19651 APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES — USE BALLPOINT PEN ONLY
+•) B.Ildin Project ldeml(ir.thm PIEWTNO.
BuRdn&Addm... 19651 ,
l e Fi6Z STI
nerame - Phone: APPLICA FION suilgrITTA-r=
G{-F • CITY OF CUPERTINOIBUILDINC DIVISION'
N _ Lia No: ' APPLICATION I PERMIT
s t
It / neer. BULDINGELECTRICALPLUMBING-MECHAMCAL CA'MCORY CONTROL N
Br
t'
QTY - IBUILPING PERMIT INFO' '
,;�;ELECTR[Q,PERMIT s FEE . - - -
Address: PERMUISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB DFSCRB'TION
Ing with Section 7000).1Divislon 3.(the Busmen and Prefevluns Code,.ed my - - '
license is in full(...ad dfect. PANELS -
CULk.
Date
N
Date Contractor
ARCHITECTS DECLARATION y 2014000 AMPS
�CX Iunderstand my plans shall be used as public record.. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ;FT.
EZu Licensed Prdemi°ral SICNS ELECTRICAL -
fn`¢ OWNER-BUILDER DECLARATION 51'ECIALCIRCUT/M -
I herebyafOren that l am exempt fmm the Contractor's License law for the
qq following reason.(Section 70715,Buslnev and Pmfevions Code:An tl or
FF'q county which requtre.a permit reconstruct,alter,knprove,demolish,mrepalr TIMP.METIROR PO LE NST.
P'4 ❑❑ anystructum prior to Its Issuance, requimsthe applicant forsuch permit t° [OWER DEVICES
C0.s file a signed statement that he Is Ilmosed pursuant to the provisions of the
3 u,y Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOLE ECTRI
IE
ppHO skm3.fthe Business and Profevl.ra Code)orthat he d exempt therefromand VALUATION
I:1 6 5 the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWfTCt{FS F5
[�
applicant fora permit subject.the applicant to a civil penalty of net morethan
^� live hundred demo.(g500). NEW RESIDENTIAL ECTR SQ.FT, STORIES TYPECONSTRL'CTION
�}•9.7< ❑I,as owner of the property,or my employees with wages r thele sole
compensation,willdo Businethewarkandthes Code:Thcre C.nended License d for
Law
�p vie(See.201d,Business ami Professions Code:The Contractor.License Law
$� doe.not apply to on ownerrdproperty who build.orimprws.therm,and OCC,GROUP RES.UNITS
who does such work himself ortheaugh his own employees,provided that such
Improvements are not Intended muttered for sale,Ifhowever,thebulkhrigw TOTAL:
Improvement issold within one year ofcompletion,the owner-builderwlll have '
t Nen of proving that he did nm build or improve for purpose°fials.). Qpg PLUMBING PERMIT `,FEE FLOOD ZONE APN
L as owner a the property,am exclusively Business
cosin.....g with licensed PQ{MITISSUANCE (ix�
The Contractor's
to construes the project(Sec.apply
Busmen and Prolene.Code:
The C.or Improves
License law doe.nm apply to f owner d property who ALTER-DRAIN&VENT-WATER(EA) -
bullde t r Improves thereon, and who rontram for sech w. with a
➢.t.[actor(.exemptt under ant to the Contractor's License Law. t' "s ',`,FEE SUMMARY' '
LII am exempt under Sea e&P C for<hie reason BACK FLOW PROTECT.DEVICE
1-ulTelfle 1-1;1;%
DRAINS FLOG ROOF, SANITARY Y N
. Owner Date R REA,'COND. RECEIPT
WORKMAN COMPENSATION DECLARATION FD•(UgpS,PER TRAP SCHOOLTAX Y_ N_
❑I hereby affkm that I have o lesu ate.f consent to rpythsurc,ora RECEIPT N
certificate of Warken'Compeoeatl.nlvurance ora certified ropy thereof(Sea GAS EA. EM-1 OUTLETS
3800,lab C.) ['ARK FEE Y N
Co.PolGAS EA.SYSTEM.OVER 4(EA), - — RI)CPPp
BUILDING DIVISION FEES
copy b herebyfurnished.the city
- GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy bfiled with the city lmpedl.n divltlon. _
CERTIFICATE OF EXEMPTION FROM WORKERS' CRFASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARY STORM EA 20077' .Date Recei
(fhiesectl.n need nm fx completed if the permiHe(.eons hundred dollars - pt#
($laa)wkn.) - WATERREATIt w/VFNT/ELECTR ENERGY,FEE Y- N
I certify that In the peers..Icemthe work an as t beemesenn,Hkatlssuee
7 shall not emPl y person In y na'. eo u to become ub' o the WAM SYSTEM/TREATING ZIOO PAID
Worker.'Co L. oj��p(ifomla. Date ---(�—
O Z NOT[Applicant C.(J'� [� NEW RESIDENTIAL PINE. $QFT, Daft RCCCI tic
Z O NOTI{',Fv7l3AP CANT.11, Ner ma 1 i.Certificate of Exemption,you
Hshod become subject to the Workers'Claffiperesation provisions of the Labor TOTAL:
Ln Code,you must forthwith comply with.uch proved..mthb pamd,hall be
W j deemed rev.ked. BUILDING FEE
W
G CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Z Ihcrebyaffirm that them is a construction lendingagency,for the perform-
ance
TOTAL: (KJ•� ELECTRIC FEE
- ofthe work for which this permit is Ltmed(Sec.3097,Civ.C.) + r_
U O lender.Name PLUMBING FEE
IL Hlender's Address QTY. MECHANICAL•PERMIT!,•,. FEE' MECHANICAL FEE
O W Is correct.l artlfythat l have read thisapp0ationandaatethatthe above information
1 I agree to comply with all city and county ordinances and state laws PERMUISSUANCE FEES PAID:
} N mining to building construction,and hereby authorize representatives.fthl.
