99090015 iIPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY OD
CITY DI CUPVISION PUHA NG-MECHANICA iRMITN
BUILDING DIVISION APPLICATION/PERMIT PLUMPING M1IRCHANDIL
'�J BUILDING PR(IJR(:T IUEN'1'Ih'll'ATION
�RUILDINGADDRESS: SSANITARY NO. APPLICATION SUBMI ITAL DA'11
O � l PO�4 L w4lA,o C•4 • oWNPf)
]UNTRAQI'(312'S M46
C� LIC N ',
6� LIC
J NIC CON'1'ROLp
RCHITECDENGINPER: LIC NO: ADDRESS: ❑
CON'1'AC'1': PHONE: DUILDING PERMIT INFO
0of.j S C_A I 1 ❑ Consultant Feet Paid by Applicant(Initial) BLDG ELECT P MB NIECH
3SYf-�6r6 ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION Cry FLECTRIC PERMIT FEE
1 hereby afnrnn that 1 am licensed under pro-ons of chapter 9(commencing JOA DESCRIPTION
woo with Sation]OOly of Uivision3ofNC Businox and Pwdersianx Cade.anA my liens i. PERMIT ISSUANCE R -ID _NTIA
FSB in full force and effect. ❑SFTOWL ❑KITCHEN REMODEL
aUV License Class Cmur APPLIANCES-RBSIDF,NI'IAT, ❑AUDI'T'ION ❑PLUMBING RE-PIPE
tF�W Date Cantrocnlr
f-Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
ZOy? I understand my plana.hall bausedaspublic record• UP TO 2IXIAMPS MODIFICATION
OZ—� ❑INTERIOR ❑CHIMNEY REPAIR
Pa�nLW Licensed PodsWonul 201.10m)AMPS IMPROVEMENT []SWIMMING POOLS
5 Y 2_T UWNI!R-BUILDEB DECLARATION OVER]BRANDS •�89Tit REM0 ]REPAIR ❑DEMOLITION
CCG 1 hereby affirm that I am exempt from the Commcfors License hew far the /)
k 3 a U following mama(Section 903I.S,Business.M Profe..in .,Cmle Any city or enumY SIGNS ELECTRICAL ❑OTHER 1V ��
LL LL y which requires a pemnit to construct,alcor,improve.demolish,or repair any structure
Fii:aa promo iula,amar, lL ,vquirent heapplicmt lin such permh In file a signed statement SPECIAL CIRCUIT/MISC.
That he is licensed inarstrant it,the provisionsof in,Contractors License Le.(Crime,9
W=00 (commencing with Section 70013)tit Division ofthe Business and Professions CWe)ur TEMRME`fERORPOLEINSI'. OM
MERCIAL
a X K that he is exempt therefrom and the basis for the alleged exemption.Any violation of [IT
NEW BLDG/ADDIION El DEMOLITION
LL„ySafina 903 LS by tiny applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
El TENANT ❑FOODSERVICE
'SOfoul moor than five hundred dolhu.($500). IMPROVEMENT
etwo is tpar propcny.our my employee,with wegcs as 6,oale compensation, SWIMMING PHUT.ELECTRIC []OTHERF. ill do the work,and lMaaueure is not intcndedo,offered for sale(See TDW.Business
C 1,m and Professions Cale:The Committees m ES
mrs Lice law does mapply to an owner of OUTLETS
pmpeny who builds our improves thereon,and who docs such work porsuff or through
his own employees,provided thin such Improvanents aft not intended or ulTered lin NEW RT SIDIWI'I Al,ELEC I'R SQ FT
sale.If.however.the building or improvement is sold within one year of completion,"he
SQ.FT.FLOUR AREA 5/SQ.R
ncclasilder wil I have the burden of proving that he did not build in improve for pur-
pose of sola.).
[:j 1,ux ownv of the prnIst ane exclusively contracting with licensed cammcmrs at TOTAL
instruct the project(See.](94,Renfro,and Professions GNc:)TTe C0111mainu Lb
come,Law does not apply to an owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whurommets for such projects with a contractor(s)licensed pursuant o the Conhuctors
License law. I I PERMIT ISSUANCE
� Imm cxc t undr,S,c ,P&P C fadusrcn.on
ALI'FIT-DRAIN&VENT-WATER(EA) VALUATION
tic no.
