99120063 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'O
CITY OF CUPERTINO BUILDING.ELECTRICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL _.
BUILDING PROJECT IDE."IMCATION
BUILDING ADDRESS: SANITAR ICA S DATEi
y-+ A /C-
j2- 9- `J4
NER'5 NAM C: PHONE: ONTRACI'�R"NAME: LICNO-
_ NIC CONTROL))
,RCHITELT/IiNGINEER: LIC NO: D FSS: ❑
zl
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fern Paid by Applicant(Initial) BLDG ELECT PLUMB MEC114
❑ El J4
LICENSE I)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby M.that 1 eat licensed under vrevision,of chapter v(commencing JOB DESCRIPTION
DMZ with Section 7000)of Divisinn}ufthe Business and Prafesslmn C.de.and my license iS RESIDENTIAL'
I+IOp PERMIT ISSUANCE:
C a'F 71ul1 force and eRect .Gr/ I 2 ❑SFDWL ❑KITCHEN REMODEL
<UU it mej( .c Lica 'T7 / APPLIANCIS-RB.SIDENTIAL []ADDITION El PLUMBING RE-PIPE
aF 6 a Dam � Comrano OYI
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
F-D h PANELS MODIFICATION
Z O N Z 1 understand my plans shall be used as public records
OZ=M UP TO SW AMPS [I INTERIOR [I CHIMNEY REPAIR
F�E'W Licensed Paw.,anal 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER UECLARAI'[ON
OVER IIXX)AMYS El BATH REMUREPAIR ❑DEMOLITION
'Z 6 1 hereby allina that I oat csmm
npt from the Comemr'S License Law for the
X 3 a U following roast n.(Suction]0)1.5.Ban ma,and Prob,,,ions C do Any city or county SIGNS ELECTRICAL ❑0TH R
ad ¢h wh'mh requires n))email to construct,altar,improve,demolikh,or repair any structure
06 pro, "mancerikon,ilanc,Im aip,fi,waI hpc r to file—,ardfaletacm
SPECIAL CIRCIIITIMISC.
Oct be d1hao,and to the p the Contractor',License Law'(Clapter9
a d� (mnnmcmu nb w.11,Scrii 7(XX))tl Division 3tfthv B-am, nd Prefc.v t .-Cafe)., TEMP.MISI'HR OR POLE INS'I'. COMMERCIAL,
a q o a Ihat he is exempt therefrom.,,it the basis for the:flcycJ cxmnptimt.Any violation of JEINEW BLDG/ADDITION ❑DEMOLITION
W Section 9031.5 by any applivnnt for a permits.hjcc,,the applican to u civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE.
N nl more than live bundmd dollmc(851X)),
FZN '00OTHERIMPROVEMENT
0 L.ffic or.aftbapmpenyor MentploycedoitM1 eedfostheiRec.compensation, SWIMMING I'001,ELECTRIC
willdmMw.rk,endthe strvcwreisnot intcndcd caroffucJ for or apply it)
Business OTHER
a 3 w and Pmfcssions Cade:'Nc Cowovoor's License Law does nm apply ea an owner of OUTLErS-SN'ITCIIIiS-PI%TURIiS
proWiry who builds or improves Thema,anti who does such work himself or through
his own employees,provided but such impmvemems art not intended or offend for NEW RESIDENTIAL.ELECI R SQ Ff.
sale.If,throes,the building or improvement is sold within one year ofcompletionJM1c SQ.FT.FLOOR AREA S/SQ.II'.
er-builder will have the burden of proving that he did not hui1J or improve for pur-
praa of,air.).
