S 4370 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'1'RICAI, 1'h.HMI'f NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4370
BUILDING PROJECT IDENTIFICATION
BWLDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
OSSS' DRANi-e Ce r Cama 2
NER' �A [ PHONE: CON FRACIOR'S NAME. LIC NO:
{Y/1 NIC CONTROL#
Iq 'I I IF.CT'IENGINEIiR; LIC NO ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
6WI� / Oft)V-2- ❑ Consultant Foes Paid by Applicant(Initial) JamDO. ELECT LQ UMe SUCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ��Sy'y'
I hereby aflinn Ilial I um licensed under provisiaav of Chopmr 9(commencing JOB DESCRIPTION
aUV hiecn.cC 1OnlurNC liuxinevcnnd Pndc,xinnx Cala,and mylie,nu is RESIDENTIAL:
CO wnM1$• rce and effect.
Divi.
�O I'T:RM111'f ISSUANCE
FUS in all Class and effect. ❑SPDWL [I KITCHEN RIiMODF.I.
Ins Lia.# APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING BE PIPE
F Z W Dutc Comcamor
dn6y ❑MULTI-UNIT ❑STRUCTURAL,
F..Dm ARCIIHIiCI'S DECLARATION PANELS MODIFICATION
ZOtHZ I understand my plansshull keened u,public rmords UP T02g1AMP$
OZ—O [I INTERIOR ❑CHIMNEY REPAIR
W Limmd Professional 201-I000AMPS IMPROVEMENT 0SWIMMING POOLS
W• MJ OWNIR-BUILDER DECLARATION OVER["AMPS El REMODEfJREPAIR [I DEMOLITION
C C d 1 hereby affirThal 1 am exempt from the Contractor's License Law franc 3 m faaa.H following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHERwh ch 4 pe I I construct,all p J 1'.h p y structure >_
O prior to is1: 4 the ppla t for suchp tt filea signed tatcrrenl SPLCI AL CIRCUIT IMI SC.
y Jim1,c df : ,i II I : : IIM1 C t 't 1 1' (Ch pmr9
11 � (consim .ng with Swlon Mull ofDvson Sof the Bu,sssmd Poole,use,Codcl or TEMP.MET ER OR POLE INS T. COMMERGIAI:
G.X n IY thus he ix exempt tnaefrom veld the bulls for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,5 by any applicant nor.permit subjects the applicant civil perellyof POWER DF-VI ❑TENANT ❑FOOD SERVICE
m
nmom than five handled dollars($50(b. IMPROVEMENT
RSG 01. sownerofthepmpeny,ofmyempinyms%ithwagesatheirsnl,compensation, IhLNfN'G POOL C:'
F. will du Ne work.and the.tmcwrcis not intended oroRertdfonale(SaJDW.Resines 5� ` ❑OTHER
W
3 m vad Ihnfcssions Cade:The Cnno-ucmGs License law docs nm apply Ina o l OfIT1aTS�S W Isf�fl� PI v VRCS
pmpcny who builds or impnwa hereon,and who Jtcs such wor g
his own empluyecx,provided Ilial.men improvements is.not t I r alk iu of �1•NF W, SIDENT L EL R S Ff.
sale ll h IM1 build 6 p enI Id ,thinon n pl fon. RARFA $ISQ.fT.
owner boulder ill have the burden I moving 6 h t he did norli fur, e
pow t f ). 'IOTA
❑ I f the property, l : ely conlowliff, it I Jrommucto
cm,mea I the project(Sec 7(00 Business unit Profession,C ,of. Jnr
nsc In does t apply to of properly h hildvo p d QTY. PLUMBING PERMIT
who contractsf...&projects with a connacrods)licensed pursuantr ...fee,
License law. PERMIT ISSUANCE
I am exempt under Sec. ,B&1'C for this reaun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Da.
