S 0557 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY y
CITY OF CUPERTINO BUILDING-ELECTRICAL PERhf I'INo
S 0557
BUILDING DIVISION API'LICATION/1'ERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL 1) I'S
2. 1 UAO 2P4z�,
OW ik'S ME: ` PHONE CO ACIOR:S M LIC No
/�GL•Nl NIC CON'I'ROIL 4
Al (ITE ENG Nli' LICNO: & ADDRESS: ❑
O
CONFACT: PHONE: � ��/r� BUILDING PERMIT INFO
4rr/'l„o ❑ Consultant Fecs Paid by Applicant(Initial) RLD� a� PLUMB n�H
LICENSED CO RACfOR'S DECLARA'I ION v� QTY. ELECTRIC PERMIT 17EE
1 hereby amrt that I ten ficen.aed under provisions of chapter v(commencing JOB DESCRIPTION
C
Zp (with S•tionv00)uf Diem..NCI"Inc Bmndnnasand emrcesimtnctole,and myliccnw is RP.SIDENTIAI:
PI!RMI'S ISSUANCE
COF IiJl mousse an 11'e ❑SFDWI. ❑KI'ICI{lith kIiMODI!I.
% 1- license Class Lic.N APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PB'H
,UUF Z W I Conlrac
odd ARCHITECTS UECLA A 10E❑MULTI-UNIT [J STRUCTURAL
F,0 y PANELS MODIFICATION
OZ�Z 1 undersandmy plainnnall beusedreladiir.,)rite GPTO 2t10 AMCS
[I INTERIOR ❑[HUv NEYREPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT •XiLaJWIMMING POOLS
KSS; OWNER BUILDER DECLARATSEEN DEMOLITION
ION OVER 1000AMPS ❑BATH SEEDEMOLITION
E C C d 1 hereby u[firm(hal 1 am exempt from the Contractor's License Law for the
X a a,F fulbving reason.(Section 91131 s,Ha ire,and Proon,iona Our:Any city or county SIGNS ELECTRICAL ❑OTHI!k
y which requires a permit to eanalrucl,Blinn improve,denmdi.sh,it repair any ndwmre
FLL'O�
,for to t, arre,alsoq ''be applicantfsuch P ..to II 'g da Ranml SPECIAL CIRCUS F/MISC.
��}•]
that he licensed p It the p fIM1 Contractor,I 1 (Chapter COMMERCIAL:
41 00 (commencing with Secton'/(XXB of D vision 3 ofthe Business and Profession:Code)or TEMP.METER OR POLF.INST.
a a e K tbut he is exempt domffom and IM1e basis for the allcgcJ exemption.Any violation of El NEW BLDG/ADDITION C]DEMOLITIONm Seninn 703 L5 by any applicant far a permit subjects the applicant o civil penalty of POWER DEVICES ❑TENANT ❑P(IOD SIiRVIGE
FZY not mom than five hundred dolma. SAXB. IMPROVEMENT
�Sp ❑ [,as owner of the property,or any employees with wage%as their sole compensation. SWIMMING POOL CLECIBIC
p. C]01
will Jo the work and the structure is not intended or offered for%ale lSecJ(W/.Business
Wim and Profe"mr,Code: Fit,Commeror's License Law do"not apply no an owner of UU9 ^.EfS-SWITCHES-PI%'TURES
properly who bu11Ja or improves thereon,and who doca ouch work hianua(ar Ihmugh
Iii, ou
ie own employee,,Provided that ch impnwemreme he nal Intended nr offered fir NEW RESIDI!NT[A],FIAzCI'k SQ FI.
%ak.IL bmvever,the Fuildin6 nr intpnrvcanent ie sold within one yea of completion.the SV.I'I'.Iq.(IOR ARBA BISQ1%'.
