S 2654 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2654
EIDEN
BUILDING ADDRESS: BUILDING PRCEFTIFICATION SANITARY NO. APPLICATION SUBMITTAL DATE
f y_ -z--� 9
OWN tR'S NAMIi: PHONE: CO RACTOR'S NAME: LIC NO:
x6TI ta N/C CONTROL#
ARCHITECDENGWEER'. LIC NO, ADDRESS: ❑
G
CONTACT: PHONE: BUILDING PERMIT INFO
W I azo
O ' ❑ ConanFees cant(Initial) B
sultt FPaid by Applicant ELECT PLUMB MECH
❑ ❑ CK ❑
LICENSED CONTRACTORS DECLARATION"kja QTY. ELECTRIC PERMIT FEE
1 hareby of imn shot 1 am licensed under provision,of Chapter 9(commencing 70B DESCRIPTION
woZ wan SentlonJWNol'Di enardhotlneBiaim,,and Prafacslons Gtde.ananty Baa.eia - RESIDENTIAL
h,W0 in fullforce ani elTe ry PERMIT ISSUANCE
aUV License. ss Lie# ' `� OSFDWI. O KITCHEN REMODEL
DIDc Comes, tar fAMTE& WfAttllli APPLIANCES-RESIDENTIAL ❑ADDITION [_1 PLUMBING RF.-PIPE
ARCHOECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
.Z.Z Zy I unierswnd my plans shall be used u public rcands MODIFICATION
mFp UP T0200 AMPS ❑INTERIOR El CHIMNEY REPAIR
Ixl Licensed Pmfosannal UP T0011 AMPS
6 ; IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
1 hereby affirm Wal 1 um exempt rmm the Conaacmr's License Law Rama OVER IOIMIAMPS El BATH REMODEL/RE
APAIR ❑DEMOLITION
Wollow g n Section 7031 5 Basin... d P f.. es C r A y lY aunty SIGNS ELECTRICAL ❑OTHER /(��A_ IAdEWT'A4 .
41I OyQ hicl require, q. nit I I I shim p demolish, p r any structure �./�r+ S6
yN.i prior ot loi y toapplicantf hcattail t flsignedstatement SPECIAL CIRCUIT/MISC.
'hat he is licensed pun a the provisions ofed Contractor',Len.e Law(Chapter 9 r,dL L 0 Cr
(commencing wlW Section 7000)of Di vision 3or'he Business and Pndeaomr,Code)nr TEMP MR.I BE OR POLE INST. COMMERCIAL'
d W o C that he is exempt therefrom and Iha basis for the.11,N l eacmp'ion.Any Aulation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W.M.rn Section 703 IS by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Fyy not more than five hundred dollars(&500). ❑TENANT ❑FOOD SERVICE
Sxo 0 Las owner oftheproperty,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
I .Fr will do the work,and the structure is not intended m offered for sale(See 7044,Business OTHCR
a m and Professions Code The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself an Wmugh
his own employees,Provided that such improvements are no'intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement i,sold within one year ofcompletioq the SQ. ' OOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
Push of sale).
0 1,as owner of the property,am exclusively Profession,
with licensed contractors m TOTAL:
,nsnua the project(Sec.7(004,Rosiness and Profcssiooe Gu1e:)The Connadar'e Li-
seLaw does not apply to an owner ofpropery who builds or improves thereon,and QTY. PLUMBINGPERMIT FEE
who contracts for such projects with v conlmner(s)licensed pursu:mt to the Contractors
Liam,Lvw, PERMIT ISSUANCE
I am exempt under Sec. ,B&P C far this reason
Owner ALTER-DRAIN&VENT-WATER(EA)
Date VALUA'T'[ON
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby vf0rm under penalty of perjury one of the following declandi,ns �� I Q r 1.-
❑I have had will ntainlaina Cenifieseof Comm lo,alf-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES _'/TYPE CONSTRUCTION
tore,,us viacd for by Section 3700 of the Labor Code.for the performance of the
work which this peter'is issued. FIXTURES-PER']RAP
r have and will mainaln Worker's Compensation Insurance,as required by Section
J00 of the Labor Code,for the performance of the work for which this penni'is issued. GAS-EA.SYSTEM-1 INC.4 OUTLET'S OCC GROUP APN
MYwiP�OMi%271 erlerana Pminy roe t,.
Carie PIONFRO WORKER F1IaAf1 GAS-EA.SYSTEM-OVBR4(BA)
CERTIFICATE OF SAI IO INS FROM WORKERS' -
COMPF,NSAI'ION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This section need not len completed if the BUILDING DIVISION FEES
p permit is for hundred dollars l$IINp GREASETRAP or less') PLANCHECK FEE
I,any pehat nce
Wa performanymannce erofthework for which this Earthe ed WrkesuCompn SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner so as become subject to the Workers'Compen- ENERGYFEE
O ,Z Applicant
pliain nws of California.Uetc WATER HEATER W/VENT/F.LECTR
Applicata 1 D 0 GRADING FEE
atiNOTICE by APPLICANT:rs after making this wisimeute h E otnptinn,you should WATER SYSTEM/fREA'1'ING
hwhmo subject m the Worker's Compensation provisions of he Labor Cale,you most SOILS FEE
W forthwith comply with such provisions or this permit shall be Deemed revokal. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FII PAID
I hereby affnn that there is a c,nsaveti,n lending agency for the performance of Data Rweipl#
the work for which this permit is issued(Sec.3097,Civ.C.)