WORKER'S COMPENSATION DECLARAHON HACK FLOW PR(7I'LCl'.DEV
I hereby union under lwnalty of perjury one of the following declarin
Ih:rvc anA will maimuin xCcnilicatc of Cnrocm aucll-inxurelin WorkerGtmpcm bkAINS-FLOOR.I200E AR A.CO STOlilliS TYPE CONSI'RUCDOC
it"sallun,as provided for by Section 300(of the Labor Cade,lie the perforivanum of the
work for which this permit is i.wued. FIXTURES-PF TRAP00,
I have and will maintain Worker's Compensation Immune,us required by Section
3700 of the Labor Code,for the perforators, of the work for which this pertnil is issued. GAS-EA.SYSTEM-I INC.d OUTLETS OCC GROUP I '
My Wnrkcr�'v-_JytpTpytinn 1pS:tr,�_alrtc'CaPall y No
GAS-EA.SYSTEMOvfµalG) �7�
rrsot
CERTIFICATE OP EXEMPTION FROM WOR ERS' GREASI%INDUSTRL WAS'1'F INTERCEPTOR
V
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This.ccetionncd nal berouplacdlfthe pc—it is throne hindovddollars($IIYJ) GRFASETRAP
in leu) PLANCHLCK FEI1
I mrify that Indic performance oflhe work for michlins lverotit is Issued,l shall SIiWER-SANITARY-STORM EA.200 FT.
,lot employ any person in any mature,so us ut become subject In Ibc Worker"Corolla- FEE
n
Z 'ai'm law,of California.Date WATER HEATER WNENTIFLEMR
O O Applicant GRADING FEE
z ! NOTICE:TO APPLICANT.IL after making this Cenificam of Exemption.you should WATER SYSTENIGREATING
h" ? become subject to the Worker's Compensation provisions of the Labor Calk,you must SOILS FEE
fothwid,comply with with provisions or Nis permit shallh deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID
U 0 thereby ufGmnhanhere is o ennnmctin.Undingngeney fnnhe performance of Date caipl#
W Lr We work for which this permit is i,xu..Iis".3097,Ci¢C.1
O U 1<ndc6 Nuns TOTAL:
TOTAL'
W Isnde-,Address .
r 6. 1 certify that I base read Phi,,feliemon, ad ,are that life.1i information is BUILDING 1 E /a
F to c nect.l ngrcemcomply wiN all cidy nnJ ammy ordinances and etre laws remlingm QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby suNnritc representatives of this city to enter upon the SEISMIC FEE
CP
aMwe-mentioned property fell impeclum purpose. PERMIT ISSUANCE ELECTRIC FEE
(WO race to save,indemnify and keep harmless the City of Cupertino against
I ivhilifie,.judgments.costs and expenses which may in any way accrue against said City AIIERORADDTOMECH. PLUMBING FEE
In consequent f,he grantingof this permit. iii
APPLICANT INDE:STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL It
SOURCE REC ULAT ON
AIR HANDLING UNI'T(OVER II.P00 CFM) CONSTRUCTIO. TAX
Signamrcof ,he nl/Contceaur Dote EXHAUST HOOD(W/DUCT) HOUSING MIT I( '1'ION FEE
HAZARDOl1S MAIERIALS DISCLOSURE
will ,applicant orfanm building occupant store or handle hmardou.s material HCA PING UNIT(0100.000 BTU) /
vs defined h_ the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely
Code.Section 25532OU HEATING UNIT(OVER 100A1111 BTU)
C]Ye' ❑No VENT]LATION FAN(SINGLE BPS)D) PAID
Date ceipt#
e Will the applicant ur I'murc&fiord by he[i use co A,,em nr devices wbicb BOILER-COMP(3H-OR Ig1,IX10 RTU)
snit naennbus air cnmuminants ns dcfind by the Bay Arm Air Quality Management TOTAL:
Distncf, BOILER-COMP(OVER Ioo'om)B'I U)
❑Yc, [:1 No
I have read tare humunu......mal,requesurctns under Chopmr 6,95 of the Culi- AIR CONDITIONER ISSUANCE DATE
(atria Hull &Sof ly Cde,Sermons 25505.25533 am12553q.1 understand Lha if the NEW RESIDENTIAL.MECH. SQ.ET.
