28944 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES.USEBALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 289 ^ 4
BUILDING PROJECT IDENTIFICATION .. G v f{
BUILDING AD
,1637 7-ERP-ACE- �� r SANITARY NO. APPLICATION SUBMITTAL AT
DRESS:
N/C CONTROLp
NCHITECT/ENGINEER: LIC NO: AE.SSasoJ I g6 pO� � �
I4/
CONTACT: PHONE: VKJ BUILDING PERMIT INFO
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT FLU B MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ wLdLl fYs/
I hereby affirm ohm 1 am licensed antler pmvisiom of Chapmr 9(rnmmencing JOB DESCRIPTION
Oj wiNSenio.70kh.f Division Sothic Btiourmsand Profexsons Codenndmylicanse v. RESIDENTIAL
in full force ands ' al O QrJ�o? / PERMIT ISSUANCE
jU Licc Class f� Lic.N Off• f J / ❑SFDWL ❑KITCHEN REMODEL
<u: Da Comme •�r r) J APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS 11 MULTIUNIT r]STRUCTURAL
an Z I undersand my Plans shall b,used as public records MODIFICATION
-W UPT0200AMP5
Licensed Professional 11 INTERIOR ❑CHIMNEY REPAIR
f j OWNER-BUILDER DECLARATION 201=1000AMPS IMPROVEMENT
x 6 1 hemby affirm that I son exempt from the Contractor s License law for Ne OVER IIXxI AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
FU followingmoon.(Section 7031.5.Business and asiom Ca de:Any city orcounty SIGNS ELECTRICAL ❑OTHER
which acquires permit to r0nrw4 alter.improve.
demolish•or repair any strunurc
; p�orm its iasuance,also requires the applicant(or such permiuo fileerignrd sammmt SPECIAL CIRCUIT/MISC.
} Wl be is licensed pursuant to the provisions ofhe Conuaclers License Law(Chapter 9
mommencingwih Seetion7000)of Division 3 of the Bus sx and Rafeeaions Code)ar CI'
O O TEMP.METER OR POLE INST. COMMERCIAL
he he is exempt therefrom and the basiss� i,alleged empuon.Any violation of ❑NEW BLDG/ADDI770N (]DEMOLITION
^�m Section]031.5 by any applicant fera permit s 'cess Imant m a civil pc.ahy of POWER DEVICES
t mom than five hundred dollars(55001. ❑TENANT
Z Y FOOD SERVICE
-6Ql.as owner of he progeny.or my em loyecs i ages,Noir sole wmpensation, SWIMMING POOL ELECTRIC IMPROVEMENT
=0 win do the work.and th wcmmi t a n 0 shad for side(Sec.7044,Business ❑OTHER
3 and Professions Code(13y n t cense law docs tics tippae m an owner ii 'OUTLETS-SWITCHES-FLXTURFS
property who buildsVwJl� goce ins er n.end who does suchnWi r Nrou6h
his own employees,pm het such improvements art no.Z' Rered for NEW RESIDENTIAL ELECTS SQ FT.
We.If,however.the buil pmvementisw4dwiWWyFyyt cum crit..the SQ.FT.FLOOR AREA HSQ.FT.
wear-builder will have N mom of gialh'
di6aea Id or a for pur-
pose of sale.). ✓/
❑7.as owrcr of the property.am car with licensed contracmrs to TOTAL:
construct thc project(Sec.71164,Businanoons Code:)The Cmara or's Li- ... ..I;,,i..,. .... 'J• `4muse law does not apply to an owner who builds or improves hereon,and QT .1. PLUMBING PERMIT: ?$` 'EEE
who contracts for such pmjetts with a Perspicuous)licensed pursuant to he Contractors fix •^='_ +- w .a+n ns.P,EE
U.law.
