23967 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proect Identification 7 PERMIT NO.
Build Ing Add X853 oarE Cr eu P. 23967
w�ncrS came:
hone:
G 6•OS CITY OF CUPERTINO-BUILDING DIVISION
Cmtractor'.N, : Lic. o: APPLICATION / PERMIT
TO O BUILDING-ELWTRICALPLUMBINO-MECHANICAL CATEGORY CONTROL
Architect/Engineer. Lic.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrroe: PERMITISSUANCE ❑ El 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby ths.dtf 700D)t(DiA.Im3.ftheunder provhnd Pm Chapter9(mmmm APPLIANCESFESIDENTIAL JOBD ON
11...h .full 7000)of Dlvielon3olthe Bueinessand Pro(eulouCode,and my
Ilcense la In fu8lo and affect. PANELS S�, `�H -
LIcen�Lic.4� I W 1
Dale L Contractor o _LBf� pr'-� �
ARCHITECTS DECLARATION
p�u ail Z I understand my plans shall be used u public remnla OVER IBM AMPS r SQ.FT.FLOOR AREA .j/SQ.FT.
h:� Licensed Professional SIGNSELECTMCAL ALE D I
6 OWNER-BUILDER DECLARATION IV /I 1 11
C, 5 ECIALCB2CUIT/M SC
H YYI
ZThereby afllnntlutlam exempt Contractor's License Law(sash. VV E AVY
following mum.(Section 70315,Business and Professions Code:Any city or
O TEMP METER OR POLE LIST.
Rci couany tm hlch mpr rtolmlairrea M ealsom uim.theaprove,demalhh, er ttr �� y2
any atmduretatementshat le,Is ahosed pursuant t the fineuchpermitto
fife a signed statement that he t r9(cod ereirg it the provisions of the POWER DEVICES A
Ow Contractors License Law(Chapters(mnurcnMgwbh Section
mptthrefonnerul
HBOsum 3oltheguDineeemdl'rofemlouCode)orthat hehexemptthare(romand SWIMMING IDOL ELECTRIC VALUATION
Q the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFf%'fUI4E5
applicant fora permit subjecutheapplindnt too dvil penalty not more than
O6una ed owns of the pro NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n I,as awem of the property,or my employees with wager as their Ale
compensation,will do the work and the structure isnot intended or offend for
O ale(Sec.7004,Business and Professions Code:The Contractor's License Law
'$ does not apply to an owner of property who builds or lmprovesthereon,and OCC.GROUP RFS UNITS
who doe,such work himself urthrough his own employees,provided that such
improvements are nal intended or offered for sale.If,however,the building or TOTAL:
Impmvemcnt issold withinoneyearofcompldioNtheowner-bu0derwdl have
tilLIpardenofpcovingthat he did nal build or improve for purpose ofule,L QTY. PLUMBING PERMIT FEE FLOOD7ONE APN
Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cont'-dame to mumrd the project(Sec.7044,Business and Professions Code:
The Contradoes Llrarue Law does not apply to an owner d property who ALTER-DRAW&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pSod
jea with a FEE SUMMARY
�qp4(+ctorW Bcenud pursuant to the Contractor'.License Law. BACK PLOW PROTECT.DEVICE.
IJ 1 am exempt under Sm B 4 P C for this naaon
FFS
Owner
DRAINS FLOOR ROOF,AREA,COND. B Y
Date R
WORKMAN COMPENSATION DECLARATION
F7X'NRES PER TRAP L A% Y N
❑I hereby o,kl n that I have a l...e of consent d apythaure,ora BBC=M
3800,.OifLab olWorken'Compeuatlmlmurance onacertl(hd copythereof(Secs GAS F.A.SYSTEM.1 INCAOUTLEI'S PARK FEF. Y N
380q Tab CJ —
Pollry N RECEIPT a
GAS EA.SYSTEhM-OVER 4(RA)
Com eny BUILDING DI VISION FEES
Certified copy h herebyfamished,the city CREASE/LNDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CertBied copy h filed with the city inspection dlvlelm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM PA 200FT. Date Reoei t#
(rhieudion need rad 4 e.plded ilthe permit hforom hundred dollars
(j11 comifess.) WATER HEATER W/VENT/MXCTR ENERGY FEE Y N
Tante employ any
person in
.work w"to htca permit is sewed,
I.hake not employ any.Lawn In any manner n u to become subject to the WATER SYSTEM/'TREATING
Warlicant mpenution Lawn of GBlamh. Data PAID
O Z AppNOTICE
NEW RESIDENTIAL PLMB. SORT. Date Re i t#
Z O NOIICETO APPLICANT. orkem'fter kingthh Certificate impovis Exemptlo L,ym W
should become subject to the Workers'Com provisions
n provhlou of the Labor TOTAL:
> Cade,you must forthwith comply with each provelou orthh permit shallbu
W C deemed revoked. '
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herchyof@mthatthereis iemutmdlon lending agency W7,Ci.C.) perform, ELECTRIC FEE
V7 Z Lar of the work for which this permit is issued(Sec.3097,Civ.C.) T PLUMBING FEE
O Larders Name
LL. Lnca"Bithatl QTY. MECHANICAL PER FEE MECHANICAL FEE
OW Icertifythatl have readthhappBcatbnand slatethaUheabovelnfomtatlon
1 hmrnct.I agrmtocomplywith act cityand county ordinances and Mate lawn PERMITLSSUANCE FEES PAID:
relatingto bulldingmmtrodim,aMhenbyauth.r .pneentativeeofthis
Zcity to ennrupon the abov.mentloned property for lrupadion purposes. ALTER OR ADDTO MECH. Date Recei t#
(We)agnm to save,indemnify an d keep harmless the the City of Cupertino
against lhbi tiq,ji'dgmmuceetsa expenses which mayi...yw.y.cmm AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL:
ago I i In coneeque t gra ntl thio permit.