city to enter upon the above.menti.ned property for inspection purposes. ALTMORADDTOMECH.
_ (We)agree to ave,Indemnify an d keep harmless the City of Cu pertmo Date Receipt# -
against liabilities,pdgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
agamste it In ronaequen the granting of this pe t. -
MR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
o pp a t1c. a .r rDafa I EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS M IALS DISCLOSURE '
Willthe applicant or future building occupant store.rhandle hazardous HEATING UMT(TO 100,000 BTU) Date RCCeI IM
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the' -
Ilealthand Safety Code+.in
25532(a)7 - hILATING UMT(OVPR 100,000 BTU) - TOTAL: •�E
I ❑Yea iu No
Will the appllmnt or future building occupant use equipment or devices VENTILATION PAN(SINGLERESID) ISSUANCEDATE
which emit haze ens District?
manta as de0ned by the Bry Arca Alr
Quality Management Dbtdct7 RO[LFR-COMP OFB'OR l00,IX10 BTU) ,t„ -
4 Ycs 9 No .#
have read the haze ous materials requirements under Chapter 6.95 of BOR.CR-C'OMP(OVER 100,ODOBTU) J
the Celifemla Health&Safety Code,Sections 2555,25533 and 25534. I • - .
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - 'Q.I'T. :,cit, Ap nrfw�
responsibility to notify the occupant of the requirements which must be met 7{1t1
pri.rlolasuan..f.CeAlflate.f Occupancy. ,
LJ
^�^ �U
-
Ow � sf,,� `lJ
Owner or authorized agent Date TOTAL: ISSUED BY: r'T'N h zed..) f1G•G�'
OFFICE COPY
-- r
APPLICANT TO FILL IN INFORMATION,WITHIN RED LINES — USE BALLPOINT PEN ONLY
+•) B.Ildin Project ldeml(ir.thm PIEWTNO.
BuRdn&Addm... 19651 ,
l e Fi6Z STI
nerame - Phone: APPLICA FION suilgrITTA-r=
G{-F • CITY OF CUPERTINOIBUILDINC DIVISION'
N _ Lia No: ' APPLICATION I PERMIT
s t
It / neer. BULDINGELECTRICALPLUMBING-MECHAMCAL CA'MCORY CONTROL N
Br
t'
QTY - IBUILPING PERMIT INFO' '
,;�;ELECTR[Q,PERMIT s FEE . - - -
Address: PERMUISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB DFSCRB'TION
Ing with Section 7000).1Divislon 3.(the Busmen and Prefevluns Code,.ed my - - '
license is in full(...ad dfect. PANELS -
CULk.
Date
N
Date Contractor
ARCHITECTS DECLARATION y 2014000 AMPS
�CX Iunderstand my plans shall be used as public record.. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ;FT.
EZu Licensed Prdemi°ral SICNS ELECTRICAL -
fn`¢ OWNER-BUILDER DECLARATION 51'ECIALCIRCUT/M -
I herebyafOren that l am exempt fmm the Contractor's License law for the
qq following reason.(Section 70715,Buslnev and Pmfevions Code:An tl or
FF'q county which requtre.a permit reconstruct,alter,knprove,demolish,mrepalr TIMP.METIROR PO LE NST.