❑1 am exempt under Sec. ,B&P C for this mown PERMIT ISSUANCE
ALTER-DRAW&VENT-WATER(EA)
Owocr Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby atfum under penalty of perjury one of the following declarations:
]I have and will maintain a CeniOcatcafComsentto self-insum for Worker's Compen- DRAWS-FLOOR,ROOF,AREA,COND.
aauon.as provided for by Section 37M of he Labor Code,for the pcdomance of he STORIES TYPE CONSTRUCTION
work for which his permit is issued. FIXTURES-PER TRAP
LI ve and will maintain Workers Compensation Insurance,as requimd by Section
370D of he labor Code,for the performance of the work
/fm�rywh�ircgh rthyiss permit isissued. GAS-EA.SYSTEM-1 WC.40ITfLE1'S OCC GROUP qpN
A ttrkq Cpmpey yl9a,.lp Iagce conic Policy Nm.:Cbw/49 to GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OFOFI-FEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This Scion need not be comPletW if he pemnis for one hundred dollans IS I On o,co- �`z`dli,:BIjB.DWODNISION_FEPS;';.j ",•4+ _
or less_) GREASETRAP PLANCHECK FEE
I cmify hat in the peRormance ofthe work for which this .it i'moned.lshall SEWER-SANITARYSTORM EA200 FT
..,..ploy any person in any manner so as m become subject m the Workers'Counter- . .
er- ENERGY FEE
. Z aeuoo Laws of California.Dam
O NOTICE
WATER HEATER W/VENT/ELECTR GRADING FEE
= NOTICE TO APPLICANT: 's after making his provisions
n s of or Exemption,you should WATER SYSTEMITREATING
Y , become subject y it Workers Compensation provisions of he labor Code,you must SOfLS FEE
foMxih comply with such provisions or his permit shall be tlremed rtvakW. WATER SERVICE
0
�� CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. PAID
.)0 l hereby atitrm that them is a conswction lending agency for he performance of Dm, Receip#
I-' the work for which this pcmdt is ismad(Sec.3097.Cie.C) WHO
Leader',Name L) Landers Address TOTAL: TOTAL.
yanify hat I have ad this applic ion and ram hat he a wvc info minion is BUILDING FEE
fA comet.I agree to compiv with all cite and county ordinances and state laws relating n. QTy, MECHANICAL PERMIT FEE
i Z building constrict u.end hatch,authorize represemzuvcs nfthiscity menar upon the SEISMIC FEE
moee-memitned pmpeny for imprr1mn purpose,. PERMIT ISSUANCE
(We)agree to mase,indemou,and keep harmine he Cul ALTER OR ADD TO MECH.of Cupenino against ELECTRIC r
liabilities.judgments.costs and expense,which mar inan,wayaccomadmommud City
in consomence,of he granting of his permit PLUMBING FEE •-
APPLICANT UNDERSTANDS AND o ILL COMPLIWITH ALL NON-POINT AIR HANDLING UNIT 10.000O I(Lq CFM)SOURCE REGULATIONS. 4CONSMU
EE
AIR HANDLING UNIT(OVER 10.000 CFM) A
Silea emofApplicm/Contractor Date EXHAUST H60D(W/DUCO ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.Ito,.building occupant wore or handle haurdous materiel HEATING UNIT CIO IW.ODO BTU)
as claimed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
' Cadq Semon 25532(a)7 HEATING UNIT(OVER 100,000 BTU)'
❑Yes _ nNo
VENTILATION FAN(SINGLE MID) PAID
Will the applicant m fume Wilding bcmpam use equipment or devices which Data Receipt k
mit haradous air contmnituna ns denned by he Bay Area Air Quality Management BOILER-COMP(3HP OR IW."BTU)
u tt7 .
dye;, OTqp BOILER-COMP(OVER 100,000 BTU)
1
I have rad the harardous mustedaB eximmuaots under Cheptcr 6.95 of he Calf- AMC ONDDIONEIR
ISSUANCE E
fomite H Safety Code,Sectiora 25505,25533 cad 25534.1 uMeaard that if the NEW RESIDENTIAL MECH. SQ.FT
buildin% a jrt laveaansn4 i'e my ponsibWtymnwify the occupant
of 'M1m M tP ofe aaa [p¢u .
