B 0294APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - F,LECfRICAI. 1 PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT ar rr PLUMBINGas-MF.CHANICAI, SOOO 1 0 2 9 4
t _ CHANIvp•eTsnv
LIC NO: 5f
PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
RATION QTY ELECTRIC PERMIT
I hereby affirm Net I am licensed unser provisions of Chapter 9 (commencing
won with Section 7")of Division J of she Business and Professions Cod, and my license is
W in full force and effen.
Q VZ �j License CI LIC. p
F Q W Uam Concerns
N In ARCHITECTS DE . ATION
�j 7a 1 understand my plans shall be used as le records
z c
ly
Licensed Professional
•] OWNER-RUfr DECLARATION'
1 hereby affirm4hat I am exemptmptfrom Thu Cnsda, Cas License Law for the
3aFfallowingnime, a(Section 7 ensu Busher, and Profneiodemoli Gnda: Aay city or county
LL. O which requires a permit re consumer. alma i applicant far su h pormil n or repair any strucstamen
re
poor to its i eased p also inquires thesistm for such permit n files signed se (Chapter
em
Ill., lle (commencing
ecingwiit pursuannothe of Divisional
the Contractors nd Professions
roetsons Code)
rr
I a:, (cnmmcncing wiNSection 7p0p)of DivisionJof theBusinessRof Any
violation
S oy that he is exempt theefrent and the basis for Ne alleged exemption. Any violmion of
U1 m_ 4. Section 703 L5 by any applicant far a penrdt subjects the applicant to a civil penally of
not marc then five hundred dollars ($500).
C C) h as ownerafthe property, or my employees with wages as their sole compensation,
a, o will it,, the work, and the structure is nos intended moffered farsole(Sec. 71144. Business
W m and Professions Code: The Contractor's License Use does not apply to an owner of
4i 3 property who builds or improves thereon, and who does such work himself m through
his own employees, provided that such improvements are not intended or offered for
' sale. It. however, the building or improvement is sold within one year ofcompletion, the
owmcr-bulldar will have the burden of proving that he did not build or improve for par- I
pose of sale).
❑ 1, as owner of the property, am exclusively con0acting with licensed compactors to
construct he project (Sec. 7044, Business and Professions Code:) The Comments Li.
cense Law does not apply to an owner of properly who builds or improves thrown. and QTy,
who contracts for such projects with a connectors) licensed pursuant to the Contmnofs
License Law.
l am exempt under Sec. .B&PC for this rcmmn
Ownar Dam
WORKER'S COMPENSA'DON DECLARATION
1 hereby affirm under penalty of perjury one of doe fol lowing declarations:
I have and will maintain a Certificam of Consent to self -insure for Worker's Compem
sation, as provided for by Section 3700 of the Labor Cede, for the performance of the
work for which this permit is issued.
and will muinmin Workers Cmalw sutlon Iotrol as required by Section,0 nlThe Labor Code, for the performance of the work for which this Permit is issued,
My Worker'a Cen�iom lr�ysrance caJpr and Policy nul�or ar
Currier. y(w--" Palley Nn.:
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMP mplete ON INSURANCE
(This section neednotbe completed ifthe pemtis is foronehutMed do11ars141001
in Icss.)
I canny that in the perform of the work for which this permit is issued, l shall
out employ say .a in any ma mer u
so as m We. subject the Workers' Compen-
Q z satied Laws of California. Dare n
0 Applicant \ -
sz. ^ NOTICE TO APPLICANT: If, after making this Cenifu:am of Exemption, you should
H become subject to the Worker's Compensation provisions of the Labor Code, you must
tai] Q fanhwhh comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
U O I hereby affirm that there is a construction lending agency for the performance of
PT F the work fur which this permit is issued (Sec. 3097, Civ. C.)
Q ULenders Name _
Lenders Address
y I entity thin I have read this application and sure don the above information is
fA correct. I agree to comply with all city and county ordinanres aM sum laws elating to
V z building conarectinn, and hereby auNuAu mimmunwives ofaus city in enter upon the
r abovomentioned property for inspection purposes.
(We).gree to save, indemnify and keep harmless the City of C.per ire. aphis,
liabilities, judgments, costa and expenses which may in any way wean against said City
in consequence of rhe granting of this permit.
APPLICANT UNDERSTANDSAND WILL COMPLY WITH ALL NON -POINT
soDEc?RCGUTATIONS. A - i a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore be do,occupaal store or handle haeralm, mmerial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 2 532ND
❑Yes
Will the applicant or future building occupant use equipment or devices which
anis hmmdous is contaminants as defined by the Bay Arta Air Quality Management
District?
❑Yes'
I have mad the hazvdouss materials equiremems under Chapter 6.95 of the Calm
ford. Tonilph & Safety Code, Sections 25505, 25533 and 25534.1 understood that If the
mogNina does not currently have Ra nam, that it is my msponsibility to notify IN occupant
PC EMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NI?W RESIDENTIAL ELECTR .