/ AIR HANDLING UNIT(OVER 10,"CH.) CONSTRUCTION TAX
gnatumof Applicant/Cont tor, - Date air EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD SMA IALSDISCLOSURE
Will the applicant or future building occupant store or hand le hazardous I IEATTNG UNIT(TO 100,000 M) Date Recef tit
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Code
e+,Section 2S532(W7 HEATING UNIT(OVER 100,000 BTU) TOT
Yes
❑ No
Will the applicant or future building o pant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air cmdambume as defierd by the Bay Area Air
Quality Maragemenl District? BOILER-COMP OHPOR 100,000 BTU) A p
4Yna nits aV E
havereadtheha&S.fe C.de ,h l..2menh5533aChapler6.95 of BOL R-CAMP(OVER IOD,OW BTU
theersta understandthat
building
Code,Sed1ountly have a tenant,
JUL
mapmeandyto notify
the..part of notcurrentlytenant that it is myWmet NEW RESIDENTIAL MECH. SQ.FT LS d,¢ '
ruor to issuance
c nfa Ctheompantaftherequlrcmenb which must be met /�
prior to Issuance of a Certificate of Ocmpanry. Cl7Y Uh
(��y/�4+UY^th
Owner or wthodzed agent Data I��DgT\ 1�!
TOTAL:/ 777 111
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proect Identification 7 PERMIT NO.
Build Ing Add X853 oarE Cr eu P. 23967
w�ncrS came:
hone:
G 6•OS CITY OF CUPERTINO-BUILDING DIVISION
Cmtractor'.N, : Lic. o: APPLICATION / PERMIT
TO O BUILDING-ELWTRICALPLUMBINO-MECHANICAL CATEGORY CONTROL
Architect/Engineer. Lic.Na:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrroe: PERMITISSUANCE ❑ El 1:1LICENSED CONTRACTOR'S DECLARATION
Ihereby ths.dtf 700D)t(DiA.Im3.ftheunder provhnd Pm Chapter9(mmmm APPLIANCESFESIDENTIAL JOBD ON
11...h .full 7000)of Dlvielon3olthe Bueinessand Pro(eulouCode,and my
Ilcense la In fu8lo and affect. PANELS S�, `�H -
LIcen�Lic.4� I W 1
Dale L Contractor o _LBf� pr'-� �
ARCHITECTS DECLARATION
p�u ail Z I understand my plans shall be used u public remnla OVER IBM AMPS r SQ.FT.FLOOR AREA .j/SQ.FT.
h:� Licensed Professional SIGNSELECTMCAL ALE D I
6 OWNER-BUILDER DECLARATION IV /I 1 11
C, 5 ECIALCB2CUIT/M SC
H YYI
ZThereby afllnntlutlam exempt Contractor's License Law(sash. VV E AVY
following mum.(Section 70315,Business and Professions Code:Any city or
O TEMP METER OR POLE LIST.
Rci couany tm hlch mpr rtolmlairrea M ealsom uim.theaprove,demalhh, er ttr �� y2
any atmduretatementshat le,Is ahosed pursuant t the fineuchpermitto
fife a signed statement that he t r9(cod ereirg it the provisions of the POWER DEVICES A
Ow Contractors License Law(Chapters(mnurcnMgwbh Section
mptthrefonnerul
HBOsum 3oltheguDineeemdl'rofemlouCode)orthat hehexemptthare(romand SWIMMING IDOL ELECTRIC VALUATION
Q the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFf%'fUI4E5
applicant fora permit subjecutheapplindnt too dvil penalty not more than
O6una ed owns of the pro NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n I,as awem of the property,or my employees with wager as their Ale
compensation,will do the work and the structure isnot intended or offend for
O ale(Sec.7004,Business and Professions Code:The Contractor's License Law
'$ does not apply to an owner of property who builds or lmprovesthereon,and OCC.GROUP RFS UNITS
who doe,such work himself urthrough his own employees,provided that such
improvements are nal intended or offered for sale.If,however,the building or TOTAL:
Impmvemcnt issold withinoneyearofcompldioNtheowner-bu0derwdl have
tilLIpardenofpcovingthat he did nal build or improve for purpose ofule,L QTY. PLUMBING PERMIT FEE FLOOD7ONE APN
Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cont'-dame to mumrd the project(Sec.7044,Business and Professions Code:
The Contradoes Llrarue Law does not apply to an owner d property who ALTER-DRAW&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pSod
jea with a FEE SUMMARY
�qp4(+ctorW Bcenud pursuant to the Contractor'.License Law. BACK PLOW PROTECT.DEVICE.