\ r m auBmB egrnt Dam TOTAL' ISSUED BY:
OFFICE
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES.USEBALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 289 ^ 4
BUILDING PROJECT IDENTIFICATION .. G v f{
BUILDING AD
,1637 7-ERP-ACE- �� r SANITARY NO. APPLICATION SUBMITTAL AT
DRESS:
N/C CONTROLp
NCHITECT/ENGINEER: LIC NO: AE.SSasoJ I g6 pO� � �
I4/
CONTACT: PHONE: VKJ BUILDING PERMIT INFO
El Consultant Fees Paid by Applicant(Initial) BLDG ELECT FLU B MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ❑ wLdLl fYs/
I hereby affirm ohm 1 am licensed antler pmvisiom of Chapmr 9(rnmmencing JOB DESCRIPTION
Oj wiNSenio.70kh.f Division Sothic Btiourmsand Profexsons Codenndmylicanse v. RESIDENTIAL
in full force ands ' al O QrJ�o? / PERMIT ISSUANCE
jU Licc Class f� Lic.N Off• f J / ❑SFDWL ❑KITCHEN REMODEL
<u: Da Comme •�r r) J APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS 11 MULTIUNIT r]STRUCTURAL
an Z I undersand my Plans shall b,used as public records MODIFICATION
-W UPT0200AMP5
Licensed Professional 11 INTERIOR ❑CHIMNEY REPAIR
f j OWNER-BUILDER DECLARATION 201=1000AMPS IMPROVEMENT
x 6 1 hemby affirm that I son exempt from the Contractor s License law for Ne OVER IIXxI AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
FU followingmoon.(Section 7031.5.Business and asiom Ca de:Any city orcounty SIGNS ELECTRICAL ❑OTHER
which acquires permit to r0nrw4 alter.improve.
demolish•or repair any strunurc
; p�orm its iasuance,also requires the applicant(or such permiuo fileerignrd sammmt SPECIAL CIRCUIT/MISC.
} Wl be is licensed pursuant to the provisions ofhe Conuaclers License Law(Chapter 9
mommencingwih Seetion7000)of Division 3 of the Bus sx and Rafeeaions Code)ar CI'
O O TEMP.METER OR POLE INST. COMMERCIAL
he he is exempt therefrom and the basiss� i,alleged empuon.Any violation of ❑NEW BLDG/ADDI770N (]DEMOLITION
^�m Section]031.5 by any applicant fera permit s 'cess Imant m a civil pc.ahy of POWER DEVICES
t mom than five hundred dollars(55001. ❑TENANT
Z Y FOOD SERVICE
-6Ql.as owner of he progeny.or my em loyecs i ages,Noir sole wmpensation, SWIMMING POOL ELECTRIC IMPROVEMENT
=0 win do the work.and th wcmmi t a n 0 shad for side(Sec.7044,Business ❑OTHER
3 and Professions Code(13y n t cense law docs tics tippae m an owner ii 'OUTLETS-SWITCHES-FLXTURFS
property who buildsVwJl� goce ins er n.end who does suchnWi r Nrou6h
his own employees,pm het such improvements art no.Z' Rered for NEW RESIDENTIAL ELECTS SQ FT.
We.If,however.the buil pmvementisw4dwiWWyFyyt cum crit..the SQ.FT.FLOOR AREA HSQ.FT.
wear-builder will have N mom of gialh'
di6aea Id or a for pur-
pose of sale.). ✓/
❑7.as owrcr of the property.am car with licensed contracmrs to TOTAL:
construct thc project(Sec.71164,Businanoons Code:)The Cmara or's Li- ... ..I;,,i..,. .... 'J• `4muse law does not apply to an owner who builds or improves hereon,and QT .1. PLUMBING PERMIT: ?$` 'EEE
who contracts for such pmjetts with a Perspicuous)licensed pursuant to he Contractors fix •^='_ +- w .a+n ns.P,EE
U.law.