WORKER'$COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 31, 000
I hereby uBi,a under penohy n[perjury one of the following declatutium:
I title and will nmintalna Cenificateol Consent to for Workcr'x Compen- DRAINS-FLOOR,ROOF.AREA,COND' STORIES I YET CONSI'RUCfION
saloon,as provided for by Section 37001 of the labor Code,for the performance of the
work for which This permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
370X1 of the labor Cale.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker,Cnmpen.mion Insurance conferand Policy numhr are:
Cartier: Polsvy GAS-FI.SYS'I151-OVGR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FiiES
('Iak,ec(mnueed nut be,oun ioeddhepemsit is foe one hundred dollars($100) GREASE TRAP
IPLANCIIIiCK FEE
or cl.)
I ccnify Nat in the perfornunceofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.20(1 FT.
R
not employ any person in any manner so as to become subject ,the Workers Charleroi- ENERGY FEE
Z s.fiu.laws of California.Date WAF17R HEATER WNENTIELECTR GRADING FEE
O Appicam
y NOTICE TO APPLICANT:If,alter posting this Cenifieale of Exemption,you should WA'1'BR SYSI'EM/TREATING
a >
become subject to the Worked Compensation provisions of the Labor Cede,you must SOILS FEF.
forthwith comply with such provisions or this permit shall W deemed pointed WATER SERVICE
G3z CONS'IRUCI'[ON LENDING AGI7NCY NEW TIES IDEN'IT AL PLM IL SQ.IT, PAID Plate Receipt
L)O 1 hereby affirm That here is a construction lending agency for the pi rlimmunce of
the work for which Thi,permit is issued(Sec.3097,Co.CJ
0 U Lenders Name TOTAL:
,r W Lcndcr's Address TOTAL:
0' 1 ccnify that I have mad this application and state ohm the ahoy information Is BUILDING FEE
F^ to cones,l agreem comply wall city and county ordinance and.me lewsrcloongto QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby urbanize representatives of this city to cater upon the SEISMIC LYE
almol-mcmionad property for Inspection parryrscs. PERMIT ISSUANCE
(We)ager to.ave,in lcnmify and keep harmless Ne City of Cupertino against ELECTRIC PEE
iabilities.judgmmnfs,costs and expenses which may in any way uecmcagain.a said City ALT ER OR ADD'IO MECH,
PLUMB I NG FEE
in consequence of the granting mf this pool
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,00i MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 111,003 CFM) CONS'I'RUCTION TAX
Signame of A,dwaMContralm Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA'T'ION FEE
HAZ RDOUS MATERIALS DISCLOSURE
Will the applicant or future building tucupanumre or handle harardnus material HEATING UNIT(TO 100,000 R'TU)
as dd'med by the Cupertino Municipal Code,Chapter 9.12,and the IToo and Safety
Codc.Section 25532(a)'I HEATING UNIT'(OVER 100.000 BTU)
❑lbs 0 N VENTILATION PAN(SINGLE RESID) PAID
Date Round X
Will the applicant or Ihmm building ostulwm use equipment(ir devices which
fit hemrdous air contaminants as defined by the Bay Arca Air Qualify Management BOILER—COMP(]IIP OR IfX1,INX1 B'Pl)) TOl'AI 2fox C
f.tricr! BOILER-COMP(OVER 100.000 BTU)
Cl yes 1-1 No
I have rend Nn homnlmfx m;uariuls arpflrcmcnP under Chapter 695 of the Cali- AIR CONDI9'IONL'R ISSUANCE DATE
forma Drama&Safety Calc,Sections 25505.25533 and 25534.1 mndeotund Ihat Bill, NEW ITUNDENI'IAL MECH. SQ.FT.
building does nm currently have a If that it is my resrymsibility To notify the acupont
of the mquimmens which must W met prior to issuance of a Certificate of Occupancy.
