B 0658 - APPLIGANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECI'R1CA1, 1 PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUM ROJECTFIDKN ICAC
BUILDING 1'ROJECTIDRN'1'Ih'ICA'f10N 'OVUV VVV VeDV
BUILDING AUBRFSS: RSANITARYNO. APPLICATION SUBMITTAL DA'TF
-2- gOWNIER'S NAMR: PHONE: C NTRACTORS NAME LIC NO'.Nk CO U2A! 33 -663 V` l//� coNTRol.a
CHITECNGINEER: LIC NO: A DRESS: / Y�
tD ca r376 1 �f
pNTAC. PHONE: BUILDING P'RMTf INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDfl ELECT PLUMS MEY
CS LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE eLyJ� LJ
1 herehy affirm that 1 am licensed under provisions of Chapter 9(commencing ]OB DESCRIPTION
QWz with Section 7011Bnf Divisinn3 of the Bwinex and Pmfcasiuns Code,andmyliceona n! •�JL1J.:
W O PERMIT ISSUANCE
E.WO fall force and affect. FOWL ❑KITCHEN REMODEL
QUU
in
Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PITH
k.Z Dane Conlmww
N<L ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
z Oy K I understand my plans shall M used as public records PANELS MODIFICATION
DZ:7 UPT02100AMPS ❑ibrra EOR [D CHIMNEY REPAIR
of I"VJ Licensed Professional 201-1100AMPS IMPROVEMENT []SWIMMING POOLS
f OWNER-BUILDER DECLARATION OVER["AMPS ❑OTHFiR
El REMODF.UREPAIR ❑DEMOLITION
U I herehy affirm that 1 am exempt firm the Centracum's License Law for the sy(O S U following reason.(Section 91131.5,Business and Rofcxsinns Codu:Any city or conmY SIGNS ELECTRICAL
al LL LL y which requires o permit to construct,eller,improve,demolish,or repair any swemre -
h; poor o its issuance,atm requires the applicant for such Permit to file o signed statement SPECIAL CIRCUIT/MISC.
E p. that lie is licensed pursuant to the provisions of the Contractors License Law IC
OMM R IAL'
y <� (cmnaraiingwith Section V010)of Division 3rfthe Bminessond Proledsirns Cale)oz TEMP.METER OR POLE INST.
S y e That he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLXl Scetion 7031.5 by any applicant fora permit subjects the appliam,m.civil penalty rf POWER DEVICES [I TENANT [I FOOD SERVICE
not more Bun five hundred dollars($500).
I,as owner of the m norm employees with wo their sale coat ns:nion, SWIMMINGPOOLELECfRIC IMPROVEMENT
K2 Q p pc y ygases pe [I OTHER
will drthe sions Coic:and heCanaontra rots License
awdosnot apply to an,Business
W m and Professions CNe:The Contractors Liccnu Law does not apply to an owner of OUTLETS-SWITCHES-FlXT'ORES
�' .. property who builds or improves thereon,and who does such work himself or through
his own employees,pmvidcd that such Improvements are no imenJed or oRered for NEW RESIDENTIAL ELECTR SQ FT.
sale.it,however,the building Or improvement is sold within one year ofetmpletion,theSQ.FT.FLOOR AREA S/SQ.FT.
owner Ater will have the burden of proving that he did not build or improve for pur- Sys ,a
pas f sale.). TOTAL:
L M owner of the property,am exclusively contracting wish licensed convectors m
construct the project(Sec.7044,Business and Professions Code:)The COmmctnr's Li- C�eRR)
cense Law docs not apply to an owner of properly who builds ar improves lhemm,and QTY. PLUMB] R FEE
who contracts for such projects with a contractors)licensed pursuam In Ne Commnors ,�- ^�� QO�c� D r
License law. PERMIT ISSUANCE ` C '1/VD I/(
E] 1 am exemnurder Secy •B&P C for this mason J
ALTER-GRAIN&VENT-WATER( VALUATION
l- WORKERS COMPENSATION DECLARATION BACK FLOW PROI'ECT.DEVICE O 0o
I hereby affirm under penalty of perjury one of the following declarations:
Ila ve and will meantimeCeifficamol Consenuo self-insure for Worker's Compen- DRAINS-FLOOR,FOUR AREA,COND. STORIES TYPE CONSTRUCTION
nn,as provided for by Section 3701 of the Lulvrc Cole,for the peft'oncerm Of the �rf
work for which this parmissued.
it is FIXTURES-PER TRAP L 7_11!