building d, not ct in yhave a tenant,that it is my responsibility to lifyI m at
of the regai nem ch must be noel Prior m maxim,of v Cemltc:
r/ Owner oro and ogem Dam TOTAL- ISSUED BY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC'1'RICAI, 1'h.HMI'f NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4370
BUILDING PROJECT IDENTIFICATION
BWLDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
OSSS' DRANi-e Ce r Cama 2
NER' �A [ PHONE: CON FRACIOR'S NAME. LIC NO:
{Y/1 NIC CONTROL#
Iq 'I I IF.CT'IENGINEIiR; LIC NO ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
6WI� / Oft)V-2- ❑ Consultant Foes Paid by Applicant(Initial) JamDO. ELECT LQ UMe SUCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ��Sy'y'
I hereby aflinn Ilial I um licensed under provisiaav of Chopmr 9(commencing JOB DESCRIPTION
aUV hiecn.cC 1OnlurNC liuxinevcnnd Pndc,xinnx Cala,and mylie,nu is RESIDENTIAL:
CO wnM1$• rce and effect.
Divi.
�O I'T:RM111'f ISSUANCE
FUS in all Class and effect. ❑SPDWL [I KITCHEN RIiMODF.I.
Ins Lia.# APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING BE PIPE
F Z W Dutc Comcamor
dn6y ❑MULTI-UNIT ❑STRUCTURAL,
F..Dm ARCIIHIiCI'S DECLARATION PANELS MODIFICATION
ZOtHZ I understand my plansshull keened u,public rmords UP T02g1AMP$
OZ—O [I INTERIOR ❑CHIMNEY REPAIR
W Limmd Professional 201-I000AMPS IMPROVEMENT 0SWIMMING POOLS
W• MJ OWNIR-BUILDER DECLARATION OVER["AMPS El REMODEfJREPAIR [I DEMOLITION
C C d 1 hereby affirThal 1 am exempt from the Contractor's License Law franc 3 m faaa.H following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHERwh ch 4 pe I I construct,all p J 1'.h p y structure >_
O prior to is1: 4 the ppla t for suchp tt filea signed tatcrrenl SPLCI AL CIRCUIT IMI SC.
y Jim1,c df : ,i II I : : IIM1 C t 't 1 1' (Ch pmr9
11 � (consim .ng with Swlon Mull ofDvson Sof the Bu,sssmd Poole,use,Codcl or TEMP.MET ER OR POLE INS T. COMMERGIAI:
G.X n IY thus he ix exempt tnaefrom veld the bulls for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031,5 by any applicant nor.permit subjects the applicant civil perellyof POWER DF-VI ❑TENANT ❑FOOD SERVICE
m
nmom than five handled dollars($50(b. IMPROVEMENT
RSG 01. sownerofthepmpeny,ofmyempinyms%ithwagesatheirsnl,compensation, IhLNfN'G POOL C:'
F. will du Ne work.and the.tmcwrcis not intended oroRertdfonale(SaJDW.Resines 5� ` ❑OTHER
W
3 m vad Ihnfcssions Cade:The Cnno-ucmGs License law docs nm apply Ina o l OfIT1aTS�S W Isf�fl� PI v VRCS
pmpcny who builds or impnwa hereon,and who Jtcs such wor g
his own empluyecx,provided Ilial.men improvements is.not t I r alk iu of �1•NF W, SIDENT L EL R S Ff.
sale ll h IM1 build 6 p enI Id ,thinon n pl fon. RARFA $ISQ.fT.
owner boulder ill have the burden I moving 6 h t he did norli fur, e
pow t f ). 'IOTA
❑ I f the property, l : ely conlowliff, it I Jrommucto
cm,mea I the project(Sec 7(00 Business unit Profession,C ,of. Jnr
nsc In does t apply to of properly h hildvo p d QTY. PLUMBING PERMIT
who contractsf...&projects with a connacrods)licensed pursuantr ...fee,
License law. PERMIT ISSUANCE
I am exempt under Sec. ,B&1'C for this reaun
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Da.