IJ 1 am exempt under Sm B 4 P C for this naaon
FFS
Owner
DRAINS FLOOR ROOF,AREA,COND. B Y
Date R
WORKMAN COMPENSATION DECLARATION
F7X'NRES PER TRAP L A% Y N
❑I hereby o,kl n that I have a l...e of consent d apythaure,ora BBC=M
3800,.OifLab olWorken'Compeuatlmlmurance onacertl(hd copythereof(Secs GAS F.A.SYSTEM.1 INCAOUTLEI'S PARK FEF. Y N
380q Tab CJ —
Pollry N RECEIPT a
GAS EA.SYSTEhM-OVER 4(RA)
Com eny BUILDING DI VISION FEES
Certified copy h herebyfamished,the city CREASE/LNDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CertBied copy h filed with the city inspection dlvlelm.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM PA 200FT. Date Reoei t#
(rhieudion need rad 4 e.plded ilthe permit hforom hundred dollars
(j11 comifess.) WATER HEATER W/VENT/MXCTR ENERGY FEE Y N
Tante employ any
person in
.work w"to htca permit is sewed,
I.hake not employ any.Lawn In any manner n u to become subject to the WATER SYSTEM/'TREATING
Warlicant mpenution Lawn of GBlamh. Data PAID
O Z AppNOTICE
NEW RESIDENTIAL PLMB. SORT. Date Re i t#
Z O NOIICETO APPLICANT. orkem'fter kingthh Certificate impovis Exemptlo L,ym W
should become subject to the Workers'Com provisions
n provhlou of the Labor TOTAL:
> Cade,you must forthwith comply with each provelou orthh permit shallbu
W C deemed revoked. '
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herchyof@mthatthereis iemutmdlon lending agency W7,Ci.C.) perform, ELECTRIC FEE
V7 Z Lar of the work for which this permit is issued(Sec.3097,Civ.C.) T PLUMBING FEE
O Larders Name
LL. Lnca"Bithatl QTY. MECHANICAL PER FEE MECHANICAL FEE
OW Icertifythatl have readthhappBcatbnand slatethaUheabovelnfomtatlon
1 hmrnct.I agrmtocomplywith act cityand county ordinances and Mate lawn PERMITLSSUANCE FEES PAID:
relatingto bulldingmmtrodim,aMhenbyauth.r .pneentativeeofthis
Zcity to ennrupon the abov.mentloned property for lrupadion purposes. ALTER OR ADDTO MECH. Date Recei t#
(We)agnm to save,indemnify an d keep harmless the the City of Cupertino
against lhbi tiq,ji'dgmmuceetsa expenses which mayi...yw.y.cmm AIR HANDLING UNIT CIO 10,000CFM) SUBTOTAL:
ago I i In coneeque t gra ntl thio permit.
/ AIR HANDLING UNIT(OVER 10,"CH.) CONSTRUCTION TAX
gnatumof Applicant/Cont tor, - Date air EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD SMA IALSDISCLOSURE
Will the applicant or future building occupant store or hand le hazardous I IEATTNG UNIT(TO 100,000 M) Date Recef tit
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Code
e+,Section 2S532(W7 HEATING UNIT(OVER 100,000 BTU) TOT
Yes
❑ No
Will the applicant or future building o pant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air cmdambume as defierd by the Bay Area Air
Quality Maragemenl District? BOILER-COMP OHPOR 100,000 BTU) A p
4Yna nits aV E
havereadtheha&S.fe C.de ,h l..2menh5533aChapler6.95 of BOL R-CAMP(OVER IOD,OW BTU
theersta understandthat
building
Code,Sed1ountly have a tenant,
JUL
mapmeandyto notify
the..part of notcurrentlytenant that it is myWmet NEW RESIDENTIAL MECH. SQ.FT LS d,¢ '
ruor to issuance
c nfa Ctheompantaftherequlrcmenb which must be met /�
prior to Issuance of a Certificate of Ocmpanry. Cl7Y Uh
(��y/�4+UY^th
Owner or wthodzed agent Data I��DgT\ 1�!
TOTAL:/ 777 111
OFFICE COPY