owner-builder will have the burden of proving that he did not build or improve for par- AuraPTOTAL: r, 4
❑I,as owner
of the gingen),ten exclusively mnvaning who licensed commnurs to VX
mswet the pmjcet(See.]DW.Business and professions Code:)The Contrractod Li-
Law doesnot apply manownet ofprogeny w6nbaildxorimprovesthereon.and QTY. PLUMBING PF,RbIIT FEE QTY OF Wrtk 1"NO
who contracts for such projects with a cuntmemr(s)IlcetnseJ pursuant to the Conlmaors
Licenxc law. NPERMIT ISSUANCE
1 ant exempt under Sue. .H h P C far this reason ALTER-DRAIN h VI!N'I-WAFER SEA) � VAL /4
UA'{O
Owner Date
WORK12K'S COMPENSATION DECLAHAIION BACK FLOW PRUIEC'I'.DIiVICE
I hereby affirm under penally of perjury one of the following dccla ri ions:
I have and will maintain a Canificsrt of Conscnttoself-in.,he for Workers Confirm- DRAINS-FLOOR.ROOF.AREA.COND. SPORIP_S '1'1'1'11 CONSTRUCTION
scion,as provided for by Section 3100 of the tenor Codefur the peffmanothe of IM1e
w rk for which this permit in issued. 19%TURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
J Istuf thelabs Cale.fur theptaternanceofthewitk fir which this permit is loved. GAS-EA.SYSTEM-I INCA OUTLETS OCC. H( 'Y ANN
My Workc s p tpcnat' t lite ncc c d Ynlicy numFFr_
Carrico Policy No.a GAS-EA.SYSTI[MOVIiHJEPA)
CEIGHICA'iOFHXITMPTIONFROMWORKI:RS' GREASFJINDUS'E'RI.WAS117IN'IF.RCEPIOR
COMPENSATION INSURANCE BUILI GDIVISION FEES
(Thmuction need nut te(umpldWlffhe permit in BmnnchundrcddoBar($HN) GREASETRAY
1'EANCI iC l'i
Icy any that in the performancthe e to orkbecome
fnr suichthis perthe Wois rker%Compassued,I ll SEWER-SANITARY-SIY)RM EA.20f HT r
not employ any person in any manner sins to Mrome sublet to the Worker'Compete ENIiN hili
Z cation laws of California.Dau WATER HEATER WNENTELECIR
Q Applicant OR D 1
•
z h NOTICE TO APPLICANT:If,after making thi%Cenificure of Exemption,you should WATER SYSTEMl1B1!A'1'ING
H become subject In the Worker's Cmnfer,winn prov sinm of the Lahor Code.You.'all
50
ai bmhwllh comply with Inch provisions or this permit shall he deemed revoked WATER SERVICE
d G
CONSI'RUC'DONE LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.PII PAID
U 0 (hereby affix thatthem is a conswetion lending agency forte perfoanance of Date RecciplM
U _O the work for which this permit is issued(Sec.3097.Civ.CJ
TOTAL:
0 1<rider"Name
O U TOTAL..
Lenders Address
} 1 warty that 1 have read this application add state that the above information is BUILDI G FEE
TY. MECHANICAL PERMIT FEE
SEISMI:FEE
correct. agreemeomply with all city and county nNinunecs and lime laws Mating to Q
U buiding constriction.and hereby indication representatives onhis cityto enter upon the
shove-iontinned progeny for inspection pumpusea.
PERMIT ISSUANCE 'I if IC FEE
(We)agree to save,indenutily and keep hamfle,the City al'Cupenino against
Iianilitics.judgmems,crisis anti exlrenes which may in any way accure against said City ALTER OR ADD TO MCCR PLUM(INC,FEE
quencc of the granting of Ihix permit.
AYI'LICA ' UN RST NDS ANU WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 00 IILIKKI CPM) MECIIA ICALIT:E
�
tiOURC GUL — !
AIR HANDLING UNIT(OVER IO.WO CFMf CONS'1'HU VTA%
Si croon of Ap�� ecmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATE FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplieamarturn.building occupamsmre nr handle M1azallous officinal HEATING UNIT RO I(XL(")BT
us dcl'med by the Cupertino Municipal Code,Chapter'),12,and the Health and Svkty
Code.Sodom 255321.)7 HEATING UNI'I(OVIi E II NI B'I'll)
[]Yes E]No VENTILATION PAN
Fill IS IF IID) PAID
)aid Rexip
Will the applicant or ftru a building occupant use equipment or device.which BOILER-CO IJHI'Ok I(NL(%p CTU)
mil hazardous air contaminants as defined by the Buy Arca Air Quality Management DIS
( I'AL:
'District? BOILER MPIOVER 100.000BLU)
E]Ye, O No
1 have read the hmardoun materials mquiremente under Chapter fi95 of the Cali Alk C DITIONER ISSUANCE 'li
Pimm Health k Safely Cole,Sections 25505.25533 and 25534.1 understand that Fthe NEW RESIDENI'[A],Nil; 11. SQ.IT.
muldiitich.e reatdyl ant.tum h6 tnymsl"msibi1ity to notify the accupma
of the qu' tents who comm benctpriortoiawuna of fCrnlllcumof0cucavy.