WORKER'S COMPENSATION DECLARAHON HACK FLOW PR(7I'LCl'.DEV
I hereby union under lwnalty of perjury one of the following declarin
Ih:rvc anA will maimuin xCcnilicatc of Cnrocm aucll-inxurelin WorkerGtmpcm bkAINS-FLOOR.I200E AR A.CO STOlilliS TYPE CONSI'RUCDOC
it"sallun,as provided for by Section 300(of the Labor Cade,lie the perforivanum of the
work for which this permit is i.wued. FIXTURES-PF TRAP00,
I have and will maintain Worker's Compensation Immune,us required by Section
3700 of the Labor Code,for the perforators, of the work for which this pertnil is issued. GAS-EA.SYSTEM-I INC.d OUTLETS OCC GROUP I '
My Wnrkcr�'v-_JytpTpytinn 1pS:tr,�_alrtc'CaPall y No
GAS-EA.SYSTEMOvfµalG) �7�
rrsot
CERTIFICATE OP EXEMPTION FROM WOR ERS' GREASI%INDUSTRL WAS'1'F INTERCEPTOR
V
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This.ccetionncd nal berouplacdlfthe pc—it is throne hindovddollars($IIYJ) GRFASETRAP
in leu) PLANCHLCK FEI1
I mrify that Indic performance oflhe work for michlins lverotit is Issued,l shall SIiWER-SANITARY-STORM EA.200 FT.
,lot employ any person in any mature,so us ut become subject In Ibc Worker"Corolla- FEE
n
Z 'ai'm law,of California.Date WATER HEATER WNENTIFLEMR
O O Applicant GRADING FEE
z ! NOTICE:TO APPLICANT.IL after making this Cenificam of Exemption.you should WATER SYSTENIGREATING
h" ? become subject to the Worker's Compensation provisions of the Labor Calk,you must SOILS FEE
fothwid,comply with with provisions or Nis permit shallh deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID
U 0 thereby ufGmnhanhere is o ennnmctin.Undingngeney fnnhe performance of Date caipl#
W Lr We work for which this permit is i,xu..Iis".3097,Ci¢C.1
O U 1<ndc6 Nuns TOTAL:
TOTAL'
W Isnde-,Address .
r 6. 1 certify that I base read Phi,,feliemon, ad ,are that life.1i information is BUILDING 1 E /a
F to c nect.l ngrcemcomply wiN all cidy nnJ ammy ordinances and etre laws remlingm QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby suNnritc representatives of this city to enter upon the SEISMIC FEE
CP
aMwe-mentioned property fell impeclum purpose. PERMIT ISSUANCE ELECTRIC FEE
(WO race to save,indemnify and keep harmless the City of Cupertino against
I ivhilifie,.judgments.costs and expenses which may in any way accrue against said City AIIERORADDTOMECH. PLUMBING FEE
In consequent f,he grantingof this permit. iii
APPLICANT INDE:STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL It
SOURCE REC ULAT ON
AIR HANDLING UNI'T(OVER II.P00 CFM) CONSTRUCTIO. TAX
Signamrcof ,he nl/Contceaur Dote EXHAUST HOOD(W/DUCT) HOUSING MIT I( '1'ION FEE
HAZARDOl1S MAIERIALS DISCLOSURE
will ,applicant orfanm building occupant store or handle hmardou.s material HCA PING UNIT(0100.000 BTU) /
vs defined h_ the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely
Code.Section 25532OU HEATING UNIT(OVER 100A1111 BTU)
C]Ye' ❑No VENT]LATION FAN(SINGLE BPS)D) PAID
Date ceipt#
e Will the applicant ur I'murc&fiord by he[i use co A,,em nr devices wbicb BOILER-COMP(3H-OR Ig1,IX10 RTU)
snit naennbus air cnmuminants ns dcfind by the Bay Arm Air Quality Management TOTAL:
Distncf, BOILER-COMP(OVER Ioo'om)B'I U)
❑Yc, [:1 No
I have read tare humunu......mal,requesurctns under Chopmr 6,95 of the Culi- AIR CONDITIONER ISSUANCE DATE
(atria Hull &Sof ly Cde,Sermons 25505.25533 am12553q.1 understand Lha if the NEW RESIDENTIAL.MECH. SQ.ET.
building d, not ct in yhave a tenant,that it is my responsibility to lifyI m at
of the regai nem ch must be noel Prior m maxim,of v Cemltc:
r/ Owner oro and ogem Dam TOTAL- ISSUED BY:
OFFICE