S 3129APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECT RICAL
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING -MECHANICAL
BUILDING PRIDENT'IF'ICATION
rE 1'r ND.
3129
BUILDING ADDRESS: yy 1�
015 -0;1<Y -F• 4, %Lo^ow Xv
SAN I'IARV NO.
APPLICA/ION lUI{MITTAL DATE(�
( �Z
OW R`'.qI NAME: PHOONK n
¢(/ p/v /'e1 d
CD RA OR 'S NA li: LIC NU:
(/ 14A 23
NIC
E]
COMIHOLIt
ARCHITECUENGINFER: LIC NO:
A I ES
CONTACT: PHONE
UBUILDING
PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUME MECH
EJ❑ ❑ 11-
LICENSED CONT'RACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (mtnnmoaing
QTY ELk—TRIC PERMIT - FEE
JOB DESCRIPTION
I'1?ItMIT ISSUANCE
whb Scctinn ]00(p of Division 3 m she Businesx and I'ntfaxsnns Cady, and my lienee Is
in full fors end effect.
RESIDENTIAL:
❑SPUWh Ll KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class ].Ie#
Date Coun t
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCNRAL
MODIFICATION
[-1IN'I'IiR10R El CHIMNEY REPAIR
IMPROVEMENT' C]SWIMMING POOLS
ARCIII'IECCS DECLARATION
I understand myplans,,bail be nscd as puhli..cords
PANELS
OVID 200 AMPS
Licensed Pod envintoil
201-10WAMIPS
OWNFR-RIJILDER DECLARNI'ION
1 hereby affirm That I at,, cxcmpt from the Courts s Liame I.aw for the
following reason. (Section 7031.5. ]business and Professions Code Any city or county
❑({ATH tCMODE1J12I?PNB El DEMOLITION
[101 H17R
OVER 1(MMIAMI'S
SIGNS ELECTRICAL
which requires a pemnn to construct, alter, impmve. demolish, or repair any surcmm
SPECIAL CIRCO IT/MISC.
prior to its issuance, also requires the applicant for such perming file a signed statement
that he is licensed pursuant to the provisions of the Contractor s License I... (Chapmf 9
rion00)al Division 34 do Enxina—rod Pmdeoions Code),,
(camecin,and,SwIl
'TIIM P. MCI' ER OR POLE INS'I
COMMERCIAL:
Nat he is anenpt therefrom and the burls far the alleged exemption. Any viofaJon of
❑ NEW BLDG/ADDITION ❑ OF MOLI'I'ION
Section 7031.5 by anyapplicunt far. pemtitwbjecuthuapplicam m a nod penalty of
not more than five hundred dollars (SSW),
❑Les ownenr the pmpeny,onny employees with wages as Neirsolie opecomion.
will do the work, and the swemm is not intended ornffcred far sale (Sea 7144. Business
POWER DEVICES
TENANT ❑FOOD S17RVICE
IMPROVEMENT
O I HER
SWIMMING PO(B. ELECTRIC
OUTLETS - SWI 'I CUES - FIXTURES
and Profession Calc: The Cmneunar's License Law does not apply m an owner of
property who builds or improves notation, and who Joas such work March a through
his own employees, provided than such impmvenardS ore not ninsided or offered our
sale. If, howcvcr, the building or improvement is sold within one year ofronedrior, the
NEW RI?fi DENT ]At, LLECr SQ L'1'.
SQ. Fr. FLOOR AREA
S/SQ. FF..
nervbuilder will have the burden of proving thm he did not build m improve for pur-
p,uis ea.
[fir nes of the property, um exclusively corroscorrosion,rng with licensed commnon.
TOTAL:
construct rhe pnject (Sec. 70,14. 1lminoss and Pmf .. on, CWc:) no Cnn orcuois Li-
meLawdaeNn. apply to an owner of property who hones or improves thereon,and
QTY. PLLIMRING PER MIT FEE",
who counic"s install Pfajwts will, a conuacmgs) licensed pursuanna the Contractor's
PERMIT ISSUANC17
License Law.
❑ I am exasnpt under Sec. ,B& P C for this reason
Owner Data
AUHER - DRAIN & VENT- WATER (EA)
VALUATION
FLOW IR(TI'IiCr. DEVICE
WORKER'S COMPENSATION DECLARATIONPACK
1 hair ulfinnunder scantily
haperjuryonenl'rhefollowingW..setlom':
Sana of Con senna Chile, ce,I'n-
❑Ihave proyidl for performance
anion, ns Jed for h Swoon 3]NI of Luhnr CuJ for the Hnmunce of rho
prick Y, F pe
UItAINS- NIAOR. ROOF, AREA, ❑OND.
STORIES
TVPE CONSTRUCTION
work far which this permit is c)r.
