28896 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 2886
9
BUILDING DIVISION APPLICATIONAIERMIT PLUMRING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILODING l)7 SANITARY NO. APPLICADON SUBMITTAL DATE
OWNAME: PHONHCON'UN -LICNO: UC
O OAdak A ,WA VI a/ p
2CHUECT/F.NGINEER: LIC NO. ADDRESS: ��/ ❑
VV S i�I4�✓�f? r-/T.leo-
CONTACT: PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED COMRACTOR:S DECLARATION QTY. ELECTRIC PERMIT TEE
I heachy affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ .1thSectio11701g0of Division3ofihelIusinessand Professions Code,andralicense is
0p ..full force and eft y PERMIT ISSUANCE RR NIFRRRFNTIA�
a-U Licensee - 0 I ick Llrt� ❑SFDWL ❑KITCHEN REMODEL
fit
p Cnnwcmr APPLIANCES-RP_SIDENT1AL []ADDITION ❑PLUMBING RE-PIPE
to ARCHITECT'S DECLARATION PANELS STRUM URAL
I.,Ovai ❑MULTI-UNIT ❑MODIFIICATIO
Z O y T, I understand my pions shall be coved os public recoNs ' ,MODIFICATION
O Z I1PT0 200 AMPS
F4��O ❑IMPROVE ❑CHIMNISY REPAIR
Liceused Professional 201-1000 AMPS IMPROVEMENT
p� OWNER-BUILDER DECLARATION OVER 1000AMPS
C Q I hereby affirm erste 1 ten esempt from the Cemractor's License Law for me El BATH REMODEIIREPAIR El DEMOLITION
11.0 a U following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
ul a.O F which.,.I.is Ixrmit to conservct,alcor,improve,demolish,or repair any suunure
q prior m its iswuce,also repnesthe applicant for such Aconin,file asii,ed.vtatemcnt SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant to the provisions of the Contractors license Low(Chapter Y
(commencing with Seelinn 7000)of Division 3ofehe Businessland Professions Code)or TEMP.METER OR POLE INST COMMFRCIAL-
G e C thin he is exemM therefrom end the basis for the alleged excmpdmu.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
,may Section 7031.5 by any applicant for v permit suhjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
E � not more than live hundred dollars ISoRn. IMPROVEMENT
❑1,as owner of me property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC /'s
will d.dm wmk,cad me mumure is roe imended.rnf(ered for sale fSecAo44.Business ❑OTHER
and Professions Code:The ControsonA License Law does not apply ,,an owner of OUTLETS-SWITCHES-FIXTURES
prop,ny who builds or in......c,tiler....,and who does such work notwif nr through
his own employees,provided Nal such improvements arc not intended or offered for NEW RESIDENTIAL HLECTR SQ IW.
sale.If hawevecae building or impmvemenl is sold within one year ofcompledondhe SQ.PF FLOOR AREA &SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pos..fsale.).' T n
Las owner of the property,am aclusively contract,with licensed contractors to
convect the project(Sec.7014,Bus and Professions Cale:)The Contmnors Li-
cense Law does not apply toanowner ofproperty who buitRorimproves thereon,suit QTY, PLUMBING PERMIT FEE
who contracts for such projects with a coo melons)licensed pursuant to the Contractor's
License have. PERMIT ISSUANCE
❑lamexempeunder Sec. ,B&PCfordukreawn
Owner Date ALIE R-DRAIN&VE WATER TEA) A'VALUATION,
WORKER'S COMPENSATION DECLARATION NACK PLOW TROT.C'1'.DEVICE
1 hereby affirm under Penalty of perjury one of me following declarations
❑I have and will maintain a CeNfcute ofConsent to self-insure for Worker's Carl BRAINS-M ,ROOF,AREA,CO
wino,as provided for by Section 37W of the Lahr Cade,for the performance of th, ST �P CONSTRUCTION
work for which this permit is issued, LrXTU -"PER TRAP - CI�.I 9��
Fl I have and will maintain Worker's Compensation Insurance,as required by Section V UI- f
3700.E Ne Labor Cede,forth,perfmmanceoOhe work forwhirhthis permit is issued. GAS-EA.SYSTEM-I INCAOUTLEfS OCC.GROUP ss )) pPN
My Workers Compensation insurance carrier and policy anoher are: VL)
arra'. Policy No,; MS-EA.SYSTEM-OVER 4 MA)
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE ORE- SMNDUSTRL WASTE INTERCEPTOR
(This section neeJ not be completed if Ne permit is f.nmc hundred Jnllnrs($I p) BUILDING DIVISION FELLS
or less)- GREASB'I'RAP -
PLANCITfA]K TBP,
I.,im Nascathe performance of Ne work forty bjmto the Wrkent'ed,lsh II SEWER-SANT RY-S' MEA.
notemploy any personi m as to bcenme subjttu..the Wnrkrn'Compe - ENERGY FEE
0 ,Z saion Lawv..f _ WATER HRATF.R E LCrft
Z 0 Applicant - • GRADING FEE
rN. NOTICE TO APPLICANT If,after making Nis Cerdfcamof Exemption,you should WATER SYS
a become ailt a the Workers Compensation provisions of the Labor Cale,you most KIPWrl SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. W ;R S'R C t
Q
CONS'I'RUCT1(IN LENDING AGENCYF. LEN TA PL B. SQ.FC PAID
V Iherehyamrm thauhere iso amswction lending agency forth,perfommnce of Date Receipt#
Lts the work for which this permit is issued(Sec.3097,Civ.C.) .