Own age Date 1'O'1'AL: ISSUED li1':
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY y
CITY OF CUPERTINO BUILDING-ELECTRICAL PERhf I'INo
S 0557
BUILDING DIVISION API'LICATION/1'ERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL 1) I'S
2. 1 UAO 2P4z�,
OW ik'S ME: ` PHONE CO ACIOR:S M LIC No
/�GL•Nl NIC CON'I'ROIL 4
Al (ITE ENG Nli' LICNO: & ADDRESS: ❑
O
CONFACT: PHONE: � ��/r� BUILDING PERMIT INFO
4rr/'l„o ❑ Consultant Fecs Paid by Applicant(Initial) RLD� a� PLUMB n�H
LICENSED CO RACfOR'S DECLARA'I ION v� QTY. ELECTRIC PERMIT 17EE
1 hereby amrt that I ten ficen.aed under provisions of chapter v(commencing JOB DESCRIPTION
C
Zp (with S•tionv00)uf Diem..NCI"Inc Bmndnnasand emrcesimtnctole,and myliccnw is RP.SIDENTIAI:
PI!RMI'S ISSUANCE
COF IiJl mousse an 11'e ❑SFDWI. ❑KI'ICI{lith kIiMODI!I.
% 1- license Class Lic.N APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PB'H
,UUF Z W I Conlrac
odd ARCHITECTS UECLA A 10E❑MULTI-UNIT [J STRUCTURAL
F,0 y PANELS MODIFICATION
OZ�Z 1 undersandmy plainnnall beusedreladiir.,)rite GPTO 2t10 AMCS
[I INTERIOR ❑[HUv NEYREPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT •XiLaJWIMMING POOLS
KSS; OWNER BUILDER DECLARATSEEN DEMOLITION
ION OVER 1000AMPS ❑BATH SEEDEMOLITION
E C C d 1 hereby u[firm(hal 1 am exempt from the Contractor's License Law for the
X a a,F fulbving reason.(Section 91131 s,Ha ire,and Proon,iona Our:Any city or county SIGNS ELECTRICAL ❑OTHI!k
y which requires a permit to eanalrucl,Blinn improve,denmdi.sh,it repair any ndwmre
FLL'O�
,for to t, arre,alsoq ''be applicantfsuch P ..to II 'g da Ranml SPECIAL CIRCUS F/MISC.
��}•]
that he licensed p It the p fIM1 Contractor,I 1 (Chapter COMMERCIAL:
41 00 (commencing with Secton'/(XXB of D vision 3 ofthe Business and Profession:Code)or TEMP.METER OR POLF.INST.
a a e K tbut he is exempt domffom and IM1e basis for the allcgcJ exemption.Any violation of El NEW BLDG/ADDITION C]DEMOLITIONm Seninn 703 L5 by any applicant far a permit subjects the applicant o civil penalty of POWER DEVICES ❑TENANT ❑P(IOD SIiRVIGE
FZY not mom than five hundred dolma. SAXB. IMPROVEMENT
�Sp ❑ [,as owner of the property,or any employees with wage%as their sole compensation. SWIMMING POOL CLECIBIC
p. C]01
will Jo the work and the structure is not intended or offered for%ale lSecJ(W/.Business
Wim and Profe"mr,Code: Fit,Commeror's License Law do"not apply no an owner of UU9 ^.EfS-SWITCHES-PI%'TURES
properly who bu11Ja or improves thereon,and who doca ouch work hianua(ar Ihmugh
Iii, ou
ie own employee,,Provided that ch impnwemreme he nal Intended nr offered fir NEW RESIDI!NT[A],FIAzCI'k SQ FI.
%ak.IL bmvever,the Fuildin6 nr intpnrvcanent ie sold within one yea of completion.the SV.I'I'.Iq.(IOR ARBA BISQ1%'.