PLUMBING PERMIT
ALTCR- DRAIN & VENT- WATER (EA)
SQ FT.
N
I ❑OTHER
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SO. FT. FLUOR AREA
JUL 0 8 MST
/
FEE COY i UUrrmIIIVU
U W Z '¢
FEE
JOB DESCRIPTION
RESIDENTIAL: ,�,�
❑SFDWL �TCHEN REMODEL
❑ADDITION ❑PLUMBING RI_PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT L]SWIMMING POOLS
❑ BATH RF,MODEUREPAIR ❑DEMOLITION
1I
DRAINS - FLOOR. ROOF, AREA, COND.
STORIES
I ❑OTHER
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SO. FT. FLUOR AREA
JUL 0 8 MST
/
FEE COY i UUrrmIIIVU
OFFICE
TOTAL:I Hyo XV I ISSUED
BACK FLOW PROTECT. DEVICE:
"f ? -f�c rg_ ry
L
�TYYPE
DRAINS - FLOOR. ROOF, AREA, COND.
STORIES
C(
FIXTURES -PER TRAP
GAS -EA. SYSTEM .1 INC, 4OU'TLETS
•
OCCGROUP
GAS - EA. SYSTEM -OVEN 4 (IIA)
GREASE/INDUSTRL WASTE INI'ERCEPTDR
BUILDING DIVISION FGIiS
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENTIELECfR
_
GRADING FEE
WATER SYSTEMTREATING
SOILS FEC
WATER SERVICE
PAID
NEW RESIDENTIAL. PLMR. SQ. FT,
Date Receipt #
TOTAL:
TOTAL.:
Wor
BUILDING PER
QTY.
MECHANICAL PERMIT
FEE
SEISMIC FEE
ELECTRIC FTE
I
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
PLUMBING HE
AIR HANDLING UNIT TO Main CFM)
MECIIANTCAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONST RUCTION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
11 RATING UNIT 00 100.000 BTU)
HEATING UNIT (OVER 11),000 BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Date Receipt M
BOILER- COMP 0HP OR 100000 BTU)
TOTAL:
HOB.ER-COMP (OVER 100,000 PTU)
I �
YV
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECH, SQ. FT.
OFFICE
TOTAL:I Hyo XV I ISSUED
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - F,LECfRICAI. 1 PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT ar rr PLUMBINGas-MF.CHANICAI, SOOO 1 0 2 9 4
t _ CHANIvp•eTsnv
LIC NO: 5f
PHONE:
❑ Consultant Fees Paid by Applicant (Initial)
RATION QTY ELECTRIC PERMIT
I hereby affirm Net I am licensed unser provisions of Chapter 9 (commencing
won with Section 7")of Division J of she Business and Professions Cod, and my license is
W in full force and effen.
Q VZ �j License CI LIC. p
F Q W Uam Concerns
N In ARCHITECTS DE . ATION
�j 7a 1 understand my plans shall be used as le records
z c
ly
Licensed Professional
•] OWNER-RUfr DECLARATION'
1 hereby affirm4hat I am exemptmptfrom Thu Cnsda, Cas License Law for the
3aFfallowingnime, a(Section 7 ensu Busher, and Profneiodemoli Gnda: Aay city or county
LL. O which requires a permit re consumer. alma i applicant far su h pormil n or repair any strucstamen
re
poor to its i eased p also inquires thesistm for such permit n files signed se (Chapter
em
Ill., lle (commencing
ecingwiit pursuannothe of Divisional
the Contractors nd Professions
roetsons Code)
rr
I a:, (cnmmcncing wiNSection 7p0p)of DivisionJof theBusinessRof Any
violation
S oy that he is exempt theefrent and the basis for Ne alleged exemption. Any violmion of
U1 m_ 4. Section 703 L5 by any applicant far a penrdt subjects the applicant to a civil penally of
not marc then five hundred dollars ($500).
C C) h as ownerafthe property, or my employees with wages as their sole compensation,
a, o will it,, the work, and the structure is nos intended moffered farsole(Sec. 71144. Business
W m and Professions Code: The Contractor's License Use does not apply to an owner of
4i 3 property who builds or improves thereon, and who does such work himself m through
his own employees, provided that such improvements are not intended or offered for
' sale. It. however, the building or improvement is sold within one year ofcompletion, the
owmcr-bulldar will have the burden of proving that he did not build or improve for par- I
pose of sale).