0 U Lender's Nmne - TOTAL:
Lender's ess Addr 'fUTAL:
y 1 certify that I have read this application and stain that the above infomation is BUILDING FEE
0 court l agree to comply with all city and county ordinances and state laws reining to Q MECH ICALPERMIT FEE
V 4 building convection,and hereby authorize representatives al finicky to,enterupon the SEISMIC FEE '
unrest,mentioned property for inspection purlwses'm :RMIT ISgI CE
(We)agree to save,indemnify and keep homeless the City of Cupertino against ELECTRIC FEE
m
liuhilitics,judgments.cam and expcnus which not,many way neceegainst said City AL ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT ABR HANDLING UNIT(TO 10,0(0 CFM)
SOUR F. GilNS MECHANICAL FEE
r AIR HANDLING UNIT(OVER 10.000CRA)
STR
7/ CONUCf10N TA%
Slgnamm..l'Applaunt/Contracmr /hate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wills cit,licam.r future building.acupamumcor handle Inumilous are .] HEATING UNIT TIO 1100.000 BTU)
fin
as deed by the Cupertino Municipal Cale,Chaplet 9.12,and the Health and Safety
Code,Section 25532(x)'! HEATING I3NIT(ovER 00,000 BTU)
❑Yes FIN. VENTILATION FAN(SINGLE RQSID) PAID
Date Receipt#
mi
Will the applicant or antra building use equipments devices which BOILER-COMP CHP OR 100,000 BTU) _
et hazadnux air contaminants as Jefinaf by by the the pay Area Air Quality Management
L�uimments
- TOTAL:
cs ❑No BOILER-COMP LOVER IW,WO BTU)
e revel the hazardous cocoanuts reuircmcn¢under Charter 6.95 of,he Cali- AIR CONDITIONER4 P ISSUAN&Smay Gude,Sections 25505,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ.14.s not cunen ly have a tenant,that it is my mspomihility en notify the occupant
ments which must be east priorto issuance of a Certificate of Occapaney.thoruc d agent Date TOTAL: ISSUED BY.
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 2886
9
BUILDING DIVISION APPLICATIONAIERMIT PLUMRING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILODING l)7 SANITARY NO. APPLICADON SUBMITTAL DATE
OWNAME: PHONHCON'UN -LICNO: UC
O OAdak A ,WA VI a/ p
2CHUECT/F.NGINEER: LIC NO. ADDRESS: ��/ ❑
VV S i�I4�✓�f? r-/T.leo-
CONTACT: PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED COMRACTOR:S DECLARATION QTY. ELECTRIC PERMIT TEE
I heachy affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
aZ .1thSectio11701g0of Division3ofihelIusinessand Professions Code,andralicense is
0p ..full force and eft y PERMIT ISSUANCE RR NIFRRRFNTIA�
a-U Licensee - 0 I ick Llrt� ❑SFDWL ❑KITCHEN REMODEL
fit
p Cnnwcmr APPLIANCES-RP_SIDENT1AL []ADDITION ❑PLUMBING RE-PIPE
to ARCHITECT'S DECLARATION PANELS STRUM URAL
I.,Ovai ❑MULTI-UNIT ❑MODIFIICATIO
Z O y T, I understand my pions shall be coved os public recoNs ' ,MODIFICATION
O Z I1PT0 200 AMPS
F4��O ❑IMPROVE ❑CHIMNISY REPAIR
Liceused Professional 201-1000 AMPS IMPROVEMENT
p� OWNER-BUILDER DECLARATION OVER 1000AMPS
C Q I hereby affirm erste 1 ten esempt from the Cemractor's License Law for me El BATH REMODEIIREPAIR El DEMOLITION
11.0 a U following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
ul a.O F which.,.I.is Ixrmit to conservct,alcor,improve,demolish,or repair any suunure
q prior m its iswuce,also repnesthe applicant for such Aconin,file asii,ed.vtatemcnt SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant to the provisions of the Contractors license Low(Chapter Y
(commencing with Seelinn 7000)of Division 3ofehe Businessland Professions Code)or TEMP.METER OR POLE INST COMMFRCIAL-
G e C thin he is exemM therefrom end the basis for the alleged excmpdmu.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
,may Section 7031.5 by any applicant for v permit suhjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
E � not more than live hundred dollars ISoRn. IMPROVEMENT
❑1,as owner of me property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC /'s
will d.dm wmk,cad me mumure is roe imended.rnf(ered for sale fSecAo44.Business ❑OTHER
and Professions Code:The ControsonA License Law does not apply ,,an owner of OUTLETS-SWITCHES-FIXTURES
prop,ny who builds or in......c,tiler....,and who does such work notwif nr through
his own employees,provided Nal such improvements arc not intended or offered for NEW RESIDENTIAL HLECTR SQ IW.