owner-builder will have the burden of proving that he did not build or improve for par- AuraPTOTAL: r, 4
❑I,as owner
of the gingen),ten exclusively mnvaning who licensed commnurs to VX
mswet the pmjcet(See.]DW.Business and professions Code:)The Contrractod Li-
Law doesnot apply manownet ofprogeny w6nbaildxorimprovesthereon.and QTY. PLUMBING PF,RbIIT FEE QTY OF Wrtk 1"NO
who contracts for such projects with a cuntmemr(s)IlcetnseJ pursuant to the Conlmaors
Licenxc law. NPERMIT ISSUANCE
1 ant exempt under Sue. .H h P C far this reason ALTER-DRAIN h VI!N'I-WAFER SEA) � VAL /4
UA'{O
Owner Date
WORK12K'S COMPENSATION DECLAHAIION BACK FLOW PRUIEC'I'.DIiVICE
I hereby affirm under penally of perjury one of the following dccla ri ions:
I have and will maintain a Canificsrt of Conscnttoself-in.,he for Workers Confirm- DRAINS-FLOOR.ROOF.AREA.COND. SPORIP_S '1'1'1'11 CONSTRUCTION
scion,as provided for by Section 3100 of the tenor Codefur the peffmanothe of IM1e
w rk for which this permit in issued. 19%TURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
J Istuf thelabs Cale.fur theptaternanceofthewitk fir which this permit is loved. GAS-EA.SYSTEM-I INCA OUTLETS OCC. H( 'Y ANN
My Workc s p tpcnat' t lite ncc c d Ynlicy numFFr_
Carrico Policy No.a GAS-EA.SYSTI[MOVIiHJEPA)
CEIGHICA'iOFHXITMPTIONFROMWORKI:RS' GREASFJINDUS'E'RI.WAS117IN'IF.RCEPIOR
COMPENSATION INSURANCE BUILI GDIVISION FEES
(Thmuction need nut te(umpldWlffhe permit in BmnnchundrcddoBar($HN) GREASETRAY
1'EANCI iC l'i
Icy any that in the performancthe e to orkbecome
fnr suichthis perthe Wois rker%Compassued,I ll SEWER-SANITARY-SIY)RM EA.20f HT r
not employ any person in any manner sins to Mrome sublet to the Worker'Compete ENIiN hili
Z cation laws of California.Dau WATER HEATER WNENTELECIR
Q Applicant OR D 1
•
z h NOTICE TO APPLICANT:If,after making thi%Cenificure of Exemption,you should WATER SYSTEMl1B1!A'1'ING
H become subject In the Worker's Cmnfer,winn prov sinm of the Lahor Code.You.'all
50
ai bmhwllh comply with Inch provisions or this permit shall he deemed revoked WATER SERVICE
d G
CONSI'RUC'DONE LENDING AGENCY NEW RESIDENTIAL('LMB. SQ.PII PAID
U 0 (hereby affix thatthem is a conswetion lending agency forte perfoanance of Date RecciplM
U _O the work for which this permit is issued(Sec.3097.Civ.CJ
TOTAL:
0 1<rider"Name
O U TOTAL..
Lenders Address
} 1 warty that 1 have read this application add state that the above information is BUILDI G ITS;
TY. MECHANICAL PERMIT FEE
SEISMI:FEE
correct. agreemeomply with all city and county nNinunecs and lime laws Mating to Q
U buiding constriction.and hereby indication representatives onhis cityto enter upon the
shove-iontinned progeny for inspection pumpusea.
PERMIT ISSUANCE 'I if IC FEE
(We)agree to save,indenutily and keep hamfle,the City al'Cupenino against
Iianilitics.judgmems,crisis anti exlrenes which may in any way accure against said City ALTER OR ADD TO MCCR PLUM(INC,FEE
quencc of the granting of Ihix permit.
AYI'LICA ' UN RST NDS ANU WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 00 IILIKKI CPM) MECIIA ICALIT:E
�
tiOURC GUL — !
AIR HANDLING UNIT(OVER IO.WO CFMf CONS'1'HU VTA%
Si croon of Ap�� ecmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATE FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplieamarturn.building occupamsmre nr handle M1azallous officinal HEATING UNIT RO I(XL(")BT
us dcl'med by the Cupertino Municipal Code,Chapter'),12,and the Health and Svkty
Code.Sodom 255321.)7 HEATING UNI'I(OVIi E II NI B'I'll)
[]Yes E]No VENTILATION PAN
Fill IS IF IID) PAID
)aid Rexip
Will the applicant or ftru a building occupant use equipment or device.which BOILER-CO IJHI'Ok I(NL(%p CTU)
mil hazardous air contaminants as defined by the Buy Arca Air Quality Management DIS
( I'AL:
'District? BOILER MPIOVER 100.000BLU)
E]Ye, O No
1 have read the hmardoun materials mquiremente under Chapter fi95 of the Cali Alk C DITIONER ISSUANCE 'li
Pimm Health k Safely Cole,Sections 25505.25533 and 25534.1 understand that Fthe NEW RESIDENI'[A],Nil; 11. SQ.IT.
muldiitich.e reatdyl ant.tum h6 tnymsl"msibi1ity to notify the accupma
of the qu' tents who comm benctpriortoiawuna of fCrnlllcumof0cucavy.
Own age Date 1'O'1'AL: ISSUED li1':
OFFICE