21722 APPLIC4NTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
766 k'/ /zoo Lr. Lo- 36h 21722
name: V... ane. A _ A A
CITY OF CUPERTINO-BUILDING DIVISION
TE
AM t ora am LI. ' APPLICATION /PERMIT �� - 91
I BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
t
Ent r, r. r l
TY ELECTRIC PERMiT FEE BUILDING PERMIT INFO
Addres. - - -
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am ilcevedunder pmvlalonsof Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DFSLWI ON
'ngwith Scction7000)of Divlslon3 oftl(ell slnesand PlofesslonsCode,andry
LkersClass license I,In 11 in dLd�e1R= 3 r� PANELS w
Date Contractor (� rJu) L
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�uu 2 I understand my plans shall be used as public rend. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT,
00
q Z E Licensed Professional - SIGNS ELECTRICAL
I'<<w Fn OWNER-BUILDER DECLARATION
n / Ihertby afOrm that lam exempt from the Cctor'.
ontraLicenseSPFGIALCIRCUIT/MLSCnse Law for the l
'0O(..,_'� following resson.(Semon 7m15,Bminex and Pmfeslon.Code:Any city or - I/// "�
OZE.� 7 V
u,p nlywhich requlrnapermltroconsWR,altcr,lmprove, mn
delbh,orrcpair TEMP.ME=OR POLE INST. _
�j'ci muanystructuprior to Its unce,slen requlreatheappllant for such permtto LOWER DEVICES
( fire Wa
le a signed statement that he oi licensed pursuant to the provisions of the
3Mil Uµ'u Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMINGIDOLELECCWC-
v,�OsO
sion3oftheBusinnss and ProessioruCode)orthat he b exempt thercfromaM VALUATION ti the W s6 for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSSWITCI-IF_SFTXTURFS
Q applicant fora permit.ubjects the applicant to a dull penalty of nit rtnre than
a. mC"u flue hum md s owner
(epos NEWRFSID=ALELDCTR SQ.FT. STORIES TYI'ECONSTRUCTION
❑I,as owner of the property,or my employees with wages r their sole
compensation,Burners w•ark,and thes Code:TVnot Intended oroffered for
5gO salepec. pply toalnosandfmissions Code:The Contractors theemeIaw
does not applytoan owner o(property hhiswho
nempiym,prothercoRand - OCC.GROUP, RES UNTI5
E: whodaessuchwohhlmseUorthvugh hisownemplgecs,provided that such
Improvement am nit Intended orof(emd formte.If,however thebullding or TOTAL:
Improvement bsold withinonehrearofcomplMiom theowner-bulWerwill have
tis,e*rden of proving that he did not Wild or improve for purpose of sate.). QTY. PLUMBING PERMIT FF_EFLOOD ZONE APN
IJ L as owner of the Property,am exclusively contracting with Itansed pp Tp IS6UANCE
contractors to construct the project(Sec.7011,Bushes and Professions Code:
The Contender.License law docs not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds of Improves theeon,and who contracts for such ploject.with a FEE SUMMARY
eactor00 aw
licensed pursuant to the Contractor's License L . BACK FIAWPROTCCT.DEVICE
5pNf1 am exempt under Sec. B k P C for this mason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N�
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PERTRAP $CA{DOL TAX Y_vN
01 hereby affirm that I have a¢rtlffeate of consent to self-tesue,or a RMIEI T N
¢rtiflcab CJ S F.A.teof Worken'Compensatimimuran¢ora¢rtifiMcopyther f(Sec'
3900,LaGASYSTEM-1 INCA DUILEI$ PARK FEE Y_ N
Porky N RECEIPT N
GAS.E.A.SYSTEM-OVER 4(FA)
Com any r / "�/ GBUILDING DIVISION FE ES
Certl/led copy b hereby furnished. GR[ASE/INDUSI?tL WASTE INTFRCEPTUR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF FXEMI4ION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
ffhissectlon need no be completed lthe permit b(orone hundred dollars SEWFR-SANITARY-STORM E.A.200FT. Date RCOCI t#
R1W)ofy that
WATER HEATER W/VENT/E3,FGTR ENERGYFEE Y N
rectify IIn the performance the work(orwhlch thispermit is Issued, -
I shall not employ any person In any manner so ss to became subject to the WA71R SYSTEM/TREATING
Workcrs'Compcnsation Laws o(GII(ornla.Date PAID
licant
Z Z NOTICE TO APPLICANT:ILafter making this Certificate of Eaampik, you NEW RESIDENTIAL PLMB. SQAT. Date Recei t#
O should become.ubjeet to the worker:Compensation provisions of the Labor TOTAL:
~ y code, ou=at forthwith comply provisions I with such virions or this permit shall be
l S j rimmed revoked. BUILDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE a
M Iherebyaffirm that there is a construction lendlngagenry for the perform : ELECTRIC FEE
7O ana of the work for which this perMtV ,�,ed(Se:.30Y/,Civ.C.) TOTAL
U lender.N.me I n PLUMBING FEE• _
LL E- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
+ O W cormot.I hgrmnvc comply
tithally county
untc ordinances
rdina cess and
laws
rngto .grato complywo,andheredcothouto representatives
statelawsPERMmsavANCE FGES AI
} N relating to build Ing construction,and hereby authortu reprosentativns olthis - /// V
(— Z s city to enter upon the above-mentioned property Wpectlon purposes. ALTERORADD'IDMECIL Da
(We)agree to save,indemnify an d keep harmlethe City of Cupertino e Receipt#
V agalnat llabllltles,jtdgment.co.taand expenses which rtu
SUBTOTAL:
In any way accrue AIREUNDLINC UN9T 8010,000 CtM)
against.urt City In consequence of the granting of thls pe +it AIR HANDLING UMT(OVER I0,000CFM) CONSTRUCTION TAX -
�> /T 4%TION TAX Y
Signalureof Ap Ilcant/Contractor to EXHAUST I IOOD(W/DUCT) (oO
HAZARDOUS MA
It UISCLOS E
Will thcappllcant orfuture Wildingo¢upant store or handle hazardous HEATING UNIT(TO IOD,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Iiee
O Yand Safely Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)No TOTAL•
Will the applia or or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardam air contaminants as deilned by the Bay Area Nr
jpuality Management District? BOILFR-COMP DIM OR IM"BTU)
Ya ❑No
have read the 0.a materials requirement,under Chapter G95 of BOILER-COMP(OVER 100,000 BN) FEB 1 ,4 �CT�1
the CIfornla Health k Safety Code,Sections 25505,25573 and 2553/, I rE L s7 1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibilityto notifytheoccupant ofthe requirementswhich mustherrict pt f0cmpancy.
priorloLssua fa CcrUicateo {/ "\'�
�(a
Owner cera tis dagent '1 ate — ISSUED BY:
1ErE TOTAL:
OFFICE COPY
APPLIC4NTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
766 k'/ /zoo Lr. Lo- 36h 21722
name: V... ane. A _ A A
CITY OF CUPERTINO-BUILDING DIVISION
TE
AM t ora am LI. ' APPLICATION /PERMIT �� - 91
I BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
t
Ent r, r. r l
TY ELECTRIC PERMiT FEE BUILDING PERMIT INFO
Addres. - - -
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am ilcevedunder pmvlalonsof Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DFSLWI ON
'ngwith Scction7000)of Divlslon3 oftl(ell slnesand PlofesslonsCode,andry
LkersClass license I,In 11 in dLd�e1R= 3 r� PANELS w
Date Contractor (� rJu) L
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�uu 2 I understand my plans shall be used as public rend. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT,
00
q Z E Licensed Professional - SIGNS ELECTRICAL
I'<<w Fn OWNER-BUILDER DECLARATION
n / Ihertby afOrm that lam exempt from the Cctor'.
ontraLicenseSPFGIALCIRCUIT/MLSCnse Law for the l
'0O(..,_'� following resson.(Semon 7m15,Bminex and Pmfeslon.Code:Any city or - I/// "�
OZE.� 7 V
u,p nlywhich requlrnapermltroconsWR,altcr,lmprove, mn
delbh,orrcpair TEMP.ME=OR POLE INST. _
�j'ci muanystructuprior to Its unce,slen requlreatheappllant for such permtto LOWER DEVICES
( fire Wa
le a signed statement that he oi licensed pursuant to the provisions of the
3Mil Uµ'u Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMINGIDOLELECCWC-
v,�OsO
sion3oftheBusinnss and ProessioruCode)orthat he b exempt thercfromaM VALUATION ti the W s6 for the alleged exemption. Any violation of Section 7071.5 by any OUTLETSSWITCI-IF_SFTXTURFS
Q applicant fora permit.ubjects the applicant to a dull penalty of nit rtnre than
a. mC"u flue hum md s owner
(epos NEWRFSID=ALELDCTR SQ.FT. STORIES TYI'ECONSTRUCTION
❑I,as owner of the property,or my employees with wages r their sole
compensation,Burners w•ark,and thes Code:TVnot Intended oroffered for
5gO salepec. pply toalnosandfmissions Code:The Contractors theemeIaw
does not applytoan owner o(property hhiswho