sale.If hawevecae building or impmvemenl is sold within one year ofcompledondhe SQ.PF FLOOR AREA &SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pos..fsale.).' T n
Las owner of the property,am aclusively contract,with licensed contractors to
convect the project(Sec.7014,Bus and Professions Cale:)The Contmnors Li-
cense Law does not apply toanowner ofproperty who buitRorimproves thereon,suit QTY, PLUMBING PERMIT FEE
who contracts for such projects with a coo melons)licensed pursuant to the Contractor's
License have. PERMIT ISSUANCE
❑lamexempeunder Sec. ,B&PCfordukreawn
Owner Date ALIE R-DRAIN&VE WATER TEA) A'VALUATION,
WORKER'S COMPENSATION DECLARATION NACK PLOW TROT.C'1'.DEVICE
1 hereby affirm under Penalty of perjury one of me following declarations
❑I have and will maintain a CeNfcute ofConsent to self-insure for Worker's Carl BRAINS-M ,ROOF,AREA,CO
wino,as provided for by Section 37W of the Lahr Cade,for the performance of th, ST �P CONSTRUCTION
work for which this permit is issued, LrXTU -"PER TRAP - CI�.I 9��
Fl I have and will maintain Worker's Compensation Insurance,as required by Section V UI- f
3700.E Ne Labor Cede,forth,perfmmanceoOhe work forwhirhthis permit is issued. GAS-EA.SYSTEM-I INCAOUTLEfS OCC.GROUP ss )) pPN
My Workers Compensation insurance carrier and policy anoher are: VL)
arra'. Policy No,; MS-EA.SYSTEM-OVER 4 MA)
CERTIFICATE OF EXEMPTION FROM WOR KERS'
COMPENSATION INSURANCE ORE- SMNDUSTRL WASTE INTERCEPTOR
(This section neeJ not be completed if Ne permit is f.nmc hundred Jnllnrs($I p) BUILDING DIVISION FELLS
or less)- GREASB'I'RAP -
PLANCITfA]K TBP,
I.,im Nascathe performance of Ne work forty bjmto the Wrkent'ed,lsh II SEWER-SANT RY-S' MEA.
notemploy any personi m as to bcenme subjttu..the Wnrkrn'Compe - ENERGY FEE
0 ,Z saion Lawv..f _ WATER HRATF.R E LCrft
Z 0 Applicant - • GRADING FEE
rN. NOTICE TO APPLICANT If,after making Nis Cerdfcamof Exemption,you should WATER SYS
a become ailt a the Workers Compensation provisions of the Labor Cale,you most KIPWrl SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked. W ;R S'R C t
Q
CONS'I'RUCT1(IN LENDING AGENCYF. LEN TA PL B. SQ.FC PAID
V Iherehyamrm thauhere iso amswction lending agency forth,perfommnce of Date Receipt#
Lts the work for which this permit is issued(Sec.3097,Civ.C.) .
0 U Lender's Nmne - TOTAL:
Lender's ess Addr 'fUTAL:
y 1 certify that I have read this application and stain that the above infomation is BUILDING FEE
0 court l agree to comply with all city and county ordinances and state laws reining to Q MECH ICALPERMIT FEE
V 4 building convection,and hereby authorize representatives al finicky to,enterupon the SEISMIC FEE '
unrest,mentioned property for inspection purlwses'm :RMIT ISgI CE
(We)agree to save,indemnify and keep homeless the City of Cupertino against ELECTRIC FEE
m
liuhilitics,judgments.cam and expcnus which not,many way neceegainst said City AL ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT ABR HANDLING UNIT(TO 10,0(0 CFM)
SOUR F. GilNS MECHANICAL FEE
r AIR HANDLING UNIT(OVER 10.000CRA)
STR
7/ CONUCf10N TA%
Slgnamm..l'Applaunt/Contracmr /hate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wills cit,licam.r future building.acupamumcor handle Inumilous are .] HEATING UNIT TIO 1100.000 BTU)
fin
as deed by the Cupertino Municipal Cale,Chaplet 9.12,and the Health and Safety
Code,Section 25532(x)'! HEATING I3NIT(ovER 00,000 BTU)
❑Yes FIN. VENTILATION FAN(SINGLE RQSID) PAID
Date Receipt#
mi
Will the applicant or antra building use equipments devices which BOILER-COMP CHP OR 100,000 BTU) _
et hazadnux air contaminants as Jefinaf by by the the pay Area Air Quality Management
L�uimments
- TOTAL:
cs ❑No BOILER-COMP LOVER IW,WO BTU)
e revel the hazardous cocoanuts reuircmcn¢under Charter 6.95 of,he Cali- AIR CONDITIONER4 P ISSUAN&Smay Gude,Sections 25505,25533 and 25534,I understand that if the NEW RESIDENTIAL MECH. SQ.14.s not cunen ly have a tenant,that it is my mspomihility en notify the occupant
ments which must be east priorto issuance of a Certificate of Occapaney.thoruc d agent Date TOTAL: ISSUED BY.
OFFICE