Fl I love and will maintain Wmkers Compensation Insurance,as mqulred M Section
3700 orthe lahrr Code,for the Performance ofthe work for which this peimil is issued. GAS-EA.SYSTEM.)INC.4 OUTLETS OCC GROUT' APN
My Worker's Compensation Insurance currier and Policy number ore:
Carrier. Policy No.: GAS-BA.SYSI'RM-OVERa(IEA) R—] 375-24"DI8
CERTIFICATE OF EXEMPTION FROM WORKERS' , GREASPANDUSTRI.WASTE INERCEP OR J
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he complead ifihe permit is forone hundred dollars(S1010) GREASETRAP20
trc lens) PLAN PECK FETE
I certify that in the Performance ofthe work forwhich this permit is issued,i shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any mother so as m became subject to the Workers'Compen- EN Ff.E
O Z sation Laws of California.Data WATER HEATER W/VENT/ELECI'R GI�I G FEE
Z Applicant
NOICE TO APPLICANT.If.flet makNg this Certificate of Exemption,you should WATER SYSTIEMOREATING SO I•IEE
I•-' become subject m the Workers Compensarirn provisions of the labor Cale,you must
Ia1a O IorthwiN comply with such provisions or this permituall be domed cooked. WgTIiR SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMI3. SQ.FT. I' )
U 0 I herehyalfirm that hear iso consaucdon leading agency far Ne Pcrfotmurce of Dole Receipla
the work for which this permit is issued(Sec.3097,Ci,C.)
Q U LcnJers Nuns T
TOTAL:L.endcrs AJJfcss
1�.ss y 1 certify Nal I have real Nis application end state Nal Ne above information is JR
I'EE H
u y7 correct.l agree to comply with all city and county ordinances and state laws mlaringm QTY. MECHANICAL PERMIT 1 L.
.E
U a building cnndnation,and hereby authorize representatives of this city loemcr upon the
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE I (CITE
(We)agree to save,indemnify end keep harmless the CityOf Cupertino againstIiabibries,judgmetim costs and expenses which may in any way acenc.Ininn said City ALTER OR ADD TO MECIL ING FEE
in crnsnquence of the granting Of this permit.
APPLICA "'UNDERSTANDS AND WILL COMPLY WITH ALL NON-E'OINT AIR HANDLING UNIT E IOAQ(1CFM) ANICALFEF:
OI UL --�
/—5-- 00 AIN HANDLING UN S VLR 10.(1!10 GPM) 11 CONS CTION TAX D
$ignamre 0l APPlannVuratlacmf Dale EXHAUST HOLD(W tI," A� _ HOUSING MITIGATION FET.
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplicunt or fumrebuilding rccupum amreurhonlehmad. anarial HEATING UNITOO T#k1 I'
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety HEATING UNIT(O I W,(X0I OTU)
Code.Section 25532(u)4
E]Yes [:1 No VF.N'I'Il.AT10NFA (SLNCI.13RUSID) PAID -
Date Receipt#
Will the applicant in(more building occupant use equipment or devices which BOILER-COMP(JH 'bR•IBO.OIXtBTUI
nit hazardous air contaminants as defmad by the Bay Amo Air Quality Management -- '�— TOTAL:
stria? BOILER-COME'(OVER 1101,010 BTU)
❑Yes ❑No
1 have most dm hazardous mamrifs nortureroenu under Chapter 6.95 ofthe Cali. AIR CONDITIONER ISSUANCE DATE
(actin Health&Safety Gfq Sections 25505,235]3 unJ 25534 I uMerstend that if the N1EW RESIDENTIAL MECIL SQ.Cr. ¢
buildin tconei ly she mathatit is my resporeihility to notify the occupant
of the c whit us arm issuance ofa C#nificat�✓OccOupOy sr
er awborized ugenl / Data
TOTAL ISSUED BY:
OFFICE
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- APPLIGANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECI'R1CA1, 1 PERMIT NO.