FIXTURES -1'lilt TRAP
I have and will maintain Wkc Compensation Insurance, h hi, required by Section
perform
t]WnfNC IaMn Code, for performance of the work for which this pcmtit is issued
OCC GROUP
AI'N
WS -FLA. SYSTEM I INC. 4OUT 'LITS
My Worker's Compensation Insurance comer and Policy number am:
Cotrim'. Policy Na:
GAS - EA. SYS'r1iM-OVER 4 (EA)
CHRTIF[CNI If OF EXEMPT ION VROM WORKERS'
COMPENSATION INSURANCE
GREASEANDUS'I'RI. WASTE INTEROFFICE
BUILDING 111VISION PRIiS
(Thissemioa need not be cotnplmed if the penait is for anehundred dallams](0)
nr les.7
OREASP.TRAP
-_ -
1'LANCI IHCK FEL
S17WER-SANITARY-STORM EA. 200 FL
I crony that in the performance ofthe work for which this permit is issued, I shall
not employ in,, person in any ntmmer sa as m bcon¢ Nubjem. the Worker, China.-
ENERGY PEE
WATER BEATra W/VffsEDE.LF R
Nation laws of California. Dater
Applicant
GRADING FEE
NOTICE TO AFPLICAN'E IL after, umkir, this Cenilicma of Exemption, you should
become subject to the Worker's Congsomation provisions of the Labor Code, you must
WATER SYS TEM/fRHA'I'ING
SOILS FEE
WATER SERVICE
forthwith comply with each provisions or pemtii shall be deemed revoker.
CONS] EVICT ION [.ENDING AGENCY
I hereby affirm 'but 'here is acm,courion lendingagmmy for the perlinne ce of
NEW RESIDENTIAL PLMB. SQ. FI'.
PAID
Receiptk
the work Tatwldch this pemtit is iss.toil (Set, 3097, Civ. Cd
Lenders Name
TOTAL:
Lenders Address
infnmtation is
TOTAL
AA
RUIE.D ' FE
I comfy that E have mad Nis applicmion and state that the above
-
men.) agree . comply with an city and county ordinances and state laws relating to
building construction, and hereby authorize repremounivcsaftMs city to enter upmthe
QTY. MECI IANICAL PERMIT FEE
Sfi15 FF.
MlT ISSUANCE
HILL ll'RIC THE
abom-nmmwaral propmty for inspection purposes.I'lile
(Wo) a,ma m sive, in lamuify and kcup hantdcss the City of Cupertino u,ainst
ALTP.R ORADDTO MECI.
PLUMRI FEF
Iiabilides,judgments, costs and expenses which may in any way remeaguirst said City
nuyuenec of the graining of Nis nnit.
AIR HANDLING UNII'('E'O 10.IXN) CFM)
MECHANICAL ELF:
APPLICA ' NDERSTANDS D ML COMPLY WITH ALL NON -POINT
SOU G LLATIONS.
AIR HANDLING UNIT(OVER 10.000CFM)
CONSTRUCION'1'AX
/i M1OT �7J
p�•
��IO^Y
SiBnewra ol'Applintnt/Gsndsaasu� Uum
HAZARDOUS MATERIALS DISCLOSURE
Will theapplic,mor fmurc huildingecra,mt xmmorhandle hamNrn,smaterialHEATING
EXHAusT IIOOD(W/DUCE)
HOUSING MITIGATION ITH
UNIT(1'0 I W." RTI) �O
as defined by the Capons. Municipal Cafe. Chapter 9.12, and the Meath and Safety
Codc, Section 25532(.)^
IIHA'I'ING UNIT (OVER 100.000 B'IV)
❑Yes E] No
VENTILATION PAN (SINGLE RESID)
PAID
Duro Receipt#
BOILER- COMP(31]is OR 1101X111 Ii' I'( J)
Will the apparma orlinata confining by sacu,
Managemenc, whicht
mit hazardous air comaminanu as defined by the Buy Arca Air Quality Munugensm
Aea Airt nt it, Quality
DisNdi
❑Yes FIN.BOILER-COMB'(OVER
l'Al
100,MIi PBL)
AIR CONDI'l ION17R
Ihuve,col Nch ore, Scrom,2L 5,2553entsun5534.1 and QYSalthe Cali-
hroat h that if the
famia Ileuhh Ti Safety Code. Scainns , this i is ny and 25554.1 throaty
hu ildingdeannotcurmntly hpva yrhoamay.
andon, Ismyicalit
ISSUANCE DATE
NIiW RESIDENTIAL MECH. SQ. F1'.
erlytoteof
nf the rcyuiancnm which moa I. not pnnno oratorical x Certificate of Onvryncy.