n I,as owner of the pmprwy am exclusively contracting with licensed cnnoacmrs to 'I"GTAL:
construct the project(Sec.7(44E nosiness and Vmfic,ai ns Code:)The Contractor's ven,, QTY, PLUMBING PERMIT FEE
who commcu for such prajecu with a conowbals)licensed purrountto the Contractors
Liccme Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WATER(G) VALUATION
net °j1C2oD0
WORKERS COMPENSATION DECLARATION BACK FLOW PR[HF.CT.DEVICE
1 hemby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificam of Consent to off insum fur Wmke(s Compen- DRAINS-FLOOR.ROOF AREA,CONED. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is iaucJ. FIXTURES-PER TRAP
I have and will maintain Worker's Compensati.n]a....me.as required by Section
l]Wofthe Labor Core,lin the performance of the work fur wbichthie permit is iswed. GAS-EA.SYSTEM-I INC.4 DUE LERS OCC.GROUP /r1eIPNN
My Weaker C" tic tion Imo Ice currier and Policy f:,��{�[t (C7
Carver: �L f aU = Policy Nrv:^ K6-4DO5z GAS-EA.SYSTEM-OVIiR 4(EA)
CER'1'IPICA'fli OI'F.XCMPTION PROM WORKERS' GREASEIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
('11n,cown need not bo complete([tithe fiction is Barone hundred dollars(SIW) GREASETRAP
or
less) PLANCHHCK FEE
I cenily that in the perfinamuce at the work for which this permit is i...ed,)shall SEWER-SANITARY-STORM PA.21X1 17'.
not mnploy any penon in any nmmner sit a%to he ontesubjeel to the Workers'Compen- ENERGY FEE
O z cation l.aws4liarni° D�ulc� WATER HEATER W/VENT/L'LECfR -
z � Applinlmy -^ GRADING PEE 11 r
I
NO'FICH TO APPLICAN"T:11,.fact ntakin6 thL Ccnllianc of Esenlptimt,you should WATER SYSTENUTREATINC,. I I '
F > becomenobject to the W..ker's Colnpc'usar r provisions of the Labe,Code,you muss
WATER SERVICE
SOILS FEE"
fSXfrthwllhennIDlywilhinns nrl�ispenmhshnll he deemed rev.ked. IV'
ac 9199
C'1'EON LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.P. pate Be
V CONSTRU
I herchyaffinn that fair is.ummmcll.nlendingagcncy lo, performance erfoance of
the work for which this permit ic'nuual Sec.3097.Civ.C.)
D.liC)
O V [,ad,(,Nome TAL'.
Lemera AJdrea TOTAL:
1 cenily that 1 have lead this application uad State that the alwve information is - tlU1LDING.FE..
F'N correct.l agree m comply with all city and county imbricates and state laws relating tr QTY. MECHANICAL PIiRMIT FEE
C.1sz building comouction.ond hcrcby authorize representatives of this city to im,ropon the SEISMIC FEE
- above-mentitimd property for inspection pm Was_ PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way rams against said City ALTERORADDTOMECFL PLUMBING FEE
in onscyueme of the granting of this .it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PORN' AIR HANDLING UNIT(TO IR000CPM) MECHANICAL FEE
SOUItCIi REGULATIONS. ///��k �-/r
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sigiona eof Appf.w/Cow.Ru L Date EXHAUST HOOD(W/DUM HOUSING MITIGATION FEE
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I W.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CMc.See ..25532m)! Asa HEATING UNIT(OVER 100.000 BTU)
VF.M'ILAI'[ON FAN(SINGLE BESIDE PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which
mit h...Nous air.....tmninomc as defined by the It.,Area Air Quality Management BOILER-COMP(3HP OR 100,000 RFU) TOTAL:
District° BOILER-COME(OVER 100,M)BTU)
El Yes ❑N.
1 have read the harvrdnux innwnals mounacntcats uodcr Chapter 11.95 of the Cal4 AIR CONDITIONER ISSUANCE DATE
fomio Hcamt&Scary C«Ic,Scclionn 25505,25533 card 25534.I ondercund thm'dtre NEW RESIDENTIAL MIiCH. SQ.Ie1'.
huilding Joe's not currently have;L Icoina,that it'w my respo...dairy In notify 0c ueeuplml /
0 tic e'ta Immix wlddlnlunlIse a."prism issuance of a Ctwu'rte"ED mupuncy.
Owner-ratio iz.cd ugcm Date 'TOI'AI: ISSUED BY: O
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'O
CITY OF CUPERTINO BUILDING.ELECTRICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL _.