❑1 am exempt under Sec. ,B&P C for this mown PERMIT ISSUANCE
ALTER-DRAW&VENT-WATER(EA)
Owocr Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby atfum under penalty of perjury one of the following declarations:
]I have and will maintain a CeniOcatcafComsentto self-insum for Worker's Compen- DRAWS-FLOOR,ROOF,AREA,COND.
aauon.as provided for by Section 37M of he Labor Code,for the pcdomance of he STORIES TYPE CONSTRUCTION
work for which his permit is issued. FIXTURES-PER TRAP
LI ve and will maintain Workers Compensation Insurance,as requimd by Section
370D of he labor Code,for the performance of the work
/fm�rywh�ircgh rthyiss permit isissued. GAS-EA.SYSTEM-1 WC.40ITfLE1'S OCC GROUP qpN
A ttrkq Cpmpey yl9a,.lp Iagce conic Policy Nm.:Cbw/49 to GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OFOFI-FEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This Scion need not be comPletW if he pemnis for one hundred dollans IS I On o,co- �`z`dli,:BIjB.DWODNISION_FEPS;';.j ",•4+ _
or less_) GREASETRAP PLANCHECK FEE
I cmify hat in the peRormance ofthe work for which this .it i'moned.lshall SEWER-SANITARYSTORM EA200 FT
..,..ploy any person in any manner so as m become subject m the Workers'Counter- . .
er- ENERGY FEE
. Z aeuoo Laws of California.Dam
O NOTICE
WATER HEATER W/VENT/ELECTR GRADING FEE
= NOTICE TO APPLICANT: 's after making his provisions
n s of or Exemption,you should WATER SYSTEMITREATING
Y , become subject y it Workers Compensation provisions of he labor Code,you must SOfLS FEE
foMxih comply with such provisions or his permit shall be tlremed rtvakW. WATER SERVICE
0
�� CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FT. PAID
.)0 l hereby atitrm that them is a conswction lending agency for he performance of Dm, Receip#
I-' the work for which this pcmdt is ismad(Sec.3097.Cie.C) WHO
Leader',Name L) Landers Address TOTAL: TOTAL.
yanify hat I have ad this applic ion and ram hat he a wvc info minion is BUILDING FEE
fA comet.I agree to compiv with all cite and county ordinances and state laws relating n. QTy, MECHANICAL PERMIT FEE
i Z building constrict u.end hatch,authorize represemzuvcs nfthiscity menar upon the SEISMIC FEE
moee-memitned pmpeny for imprr1mn purpose,. PERMIT ISSUANCE
(We)agree to mase,indemou,and keep harmine he Cul ALTER OR ADD TO MECH.of Cupenino against ELECTRIC r
liabilities.judgments.costs and expense,which mar inan,wayaccomadmommud City
in consomence,of he granting of his permit PLUMBING FEE •-
APPLICANT UNDERSTANDS AND o ILL COMPLIWITH ALL NON-POINT AIR HANDLING UNIT 10.000O I(Lq CFM)SOURCE REGULATIONS. 4CONSMU
EE
AIR HANDLING UNIT(OVER 10.000 CFM) A
Silea emofApplicm/Contractor Date EXHAUST H60D(W/DUCO ON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.Ito,.building occupant wore or handle haurdous materiel HEATING UNIT CIO IW.ODO BTU)
as claimed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
' Cadq Semon 25532(a)7 HEATING UNIT(OVER 100,000 BTU)'
❑Yes _ nNo
VENTILATION FAN(SINGLE MID) PAID
Will the applicant m fume Wilding bcmpam use equipment or devices which Data Receipt k
mit haradous air contmnituna ns denned by he Bay Area Air Quality Management BOILER-COMP(3HP OR IW."BTU)
u tt7 .
dye;, OTqp BOILER-COMP(OVER 100,000 BTU)
1
I have rad the harardous mustedaB eximmuaots under Cheptcr 6.95 of he Calf- AMC ONDDIONEIR
ISSUANCE E
fomite H Safety Code,Sectiora 25505,25533 cad 25534.1 uMeaard that if the NEW RESIDENTIAL MECH. SQ.FT
buildin% a jrt laveaansn4 i'e my ponsibWtymnwify the occupant
of 'M1m M tP ofe aaa [p¢u .
\ r m auBmB egrnt Dam TOTAL' ISSUED BY:
OFFICE