nempiym,prothercoRand - OCC.GROUP, RES UNTI5
E: whodaessuchwohhlmseUorthvugh hisownemplgecs,provided that such
Improvement am nit Intended orof(emd formte.If,however thebullding or TOTAL:
Improvement bsold withinonehrearofcomplMiom theowner-bulWerwill have
tis,e*rden of proving that he did not Wild or improve for purpose of sate.). QTY. PLUMBING PERMIT FF_EFLOOD ZONE APN
IJ L as owner of the Property,am exclusively contracting with Itansed pp Tp IS6UANCE
contractors to construct the project(Sec.7011,Bushes and Professions Code:
The Contender.License law docs not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds of Improves theeon,and who contracts for such ploject.with a FEE SUMMARY
eactor00 aw
licensed pursuant to the Contractor's License L . BACK FIAWPROTCCT.DEVICE
5pNf1 am exempt under Sec. B k P C for this mason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N�
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PERTRAP $CA{DOL TAX Y_vN
01 hereby affirm that I have a¢rtlffeate of consent to self-tesue,or a RMIEI T N
¢rtiflcab CJ S F.A.teof Worken'Compensatimimuran¢ora¢rtifiMcopyther f(Sec'
3900,LaGASYSTEM-1 INCA DUILEI$ PARK FEE Y_ N
Porky N RECEIPT N
GAS.E.A.SYSTEM-OVER 4(FA)
Com any r / "�/ GBUILDING DIVISION FE ES
Certl/led copy b hereby furnished. GR[ASE/INDUSI?tL WASTE INTFRCEPTUR PLANCHECK FEE
Certified copy is filed with the city Inspection division.
CERTIFICATE OF FXEMI4ION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
ffhissectlon need no be completed lthe permit b(orone hundred dollars SEWFR-SANITARY-STORM E.A.200FT. Date RCOCI t#
R1W)ofy that
WATER HEATER W/VENT/E3,FGTR ENERGYFEE Y N
rectify IIn the performance the work(orwhlch thispermit is Issued, -
I shall not employ any person In any manner so ss to became subject to the WA71R SYSTEM/TREATING
Workcrs'Compcnsation Laws o(GII(ornla.Date PAID
licant
Z Z NOTICE TO APPLICANT:ILafter making this Certificate of Eaampik, you NEW RESIDENTIAL PLMB. SQAT. Date Recei t#
O should become.ubjeet to the worker:Compensation provisions of the Labor TOTAL:
~ y code, ou=at forthwith comply provisions I with such virions or this permit shall be
l S j rimmed revoked. BUILDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE a
M Iherebyaffirm that there is a construction lendlngagenry for the perform : ELECTRIC FEE
7O ana of the work for which this perMtV ,�,ed(Se:.30Y/,Civ.C.) TOTAL
U lender.N.me I n PLUMBING FEE• _
LL E- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
+ O W cormot.I hgrmnvc comply
tithally county
untc ordinances
rdina cess and
laws
rngto .grato complywo,andheredcothouto representatives
statelawsPERMmsavANCE FGES AI
} N relating to build Ing construction,and hereby authortu reprosentativns olthis - /// V
(— Z s city to enter upon the above-mentioned property Wpectlon purposes. ALTERORADD'IDMECIL Da
(We)agree to save,indemnify an d keep harmlethe City of Cupertino e Receipt#
V agalnat llabllltles,jtdgment.co.taand expenses which rtu
SUBTOTAL:
In any way accrue AIREUNDLINC UN9T 8010,000 CtM)
against.urt City In consequence of the granting of thls pe +it AIR HANDLING UMT(OVER I0,000CFM) CONSTRUCTION TAX -
�> /T 4%TION TAX Y
Signalureof Ap Ilcant/Contractor to EXHAUST I IOOD(W/DUCT) (oO
HAZARDOUS MA
It UISCLOS E
Will thcappllcant orfuture Wildingo¢upant store or handle hazardous HEATING UNIT(TO IOD,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Iiee
O Yand Safely Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)No TOTAL•
Will the applia or or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardam air contaminants as deilned by the Bay Area Nr
jpuality Management District? BOILFR-COMP DIM OR IM"BTU)
Ya ❑No
have read the 0.a materials requirement,under Chapter G95 of BOILER-COMP(OVER 100,000 BN) FEB 1 ,4 �CT�1
the CIfornla Health k Safety Code,Sections 25505,25573 and 2553/, I rE L s7 1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibilityto notifytheoccupant ofthe requirementswhich mustherrict pt f0cmpancy.
priorloLssua fa CcrUicateo {/ "\'�
�(a
Owner cera tis dagent '1 ate — ISSUED BY:
1ErE TOTAL:
OFFICE COPY