BUILDING PROJECT IDE."IMCATION
BUILDING ADDRESS: SANITAR ICA S DATEi
y-+ A /C-
j2- 9- `J4
NER'5 NAM C: PHONE: ONTRACI'�R"NAME: LICNO-
_ NIC CONTROL))
,RCHITELT/IiNGINEER: LIC NO: D FSS: ❑
zl
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fern Paid by Applicant(Initial) BLDG ELECT PLUMB MEC114
❑ El J4
LICENSE I)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby M.that 1 eat licensed under vrevision,of chapter v(commencing JOB DESCRIPTION
DMZ with Section 7000)of Divisinn}ufthe Business and Prafesslmn C.de.and my license iS RESIDENTIAL'
I+IOp PERMIT ISSUANCE:
C a'F 71ul1 force and eRect .Gr/ I 2 ❑SFDWL ❑KITCHEN REMODEL
<UU it mej( .c Lica 'T7 / APPLIANCIS-RB.SIDENTIAL []ADDITION El PLUMBING RE-PIPE
aF 6 a Dam � Comrano OYI
ARCHITECTS DECLARATION El MULTI-UNIT ❑STRUCTURAL
F-D h PANELS MODIFICATION
Z O N Z 1 understand my plans shall be used as public records
OZ=M UP TO SW AMPS [I INTERIOR [I CHIMNEY REPAIR
F�E'W Licensed Paw.,anal 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER UECLARAI'[ON
OVER IIXX)AMYS El BATH REMUREPAIR ❑DEMOLITION
'Z 6 1 hereby allina that I oat csmm
npt from the Comemr'S License Law for the
X 3 a U following roast n.(Suction]0)1.5.Ban ma,and Prob,,,ions C do Any city or county SIGNS ELECTRICAL ❑0TH R
ad ¢h wh'mh requires n))email to construct,altar,improve,demolikh,or repair any structure
06 pro, "mancerikon,ilanc,Im aip,fi,waI hpc r to file—,ardfaletacm
SPECIAL CIRCIIITIMISC.
Oct be d1hao,and to the p the Contractor',License Law'(Clapter9
a d� (mnnmcmu nb w.11,Scrii 7(XX))tl Division 3tfthv B-am, nd Prefc.v t .-Cafe)., TEMP.MISI'HR OR POLE INS'I'. COMMERCIAL,
a q o a Ihat he is exempt therefrom.,,it the basis for the:flcycJ cxmnptimt.Any violation of JEINEW BLDG/ADDITION ❑DEMOLITION
W Section 9031.5 by any applivnnt for a permits.hjcc,,the applican to u civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE.
N nl more than live bundmd dollmc(851X)),
FZN '00OTHERIMPROVEMENT
0 L.ffic or.aftbapmpenyor MentploycedoitM1 eedfostheiRec.compensation, SWIMMING I'001,ELECTRIC
willdmMw.rk,endthe strvcwreisnot intcndcd caroffucJ for or apply it)
Business OTHER
a 3 w and Pmfcssions Cade:'Nc Cowovoor's License Law does nm apply ea an owner of OUTLErS-SN'ITCIIIiS-PI%TURIiS
proWiry who builds or improves Thema,anti who does such work himself or through
his own employees,provided but such impmvemems art not intended or offend for NEW RESIDENTIAL.ELECI R SQ Ff.
sale.If,throes,the building or improvement is sold within one year ofcompletionJM1c SQ.FT.FLOOR AREA S/SQ.II'.
er-builder will have the burden of proving that he did not hui1J or improve for pur-
praa of,air.).