I
ISSIIDD15Y:
DTA(
Osommunwhonzed,pant Doe
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECT RICAL
BUILDING DIVISION APPLICATIONIPF,RMIT PLUMBING -MECHANICAL
BUILDING PRIDENT'IF'ICATION
rE 1'r ND.
3129
BUILDING ADDRESS: yy 1�
015 -0;1<Y -F• 4, %Lo^ow Xv
SAN I'IARV NO.
APPLICA/ION lUI{MITTAL DATE(�
( �Z
OW R`'.qI NAME: PHOONK n
¢(/ p/v /'e1 d
CD RA OR 'S NA li: LIC NU:
(/ 14A 23
NIC
E]
COMIHOLIt
ARCHITECUENGINFER: LIC NO:
A I ES
CONTACT: PHONE
UBUILDING
PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUME MECH
EJ❑ ❑ 11-
LICENSED CONT'RACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (mtnnmoaing
QTY ELk—TRIC PERMIT - FEE
JOB DESCRIPTION
I'1?ItMIT ISSUANCE
whb Scctinn ]00(p of Division 3 m she Businesx and I'ntfaxsnns Cady, and my lienee Is
in full fors end effect.
RESIDENTIAL:
❑SPUWh Ll KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class ].Ie#
Date Coun t
❑ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCNRAL
MODIFICATION
[-1IN'I'IiR10R El CHIMNEY REPAIR
IMPROVEMENT' C]SWIMMING POOLS
ARCIII'IECCS DECLARATION
I understand myplans,,bail be nscd as puhli..cords
PANELS
OVID 200 AMPS
Licensed Pod envintoil
201-10WAMIPS
OWNFR-RIJILDER DECLARNI'ION
1 hereby affirm That I at,, cxcmpt from the Courts s Liame I.aw for the
following reason. (Section 7031.5. ]business and Professions Code Any city or county
❑({ATH tCMODE1J12I?PNB El DEMOLITION
[101 H17R
OVER 1(MMIAMI'S
SIGNS ELECTRICAL
which requires a pemnn to construct, alter, impmve. demolish, or repair any surcmm
SPECIAL CIRCO IT/MISC.
prior to its issuance, also requires the applicant for such perming file a signed statement
that he is licensed pursuant to the provisions of the Contractor s License I... (Chapmf 9
rion00)al Division 34 do Enxina—rod Pmdeoions Code),,
(camecin,and,SwIl
'TIIM P. MCI' ER OR POLE INS'I
COMMERCIAL:
Nat he is anenpt therefrom and the burls far the alleged exemption. Any viofaJon of
❑ NEW BLDG/ADDITION ❑ OF MOLI'I'ION
Section 7031.5 by anyapplicunt far. pemtitwbjecuthuapplicam m a nod penalty of
not more than five hundred dollars (SSW),
❑Les ownenr the pmpeny,onny employees with wages as Neirsolie opecomion.
will do the work, and the swemm is not intended ornffcred far sale (Sea 7144. Business
POWER DEVICES
TENANT ❑FOOD S17RVICE
IMPROVEMENT
O I HER
SWIMMING PO(B. ELECTRIC
OUTLETS - SWI 'I CUES - FIXTURES
and Profession Calc: The Cmneunar's License Law does not apply m an owner of
property who builds or improves notation, and who Joas such work March a through
his own employees, provided than such impmvenardS ore not ninsided or offered our
sale. If, howcvcr, the building or improvement is sold within one year ofronedrior, the
NEW RI?fi DENT ]At, LLECr SQ L'1'.
SQ. Fr. FLOOR AREA
S/SQ. FF..
nervbuilder will have the burden of proving thm he did not build m improve for pur-
p,uis ea.
[fir nes of the property, um exclusively corroscorrosion,rng with licensed commnon.
TOTAL:
construct rhe pnject (Sec. 70,14. 1lminoss and Pmf .. on, CWc:) no Cnn orcuois Li-
meLawdaeNn. apply to an owner of property who hones or improves thereon,and
QTY. PLLIMRING PER MIT FEE",
who counic"s install Pfajwts will, a conuacmgs) licensed pursuanna the Contractor's
PERMIT ISSUANC17
License Law.
❑ I am exasnpt under Sec. ,B& P C for this reason
Owner Data
AUHER - DRAIN & VENT- WATER (EA)
VALUATION
FLOW IR(TI'IiCr. DEVICE
WORKER'S COMPENSATION DECLARATIONPACK
1 hair ulfinnunder scantily
haperjuryonenl'rhefollowingW..setlom':
Sana of Con senna Chile, ce,I'n-
❑Ihave proyidl for performance
anion, ns Jed for h Swoon 3]NI of Luhnr CuJ for the Hnmunce of rho
prick Y, F pe
UItAINS- NIAOR. ROOF, AREA, ❑OND.
STORIES
TVPE CONSTRUCTION
work far which this permit is c)r.