BUILDING DIVISION APPLICATIONMERMIT PLUM ROJECTFIDKN ICAC
BUILDING 1'ROJECTIDRN'1'Ih'ICA'f10N 'OVUV VVV VeDV
BUILDING AUBRFSS: RSANITARYNO. APPLICATION SUBMITTAL DA'TF
-2- gOWNIER'S NAMR: PHONE: C NTRACTORS NAME LIC NO'.Nk CO U2A! 33 -663 V` l//� coNTRol.a
CHITECNGINEER: LIC NO: A DRESS: / Y�
tD ca r376 1 �f
pNTAC. PHONE: BUILDING P'RMTf INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDfl ELECT PLUMS MEY
CS LICENSED CONTRACTOR'S DECLARATION QTy ELECTRIC PERMIT FEE eLyJ� LJ
1 herehy affirm that 1 am licensed under provisions of Chapter 9(commencing ]OB DESCRIPTION
QWz with Section 7011Bnf Divisinn3 of the Bwinex and Pmfcasiuns Code,andmyliceona n! •�JL1J.:
W O PERMIT ISSUANCE
E.WO fall force and affect. FOWL ❑KITCHEN REMODEL
QUU
in
Class Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PITH
k.Z Dane Conlmww
N<L ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
z Oy K I understand my plans shall M used as public records PANELS MODIFICATION
DZ:7 UPT02100AMPS ❑ibrra EOR [D CHIMNEY REPAIR
of I"VJ Licensed Professional 201-1100AMPS IMPROVEMENT []SWIMMING POOLS
f OWNER-BUILDER DECLARATION OVER["AMPS ❑OTHFiR
El REMODF.UREPAIR ❑DEMOLITION
U I herehy affirm that 1 am exempt firm the Centracum's License Law for the sy(O S U following reason.(Section 91131.5,Business and Rofcxsinns Codu:Any city or conmY SIGNS ELECTRICAL
al LL LL y which requires o permit to construct,eller,improve,demolish,or repair any swemre -
h; poor o its issuance,atm requires the applicant for such Permit to file o signed statement SPECIAL CIRCUIT/MISC.
E p. that lie is licensed pursuant to the provisions of the Contractors License Law IC
OMM R IAL'
y <� (cmnaraiingwith Section V010)of Division 3rfthe Bminessond Proledsirns Cale)oz TEMP.METER OR POLE INST.
S y e That he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LLXl Scetion 7031.5 by any applicant fora permit subjects the appliam,m.civil penalty rf POWER DEVICES [I TENANT [I FOOD SERVICE
not more Bun five hundred dollars($500).
I,as owner of the m norm employees with wo their sale coat ns:nion, SWIMMINGPOOLELECfRIC IMPROVEMENT
K2 Q p pc y ygases pe [I OTHER
will drthe sions Coic:and heCanaontra rots License
awdosnot apply to an,Business
W m and Professions CNe:The Contractors Liccnu Law does not apply to an owner of OUTLETS-SWITCHES-FlXT'ORES
�' .. property who builds or improves thereon,and who does such work himself or through
his own employees,pmvidcd that such Improvements are no imenJed or oRered for NEW RESIDENTIAL ELECTR SQ FT.
sale.it,however,the building Or improvement is sold within one year ofetmpletion,theSQ.FT.FLOOR AREA S/SQ.FT.
owner Ater will have the burden of proving that he did not build or improve for pur- Sys ,a
pas f sale.). TOTAL:
L M owner of the property,am exclusively contracting wish licensed convectors m
construct the project(Sec.7044,Business and Professions Code:)The COmmctnr's Li- C�eRR)
cense Law docs not apply to an owner of properly who builds ar improves lhemm,and QTY. PLUMB] R FEE
who contracts for such projects with a contractors)licensed pursuam In Ne Commnors ,�- ^�� QO�c� D r
License law. PERMIT ISSUANCE ` C '1/VD I/(
E] 1 am exemnurder Secy •B&P C for this mason J
ALTER-GRAIN&VENT-WATER( VALUATION
l- WORKERS COMPENSATION DECLARATION BACK FLOW PROI'ECT.DEVICE O 0o
I hereby affirm under penalty of perjury one of the following declarations:
Ila ve and will meantimeCeifficamol Consenuo self-insure for Worker's Compen- DRAINS-FLOOR,FOUR AREA,COND. STORIES TYPE CONSTRUCTION
nn,as provided for by Section 3701 of the Lulvrc Cole,for the peft'oncerm Of the �rf
work for which this parmissued.
it is FIXTURES-PER TRAP L 7_11!