n I,as owner of the pmprwy am exclusively contracting with licensed cnnoacmrs to 'I"GTAL:
construct the project(Sec.7(44E nosiness and Vmfic,ai ns Code:)The Contractor's ven,, QTY, PLUMBING PERMIT FEE
who commcu for such prajecu with a conowbals)licensed purrountto the Contractors
Liccme Law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WATER(G) VALUATION
net °j1C2oD0
WORKERS COMPENSATION DECLARATION BACK FLOW PR[HF.CT.DEVICE
1 hemby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificam of Consent to off insum fur Wmke(s Compen- DRAINS-FLOOR.ROOF AREA,CONED. STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is iaucJ. FIXTURES-PER TRAP
I have and will maintain Worker's Compensati.n]a....me.as required by Section
l]Wofthe Labor Core,lin the performance of the work fur wbichthie permit is iswed. GAS-EA.SYSTEM-I INC.4 DUE LERS OCC.GROUP /r1eIPNN
My Weaker C" tic tion Imo Ice currier and Policy f:,��{�[t (C7
Carver: �L f aU = Policy Nrv:^ K6-4DO5z GAS-EA.SYSTEM-OVIiR 4(EA)
CER'1'IPICA'fli OI'F.XCMPTION PROM WORKERS' GREASEIINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
('11n,cown need not bo complete([tithe fiction is Barone hundred dollars(SIW) GREASETRAP
or
less) PLANCHHCK FEE
I cenily that in the perfinamuce at the work for which this permit is i...ed,)shall SEWER-SANITARY-STORM PA.21X1 17'.
not mnploy any penon in any nmmner sit a%to he ontesubjeel to the Workers'Compen- ENERGY FEE
O z cation l.aws4liarni° D�ulc� WATER HEATER W/VENT/L'LECfR -
z � Applinlmy -^ GRADING PEE 11 r
I
NO'FICH TO APPLICAN"T:11,.fact ntakin6 thL Ccnllianc of Esenlptimt,you should WATER SYSTENUTREATINC,. I I '
F > becomenobject to the W..ker's Colnpc'usar r provisions of the Labe,Code,you muss
WATER SERVICE
SOILS FEE"
fSXfrthwllhennIDlywilhinns nrl�ispenmhshnll he deemed rev.ked. IV'
ac 9199
C'1'EON LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.P. pate Be
V CONSTRU
I herchyaffinn that fair is.ummmcll.nlendingagcncy lo, performance erfoance of
the work for which this permit ic'nuual Sec.3097.Civ.C.)
D.liC)
O V [,ad,(,Nome TAL'.
Lemera AJdrea TOTAL:
1 cenily that 1 have lead this application uad State that the alwve information is - tlU1LDING.FE..
F'N correct.l agree m comply with all city and county imbricates and state laws relating tr QTY. MECHANICAL PIiRMIT FEE
C.1sz building comouction.ond hcrcby authorize representatives of this city to im,ropon the SEISMIC FEE
- above-mentitimd property for inspection pm Was_ PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way rams against said City ALTERORADDTOMECFL PLUMBING FEE
in onscyueme of the granting of this .it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PORN' AIR HANDLING UNIT(TO IR000CPM) MECHANICAL FEE
SOUItCIi REGULATIONS. ///��k �-/r
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Sigiona eof Appf.w/Cow.Ru L Date EXHAUST HOOD(W/DUM HOUSING MITIGATION FEE
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I W.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
CMc.See ..25532m)! Asa HEATING UNIT(OVER 100.000 BTU)
VF.M'ILAI'[ON FAN(SINGLE BESIDE PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which
mit h...Nous air.....tmninomc as defined by the It.,Area Air Quality Management BOILER-COMP(3HP OR 100,000 RFU) TOTAL:
District^ BOILER-COME(OVER 100,M)BTU)
El Yes ❑N.
1 have read the harvrdnux innwnals mounacntcats uodcr Chapter 11.95 of the Cal4 AIR CONDITIONER ISSUANCE DATE
fomio Hcamt&Scary C«Ic,Scclionn 25505,25533 card 25534.I ondercund thm'dtre NEW RESIDENTIAL MIiCH. SQ.Ie1'.
huilding Joe's not currently have;L Icoina,that it'w my respo...dairy In notify 0c ueeuplml /
0 tic e'ta Immix wlddlnlunlIse a."prism issuance of a Ctwu'rte"ED mupuncy.
Owner-ratio iz.cd ugcm Date 'TOI'AI: ISSUED BY: O
OFFICE