Owner tie amliorwil agent Dam 'TOTAL: ISSUED RYP,
OFFICE
iIPPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY OD
CITY DI CUPVISION PUHA NG-MECHANICA iRMITN
BUILDING DIVISION APPLICATION/PERMIT PLUMPING M1IRCHANDIL
'�J BUILDING PR(IJR(:T IUEN'1'Ih'll'ATION
�RUILDINGADDRESS: SSANITARY NO. APPLICATION SUBMI ITAL DA'11
O � l PO�4 L w4lA,o C•4 • oWNPf)
]UNTRAQI'(312'S M46
C� LIC N ',
6� LIC
J NIC CON'1'ROLp
RCHITECDENGINPER: LIC NO: ADDRESS: ❑
CON'1'AC'1': PHONE: DUILDING PERMIT INFO
0of.j S C_A I 1 ❑ Consultant Feet Paid by Applicant(Initial) BLDG ELECT P MB NIECH
3SYf-�6r6 ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION Cry FLECTRIC PERMIT FEE
1 hereby afnrnn that 1 am licensed under pro-ons of chapter 9(commencing JOA DESCRIPTION
woo with Sation]OOly of Uivision3ofNC Businox and Pwdersianx Cade.anA my liens i. PERMIT ISSUANCE R -ID _NTIA
FSB in full force and effect. ❑SFTOWL ❑KITCHEN REMODEL
aUV License Class Cmur APPLIANCES-RBSIDF,NI'IAT, ❑AUDI'T'ION ❑PLUMBING RE-PIPE
tF�W Date Cantrocnlr
f-Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
ZOy? I understand my plana.hall bausedaspublic record• UP TO 2IXIAMPS MODIFICATION
OZ—� ❑INTERIOR ❑CHIMNEY REPAIR
Pa�nLW Licensed PodsWonul 201.10m)AMPS IMPROVEMENT []SWIMMING POOLS
5 Y 2_T UWNI!R-BUILDEB DECLARATION OVER]BRANDS •�89Tit REM0 ]REPAIR ❑DEMOLITION
CCG 1 hereby affirm that I am exempt from the Commcfors License hew far the /)
k 3 a U following mama(Section 903I.S,Business.M Profe..in .,Cmle Any city or enumY SIGNS ELECTRICAL ❑OTHER 1V ��
LL LL y which requires a pemnit to construct,alcor,improve.demolish,or repair any structure
Fii:aa promo iula,amar, lL ,vquirent heapplicmt lin such permh In file a signed statement SPECIAL CIRCUIT/MISC.
That he is licensed inarstrant it,the provisionsof in,Contractors License Le.(Crime,9
W=00 (commencing with Section 70013)tit Division ofthe Business and Professions CWe)ur TEMRME`fERORPOLEINSI'. OM
MERCIAL
a X K that he is exempt therefrom and the basis for the alleged exemption.Any violation of [IT
NEW BLDG/ADDIION El DEMOLITION
LL„ySafina 903 LS by tiny applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
El TENANT ❑FOODSERVICE
'SOfoul moor than five hundred dolhu.($500). IMPROVEMENT
etwo is tpar propcny.our my employee,with wegcs as 6,oale compensation, SWIMMING PHUT.ELECTRIC []OTHERF. ill do the work,and lMaaueure is not intcndedo,offered for sale(See TDW.Business
C 1,m and Professions Cale:The Committees m ES
mrs Lice law does mapply to an owner of OUTLETS
pmpeny who builds our improves thereon,and who docs such work porsuff or through
his own employees,provided thin such Improvanents aft not intended or ulTered lin NEW RT SIDIWI'I Al,ELEC I'R SQ FT
sale.If.however.the building or improvement is sold within one year of completion,"he
SQ.FT.FLOUR AREA 5/SQ.R
ncclasilder wil I have the burden of proving that he did not build in improve for pur-
pose of sola.).
[:j 1,ux ownv of the prnIst ane exclusively contracting with licensed cammcmrs at TOTAL
instruct the project(See.](94,Renfro,and Professions GNc:)TTe C0111mainu Lb
come,Law does not apply to an owner of Property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
whurommets for such projects with a contractor(s)licensed pursuant o the Conhuctors
License law. I I PERMIT ISSUANCE
� Imm cxc t undr,S,c ,P&P C fadusrcn.on
ALI'FIT-DRAIN&VENT-WATER(EA) VALUATION
tic no.