Fl I love and will maintain Wmkers Compensation Insurance,as mqulred M Section
3700 orthe lahrr Code,for the Performance ofthe work for which this peimil is issued. GAS-EA.SYSTEM.)INC.4 OUTLETS OCC GROUT' APN
My Worker's Compensation Insurance currier and Policy number ore:
Carrier. Policy No.: GAS-BA.SYSI'RM-OVERa(IEA) R—] 375-24"DI8
CERTIFICATE OF EXEMPTION FROM WORKERS' , GREASPANDUSTRI.WASTE INERCEP OR J
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he complead ifihe permit is forone hundred dollars(S1010) GREASETRAP20
trc lens) PLAN PECK FETE
I certify that in the Performance ofthe work forwhich this permit is issued,i shall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any mother so as m became subject to the Workers'Compen- EN Ff.E
O Z sation Laws of California.Data WATER HEATER W/VENT/ELECI'R GI�I G FEE
Z Applicant
NOICE TO APPLICANT.If.flet makNg this Certificate of Exemption,you should WATER SYSTIEMOREATING SO I•IEE
I•-' become subject m the Workers Compensarirn provisions of the labor Cale,you must
Ia1a O IorthwiN comply with such provisions or this permituall be domed cooked. WgTIiR SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMI3. SQ.FT. I' )
U 0 I herehyalfirm that hear iso consaucdon leading agency far Ne Pcrfotmurce of Dole Receipla
the work for which this permit is issued(Sec.3097,Ci,C.)
Q U LcnJers Nuns T
TOTAL:L.endcrs AJJfcss
1�.ss y 1 certify Nal I have real Nis application end state Nal Ne above information is JR
I'EE H
u y7 correct.l agree to comply with all city and county ordinances and state laws mlaringm QTY. MECHANICAL PERMIT 1 L.
.E
U a building cnndnation,and hereby authorize representatives of this city loemcr upon the
.hove-mentioned property for inspection purposes. PERMIT ISSUANCE I (CITE
(We)agree to save,indemnify end keep harmless the CityOf Cupertino againstIiabibries,judgmetim costs and expenses which may in any way acenc.Ininn said City ALTER OR ADD TO MECIL ING FEE
in crnsnquence of the granting Of this permit.
APPLICA "'UNDERSTANDS AND WILL COMPLY WITH ALL NON-E'OINT AIR HANDLING UNIT E IOAQ(1CFM) ANICALFEF:
OI UL --�
/—5-- 00 AIN HANDLING UN S VLR 10.(1!10 GPM) 11 CONS CTION TAX D
$ignamre 0l APPlannVuratlacmf Dale EXHAUST HOLD(W tI," A� _ HOUSING MITIGATION FET.
HAZARDOUS MATERIALS DISCLOSURE
Will lheapplicunt or fumrebuilding rccupum amreurhonlehmad. anarial HEATING UNITOO T#k1 I'
u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety HEATING UNIT(O I W,(X0I OTU)
Code.Section 25532(u)4
E]Yes [:1 No VF.N'I'Il.AT10NFA (SLNCI.13RUSID) PAID -
Date Receipt#
Will the applicant in(more building occupant use equipment or devices which BOILER-COMP(JH 'bR•IBO.OIXtBTUI
nit hazardous air contaminants as defmad by the Bay Amo Air Quality Management -- '�— TOTAL:
stria? BOILER-COME'(OVER 1101,010 BTU)
❑Yes ❑No
1 have most dm hazardous mamrifs nortureroenu under Chapter 6.95 ofthe Cali. AIR CONDITIONER ISSUANCE DATE
(actin Health&Safety Gfq Sections 25505,235]3 unJ 25534 I uMerstend that if the N1EW RESIDENTIAL MECIL SQ.Cr. ¢
buildin tconei ly she mathatit is my resporeihility to notify the occupant
of the c whit us arm issuance ofa C#nificat�✓OccOupOy sr
er awborized ugenl / Data
TOTAL ISSUED BY:
OFFICE
d
'o
U
W i
N'
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