FIXTURES -1'lilt TRAP
I have and will maintain Wkc Compensation Insurance, h hi, required by Section
perform
t]WnfNC IaMn Code, for performance of the work for which this pcmtit is issued
OCC GROUP
AI'N
WS -FLA. SYSTEM I INC. 4OUT 'LITS
My Worker's Compensation Insurance comer and Policy number am:
Cotrim'. Policy Na:
GAS - EA. SYS'r1iM-OVER 4 (EA)
CHRTIF[CNI If OF EXEMPT ION VROM WORKERS'
COMPENSATION INSURANCE
GREASEANDUS'I'RI. WASTE INTEROFFICE
BUILDING 111VISION PRIiS
(Thissemioa need not be cotnplmed if the penait is for anehundred dallams](0)
nr les.7
OREASP.TRAP
-_ -
1'LANCI IHCK FEL
S17WER-SANITARY-STORM EA. 200 FL
I crony that in the performance ofthe work for which this permit is issued, I shall
not employ in,, person in any ntmmer sa as m bcon¢ Nubjem. the Worker, China.-
ENERGY PEE
WATER BEATra W/VffsEDE.LF R
Nation laws of California. Dater
Applicant
GRADING FEE
NOTICE TO AFPLICAN'E IL after, umkir, this Cenilicma of Exemption, you should
become subject to the Worker's Congsomation provisions of the Labor Code, you must
WATER SYS TEM/fRHA'I'ING
SOILS FEE
WATER SERVICE
forthwith comply with each provisions or pemtii shall be deemed revoker.
CONS] EVICT ION [.ENDING AGENCY
I hereby affirm 'but 'here is acm,courion lendingagmmy for the perlinne ce of
NEW RESIDENTIAL PLMB. SQ. FI'.
PAID
Receiptk
the work Tatwldch this pemtit is iss.toil (Set, 3097, Civ. Cd
Lenders Name
TOTAL:
Lenders Address
infnmtation is
TOTAL
AA
RUIE.D ' FE
I comfy that E have mad Nis applicmion and state that the above
-
men.) agree . comply with an city and county ordinances and state laws relating to
building construction, and hereby authorize repremounivcsaftMs city to enter upmthe
QTY. MECI IANICAL PERMIT FEE
Sfi15 FF.
MlT ISSUANCE
HILL ll'RIC THE
abom-nmmwaral propmty for inspection purposes.I'lile
(Wo) a,ma m sive, in lamuify and kcup hantdcss the City of Cupertino u,ainst
ALTP.R ORADDTO MECI.
PLUMRI FEF
Iiabilides,judgments, costs and expenses which may in any way remeaguirst said City
nuyuenec of the graining of Nis nnit.
AIR HANDLING UNII'('E'O 10.IXN) CFM)
MECHANICAL ELF:
APPLICA ' NDERSTANDS D ML COMPLY WITH ALL NON -POINT
SOU G LLATIONS.
AIR HANDLING UNIT(OVER 10.000CFM)
CONSTRUCION'1'AX
/i M1OT �7J
p�•
��IO^Y
SiBnewra ol'Applintnt/Gsndsaasu� Uum
HAZARDOUS MATERIALS DISCLOSURE
Will theapplic,mor fmurc huildingecra,mt xmmorhandle hamNrn,smaterialHEATING
EXHAusT IIOOD(W/DUCE)
HOUSING MITIGATION ITH
UNIT(1'0 I W." RTI) �O
as defined by the Capons. Municipal Cafe. Chapter 9.12, and the Meath and Safety
Codc, Section 25532(.)^
IIHA'I'ING UNIT (OVER 100.000 B'IV)
❑Yes E] No
VENTILATION PAN (SINGLE RESID)
PAID
Duro Receipt#
BOILER- COMP(31]is OR 1101X111 Ii' I'( J)
Will the apparma orlinata confining by sacu,
Managemenc, whicht
mit hazardous air comaminanu as defined by the Buy Arca Air Quality Munugensm
Aea Airt nt it, Quality
DisNdi
❑Yes FIN.BOILER-COMB'(OVER
l'Al
100,MIi PBL)
AIR CONDI'l ION17R
Ihuve,col Nch ore, Scrom,2L 5,2553entsun5534.1 and QYSalthe Cali-
hroat h that if the
famia Ileuhh Ti Safety Code. Scainns , this i is ny and 25554.1 throaty
hu ildingdeannotcurmntly hpva yrhoamay.
andon, Ismyicalit
ISSUANCE DATE
NIiW RESIDENTIAL MECH. SQ. F1'.
erlytoteof
nf the rcyuiancnm which moa I. not pnnno oratorical x Certificate of Onvryncy.
I
ISSIIDD15Y:
DTA(
Osommunwhonzed,pant Doe
OFFICE