licensed Rv(essionel M
gK��,j6 OWNER-BUILDERDECLARATIONhe CRATION SPECIAL CIRCUIT/MISC. Co �}/I
y t V 1 hereby v(fnn that I am exempt from the Conwanrs License Lew home / /f
uX134vFs following reason(Semion 90JL3,Business and Pmfeesions Cnde:Any citymcounty TEMP.MIeTER OR POLE[NST. 49 ✓/N
1❑❑❑❑"f5„� which require.,n perms to constfuet,alcor,improve,demolish,or repair any smucturc
prion.lu imume,alsorequbesmati,plim,forsuch Permit o flea quej,stemem POWER DEVICES ME.�.--�
Com'p 0 that he is licensed pursuant to The Provisions of rhe Contractors License Law(Chapter
o.X0�' 9(commencing with Section 7")of Division 3ofthe Business road Professions Coded SWIMMING POOL ELECTRIC VALUATION
W_H or that he is exempt herefrom and me basis for The alleged exemption.Any violation of
GSection]031.5 by any applicant fora permit mbjeem Theapplicant loo civil penalty of OUTLIIS-SWITCHES-FIXTURES O �0
p
not more than Bve hundred dollars($510f). NEW RESIDENTIAL ELECTR S .
cv ElI,mowneroltheproperty,ormyemployeeswiihwagesastheirsolecompensation, Q PI'. STORIES TYPE CONSTRUCTION
iy will dothe work,and the strocture,isnotlulmdedmoffmad forsule(Sec.Jf144,Business
and Professions Cade:The Contractor'a License Law does not apply to an owner of
propertywhobuildsor improves thereon,and whodocs such work hireaelforthmugh his -----6TC—GROUP RFS.UNITS
ownemployees,pmvidedthmsuchimprovementsa nwintendMwoffetedformic.If,
however,the buildingorimprovement is sold within oneyear ofeomphoion.the owner- TOTAL:
builder will have the burden of proving tom he did not build or improve far purpose of
asks.).
❑ I,nsownerofthcpropedy,amexclusivclycon(ractingwiihlicenudcontfactorsm QTY. PLUMHINGPERMIT FEE FLOODZONE APN
comma.,the project(Seo.704q Business and Professions Cada)The Contractor's
License Lawdoesnot apply toanownerofproperrywhobuilds or improves thereon,and PERMITISSUANCE
womontracuforsuch pmiectswithncommnut(s)Iiceresedpommutothe Contmctore ALTER FEE SUMMARY
License taw. (EA)
❑ 1 am exempt under Sec. ,B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE.FEES
SANITARY Y N
• Owner Dora RECEIPTN
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMANCOMPENSATIONDECLARATION SCHOOL TAX YN
❑ Thereby uffnn shark have ecenifautc of ronsen[to self inmrc,orecertificate of R13CEIPTN
FIXTURES-PER TRAP
Wmrkeri COmpemmion lnsmrance oracenifed copy thereof(Sec.3tlW,is CJ which PARK FEE Y N
° 11 �pIpyge ypd°r NI�}�cmt t. GAS-PA.SYSTEM-I INC.40UTLLTS RECEIPTN
Policyp�INl�b-- 1/] t GK.Id. 1119� BUILDING DIVISION FEES
ar'so
GAS-FA.SYSTF.MAVER 4(FA) PIANCIiECK FEE
❑�Cenifird copy is hereby famished.
�Gasified copy is file)with the city inspection division. GRFASIyINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(flus section meednot be completed Hire permit is for onehondred dollars P$100) SEWER-SANITARY-STORM EA.20l ENERGY FEE
or less.)
I mnify that in the performance of the work for which this permit is issued,l shall WATER HEATER WIVENT/F.LECTR
not employ any Person in any manner so as to become subject to the Workers' PAID
Compensation Lowaof Califomia. Data WATER SYSTEM/IREATING Dme Receipt#
OC) Applicant
NOTICE TO APPLICANT:If,after making this Cerificam of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FL TOTAL.:
(•-' V) become subject to the Workers Cmmpurroulon Provisions of the Labor Cade,you most
,
� forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION[.ENDING AGENCY SEISMIC FEE
=) Z I hereby afBTm that him is a construction lending agency for the performance of TOTAL: ELECTRIC ME
O the work for which this permit is issued(Sec.3097,Civ.CJ
LJ. E Lender's Name
[.ender s Address Q'I'Y. MECHANICAL PERMIT FEE PLUMBING FEE
I terrify that 1 have read this application and stare that the above information is
correct.I ripemo comply with all city and county ordinances and scuta laws relating in PERMIT ISSUANCE MECHANICAL FEE
E-' building construetion,and hereby authorize representatives ofthiscity toemerupmn the CONSTRUCTION TAX
V above mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cuperinm against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO HUM CFM)
in emete,core of The granting ofjhia per, i
% ,.= AIR HANDLING UNIT(OVER IO,OW CFM)
-� Jia
Signature of APPlimut/Contianor m I EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10J.”BTU) —Date Receipt#
Will the applicant or furore building occupant em.or handle hazardous mend.]
as de0ned by the Cupertino Municipal Code,Chapter 9.12,and The Ilomth and Safety HEATING UNIT(OVER 1 W,M BTU) TOTAL:
Code,Section 25532(u)P
Cl Yea 11 No VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will Neapplicantnrfuturebuildingmcupmtus equipmentordeviceswhichemit I BOILER-COMP CHP OR I00,000 HIM
• enormous air cmntammarro.as defined by the Bay Area At,Quality Management BOILER-COMP(OVER I W,WB BTU) p ' D
District' ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 0'4
1 have read The hazardous materials requirements under Chapter 6.95 of the fJu� 151993
Californiaa ia Health As Safety CoSections 25505,23533 sad 25534. 1 understand shot
if the building Aoeanotmants yhaveatenantthat Itis mymuance ofI enotify the
pant of g d"moes not come which m t ns met prior m issuance of CerTat he /�
icy' V�IVUj%1
oma, A"-,. 1-i L1Ise9�
O ramhorizeJ ugem "Dem TOTAL: ISSUED BY:
OFFICE /