❑ 1, as owner of the property, am exclusively con0acting with licensed compactors to
construct he project (Sec. 7044, Business and Professions Code:) The Comments Li.
cense Law does not apply to an owner of properly who builds or improves thrown. and QTy,
who contracts for such projects with a connectors) licensed pursuant to the Contmnofs
License Law.
l am exempt under Sec. .B&PC for this rcmmn
Ownar Dam
WORKER'S COMPENSA'DON DECLARATION
1 hereby affirm under penalty of perjury one of doe fol lowing declarations:
I have and will maintain a Certificam of Consent to self -insure for Worker's Compem
sation, as provided for by Section 3700 of the Labor Cede, for the performance of the
work for which this permit is issued.
and will muinmin Workers Cmalw sutlon Iotrol as required by Section,0 nlThe Labor Code, for the performance of the work for which this Permit is issued,
My Worker'a Cen�iom lr�ysrance caJpr and Policy nul�or ar
Currier. y(w--" Palley Nn.:
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMP mplete ON INSURANCE
(This section neednotbe completed ifthe pemtis is foronehutMed do11ars141001
in Icss.)
I canny that in the perform of the work for which this permit is issued, l shall
out employ say .a in any ma mer u
so as m We. subject the Workers' Compen-
Q z satied Laws of California. Dare n
0 Applicant \ -
sz. ^ NOTICE TO APPLICANT: If, after making this Cenifu:am of Exemption, you should
H become subject to the Worker's Compensation provisions of the Labor Code, you must
tai] Q fanhwhh comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
U O I hereby affirm that there is a construction lending agency for the performance of
PT F the work fur which this permit is issued (Sec. 3097, Civ. C.)
Q ULenders Name _
Lenders Address
y I entity thin I have read this application and sure don the above information is
fA correct. I agree to comply with all city and county ordinanres aM sum laws elating to
V z building conarectinn, and hereby auNuAu mimmunwives ofaus city in enter upon the
r abovomentioned property for inspection purposes.
(We).gree to save, indemnify and keep harmless the City of C.per ire. aphis,
liabilities, judgments, costa and expenses which may in any way wean against said City
in consequence of rhe granting of this permit.
APPLICANT UNDERSTANDSAND WILL COMPLY WITH ALL NON -POINT
soDEc?RCGUTATIONS. A - i a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore be do,occupaal store or handle haeralm, mmerial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 2 532ND
❑Yes
Will the applicant or future building occupant use equipment or devices which
anis hmmdous is contaminants as defined by the Bay Arta Air Quality Management
District?
❑Yes'
I have mad the hazvdouss materials equiremems under Chapter 6.95 of the Calm
ford. Tonilph & Safety Code, Sections 25505, 25533 and 25534.1 understood that If the
mogNina does not currently have Ra nam, that it is my msponsibility to notify IN occupant
PC EMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NI?W RESIDENTIAL ELECTR .
PLUMBING PERMIT
ALTCR- DRAIN & VENT- WATER (EA)
SQ FT.
N
I ❑OTHER
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SO. FT. FLUOR AREA
JUL 0 8 MST
/
FEE COY i UUrrmIIIVU
U W Z '¢
FEE
JOB DESCRIPTION
RESIDENTIAL: ,�,�
❑SFDWL �TCHEN REMODEL
❑ADDITION ❑PLUMBING RI_PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT L]SWIMMING POOLS
❑ BATH RF,MODEUREPAIR ❑DEMOLITION
1I
DRAINS - FLOOR. ROOF, AREA, COND.
STORIES
I ❑OTHER
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
SO. FT. FLUOR AREA
JUL 0 8 MST
/
FEE COY i UUrrmIIIVU
OFFICE
TOTAL:I Hyo XV I ISSUED
BACK FLOW PROTECT. DEVICE:
"f ? -f�c rg_ ry
L
�TYYPE
DRAINS - FLOOR. ROOF, AREA, COND.
STORIES
C(
FIXTURES -PER TRAP
GAS -EA. SYSTEM .1 INC, 4OU'TLETS
•
OCCGROUP
GAS - EA. SYSTEM -OVEN 4 (IIA)
GREASE/INDUSTRL WASTE INI'ERCEPTDR
BUILDING DIVISION FGIiS
GREASETRAP
PLANCHECK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENTIELECfR
_
GRADING FEE
WATER SYSTEMTREATING
SOILS FEC
WATER SERVICE
PAID
NEW RESIDENTIAL. PLMR. SQ. FT,
Date Receipt #
TOTAL:
TOTAL.:
Wor
BUILDING PER
QTY.
MECHANICAL PERMIT
FEE
SEISMIC FEE
ELECTRIC FTE
I
PERMIT ISSUANCE
ALTER OR ADD TO MECH,
PLUMBING HE
AIR HANDLING UNIT TO Main CFM)
MECIIANTCAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONST RUCTION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
11 RATING UNIT 00 100.000 BTU)
HEATING UNIT (OVER 11),000 BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Date Receipt M
BOILER- COMP 0HP OR 100000 BTU)
TOTAL:
HOB.ER-COMP (OVER 100,000 PTU)
I �
YV
AIR CONDITIONER
ISSUANCE DATE
NEW RESIDENTIAL MECH, SQ. FT.
OFFICE
TOTAL:I Hyo XV I ISSUED