WORKER'$COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 31, 000
I hereby uBi,a under penohy n[perjury one of the following declatutium:
I title and will nmintalna Cenificateol Consent to for Workcr'x Compen- DRAINS-FLOOR,ROOF.AREA,COND' STORIES I YET CONSI'RUCfION
saloon,as provided for by Section 37001 of the labor Code,for the performance of the
work for which This permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
370X1 of the labor Cale.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker,Cnmpen.mion Insurance conferand Policy numhr are:
Cartier: Polsvy GAS-FI.SYS'I151-OVGR4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FiiES
('Iak,ec(mnueed nut be,oun ioeddhepemsit is foe one hundred dollars($100) GREASE TRAP
IPLANCIIIiCK FEE
or cl.)
I ccnify Nat in the perfornunceofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.20(1 FT.
R
not employ any person in any manner so as to become subject ,the Workers Charleroi- ENERGY FEE
Z s.fiu.laws of California.Date WAF17R HEATER WNENTIELECTR GRADING FEE
O Appicam
y NOTICE TO APPLICANT:If,alter posting this Cenifieale of Exemption,you should WA'1'BR SYSI'EM/TREATING
a >
become subject to the Worked Compensation provisions of the Labor Cede,you must SOILS FEF.
forthwith comply with such provisions or this permit shall W deemed pointed WATER SERVICE
G3z CONS'IRUCI'[ON LENDING AGI7NCY NEW TIES IDEN'IT AL PLM IL SQ.IT, PAID Plate Receipt
L)O 1 hereby affirm That here is a construction lending agency for the pi rlimmunce of
the work for which Thi,permit is issued(Sec.3097,Co.CJ
0 U Lenders Name TOTAL:
,r W Lcndcr's Address TOTAL:
0' 1 ccnify that I have mad this application and state ohm the ahoy information Is BUILDING FEE
F^ to cones,l agreem comply wall city and county ordinance and.me lewsrcloongto QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby urbanize representatives of this city to cater upon the SEISMIC LYE
almol-mcmionad property for Inspection parryrscs. PERMIT ISSUANCE
(We)ager to.ave,in lcnmify and keep harmless Ne City of Cupertino against ELECTRIC PEE
iabilities.judgmmnfs,costs and expenses which may in any way uecmcagain.a said City ALT ER OR ADD'IO MECH,
PLUMB I NG FEE
in consequence of the granting mf this pool
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,00i MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 111,003 CFM) CONS'I'RUCTION TAX
Signame of A,dwaMContralm Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA'T'ION FEE
HAZ RDOUS MATERIALS DISCLOSURE
Will the applicant or future building tucupanumre or handle harardnus material HEATING UNIT(TO 100,000 R'TU)
as dd'med by the Cupertino Municipal Code,Chapter 9.12,and the IToo and Safety
Codc.Section 25532(a)'I HEATING UNIT'(OVER 100.000 BTU)
❑lbs 0 N VENTILATION PAN(SINGLE RESID) PAID
Date Round X
Will the applicant or Ihmm building ostulwm use equipment(ir devices which
fit hemrdous air contaminants as defined by the Bay Arca Air Qualify Management BOILER—COMP(]IIP OR IfX1,INX1 B'Pl)) TOl'AI 2fox C
f.tricr! BOILER-COMP(OVER 100.000 BTU)
Cl yes 1-1 No
I have rend Nn homnlmfx m;uariuls arpflrcmcnP under Chapter 695 of the Cali- AIR CONDI9'IONL'R ISSUANCE DATE
forma Drama&Safety Calc,Sections 25505.25533 and 25534.1 mndeotund Ihat Bill, NEW ITUNDENI'IAL MECH. SQ.FT.
building does nm currently have a If that it is my resrymsibility To notify the acupont
of the mquimmens which must W met prior to issuance of a Certificate of Occupancy.
Owner tie amliorwil agent Dam 'TOTAL: ISSUED RYP,
OFFICE