P'4 ❑❑ anystructum prior to Its Issuance, requimsthe applicant forsuch permit t° [OWER DEVICES
C0.s file a signed statement that he Is Ilmosed pursuant to the provisions of the
3 u,y Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOLE ECTRI
IE
ppHO skm3.fthe Business and Profevl.ra Code)orthat he d exempt therefromand VALUATION
I:1 6 5 the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWfTCt{FS F5
[�
applicant fora permit subject.the applicant to a civil penalty of net morethan
^� live hundred demo.(g500). NEW RESIDENTIAL ECTR SQ.FT, STORIES TYPECONSTRL'CTION
�}•9.7< ❑I,as owner of the property,or my employees with wages r thele sole
compensation,willdo Businethewarkandthes Code:Thcre C.nended License d for
Law
�p vie(See.201d,Business ami Professions Code:The Contractor.License Law
$� doe.not apply to on ownerrdproperty who build.orimprws.therm,and OCC,GROUP RES.UNITS
who does such work himself ortheaugh his own employees,provided that such
Improvements are not Intended muttered for sale,Ifhowever,thebulkhrigw TOTAL:
Improvement issold within one year ofcompletion,the owner-builderwlll have '
t Nen of proving that he did nm build or improve for purpose°fials.). Qpg PLUMBING PERMIT `,FEE FLOOD ZONE APN
L as owner a the property,am exclusively Business
cosin.....g with licensed PQ{MITISSUANCE (ix�
The Contractor's
to construes the project(Sec.apply
Busmen and Prolene.Code:
The C.or Improves
License law doe.nm apply to f owner d property who ALTER-DRAIN&VENT-WATER(EA) -
bullde t r Improves thereon, and who rontram for sech w. with a
➢.t.[actor(.exemptt under ant to the Contractor's License Law. t' "s ',`,FEE SUMMARY' '
LII am exempt under Sea e&P C for<hie reason BACK FLOW PROTECT.DEVICE
1-ulTelfle 1-1;1;%
DRAINS FLOG ROOF, SANITARY Y N
. Owner Date R REA,'COND. RECEIPT
WORKMAN COMPENSATION DECLARATION FD•(UgpS,PER TRAP SCHOOLTAX Y_ N_
❑I hereby affkm that I have o lesu ate.f consent to rpythsurc,ora RECEIPT N
certificate of Warken'Compeoeatl.nlvurance ora certified ropy thereof(Sea GAS EA. EM-1 OUTLETS
3800,lab C.) ['ARK FEE Y N
Co.PolGAS EA.SYSTEM.OVER 4(EA), - — RI)CPPp
BUILDING DIVISION FEES
copy b herebyfurnished.the city
- GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy bfiled with the city lmpedl.n divltlon. _
CERTIFICATE OF EXEMPTION FROM WORKERS' CRFASETRAP PAID
COMPENSATION INSURANCE SEWERSANITARY STORM EA 20077' .Date Recei
(fhiesectl.n need nm fx completed if the permiHe(.eons hundred dollars - pt#
($laa)wkn.) - WATERREATIt w/VFNT/ELECTR ENERGY,FEE Y- N
I certify that In the peers..Icemthe work an as t beemesenn,Hkatlssuee
7 shall not emPl y person In y na'. eo u to become ub' o the WAM SYSTEM/TREATING ZIOO PAID
Workers'Co L. oj��p(ifomla. Date ---(�—
O Z NOT[Applicant C.(J'� [� NEW RESIDENTIAL PINE. $QFT, Daft RCCCI tic
Z O NOTI{',Fv7l3AP CANT.11, Ner ma 1 i.Certificate of Exemption,you
Hshod become subject to the Workers'Claffiperesation provisions of the Labor TOTAL:
Ln Code,you must forthwith comply with.uch proved..mthb pamd,hall be
W j deemed rev.ked. BUILDING FEE
W
G CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Z Ihcrebyaffirm that them is a construction lendingagency,for the perform-
ance
TOTAL: (KJ•� ELECTRIC FEE
- ofthe work for which this permit is Ltmed(Sec.3097,Civ.C.) + r_
U O lender.Name PLUMBING FEE
IL Hlender's Address QTY. MECHANICAL•PERMIT!,•,. FEE' MECHANICAL FEE
O W Is correct.l artlfythat l have read thisapp0ationandaatethatthe above information
1 I agree to comply with all city and county ordinances and state laws PERMUISSUANCE FEES PAID:
} N mining to building construction,and hereby authorize representatives.fthl.
city to enter upon the above.menti.ned property for inspection purposes. ALTMORADDTOMECH.
_ (We)agree to ave,Indemnify an d keep harmless the City of Cu pertmo Date Receipt# -
against liabilities,pdgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
agamste it In ronaequen the granting of this pe t. -
MR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
o pp a t1c. a .r rDafa I EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS M IALS DISCLOSURE '
Willthe applicant or future building occupant store.rhandle hazardous HEATING UMT(TO 100,000 BTU) Date RCCeI IM
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the' -
Ilealthand Safety Code+.in
25532(a)7 - hILATING UMT(OVPR 100,000 BTU) - TOTAL: •�E
I ❑Yea iu No
Will the appllmnt or future building occupant use equipment or devices VENTILATION PAN(SINGLERESID) ISSUANCEDATE
which emit haze ens District?
manta as de0ned by the Bry Asea Alr
Quality Management Dbtdct7 RO[LFR-COMP OFB'OR l00,IX10 BTU) ,t„ -
4 Ycs 9 No .#
have read the haze ous materials requirements under Chapter 6.95 of BOR.CR-C'OMP(OVER 100,ODOBTU) J
the Celifemla Health&Safety Code,Sections 2555,25533 and 25534. I • - .
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - 'Q.I'T. :,cit, Ap nrfw�
responsibility to notify the occupant of the requirements which must be met 7{1t1
pri.rlolasuanc.ma CeAlflate.f Occupancy. ,
LJ
^�^ �U
-
Ow � sf,,� `lJ
Owner or authorized agent Date TOTAL: ISSUED BY: r'T'N h zed..) f1G•G�'
OFFICE COPY
-- r