0 U Lender's Name TOTAL:
W Lenders Address TOT
6t I unre
unify that 1 have ad this application and slate that We above information is BUILDING EGB
Te. crrreh.1 agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE
Uz building couswdion.and hereby authorize representatives ofthlsclty to entert,ma the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the Ci ly of Cupeninn against PERMIT ISSUANCIif �'. ELECTRIC FEE
linhilitieajudgmants,teas and expenses which may in any wayaacrueagTi:ssald Cily ALTER OR ADD TO tG 1. -
c�nsequenceofWa TTba y this pertnil. PLUMBING FEE
APPLICAN'1'UN tSTyIEU. ANO WII 'O 1'LY WITH ALL NON-POINT tl '.t
S AIR HANDLING UN T CI O 10,000CIM).SOURCP. Gly rl rc n MECHANICAL.FEB
I/ /1]��/ AIR HANDLING UN TI{OVE@ 10 )CFM) �� CONSTRUCTION TAX
Signa o ppbc Canna Dale EXHAUST HOOD( UCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE ""[[��,,��'w'
Will the applicant or future building mceuparla car handozv
the hrdntn material HEATING UNIT('1011 m/,
011 )BTU
as relined by the Capetian,Municipal Gude,Chapter 9.12,had the Health nod Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ONo
VENTILATION FAN(SINGLE,RESID) PAID
Will thea Iicant or future building Date Receipt If _
pp l occupant use ea Air equipment devices which BOILER-COMP 31IP OR 100,000 BTU)
mit hazardous air ,enntxminnms as dehned by the Bay Area Air Quality Management (
District) TOTA.
❑Yes E:]No BOILER-COMP(OVER I(Xl,gq BTU)
I have rervd the hozwdnus mumnals 4u men under Chapter fi.95 of the Cvli AIR CONDITIONER ISSUANCE DAT
fomla Health&Safety Coda,Sectiwts^ O5,25533 end 2594.1 umkrsmna Wal if the NEW RESIDENTIAL SUCH. SQ.FP. �• 2_ 9
huilding does not cunen'ly hive SI
W ,Wal it is my respnnsibi lity trionary the occu'un /
of the requirements which must Ed,rgfu.dSsuenae nfa Cenitienm of Occupancy. —/mss
Own ran aulhonzed agent � ) Ilnfe TOTAL: ISSUED BY: /
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2654
EIDEN
BUILDING ADDRESS: BUILDING PRCEFTIFICATION SANITARY NO. APPLICATION SUBMITTAL DATE
f y_ -z--� 9
OWN tR'S NAMIi: PHONE: CO RACTOR'S NAME: LIC NO:
x6TI ta N/C CONTROL#
ARCHITECDENGWEER'. LIC NO, ADDRESS: ❑
G
CONTACT: PHONE: BUILDING PERMIT INFO
W I azo
O ' ❑ ConanFees cant(Initial) B
sultt FPaid by Applicant ELECT PLUMB MECH
❑ ❑ CK ❑
LICENSED CONTRACTORS DECLARATION"kja QTY. ELECTRIC PERMIT FEE
1 hareby of imn shot 1 am licensed under provision,of Chapter 9(commencing 70B DESCRIPTION
woZ wan SentlonJWNol'Di enardhotlneBiaim,,and Prafacslons Gtde.ananty Baa.eia - RESIDENTIAL
h,W0 in fullforce ani elTe ry PERMIT ISSUANCE
aUV License. ss Lie# ' `� OSFDWI. O KITCHEN REMODEL
DIDc Comes, tar fAMTE& WfAttllli APPLIANCES-RESIDENTIAL ❑ADDITION [_1 PLUMBING RF.-PIPE
ARCHOECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
.Z.Z Zy I unierswnd my plans shall be used u public rcands MODIFICATION
mFp UP T0200 AMPS ❑INTERIOR El CHIMNEY REPAIR
Ixl Licensed Pmfosannal UP T0011 AMPS
6 ; IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
1 hereby affirm Wal 1 um exempt rmm the Conaacmr's License Law Rama OVER IOIMIAMPS El BATH REMODEL/RE
APAIR ❑DEMOLITION
Wollow g n Section 7031 5 Basin... d P f.. es C r A y lY aunty SIGNS ELECTRICAL ❑OTHER /(��A_ IAdEWT'A4 .
41I OyQ hicl require, q. nit I I I shim p demolish, p r any structure �./�r+ S6
yN.i prior ot loi y toapplicantf hcattail t flsignedstatement SPECIAL CIRCUIT/MISC.
'hat he is licensed pun a the provisions ofed Contractor',Len.e Law(Chapter 9 r,dL L 0 Cr
(commencing wlW Section 7000)of Di vision 3or'he Business and Pndeaomr,Code)nr TEMP MR.I BE OR POLE INST. COMMERCIAL'
d W o C that he is exempt therefrom and Iha basis for the.11,N l eacmp'ion.Any Aulation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W.M.rn Section 703 IS by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Fyy not more than five hundred dollars(&500). ❑TENANT ❑FOOD SERVICE
Sxo 0 Las owner oftheproperty,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
I .Fr will do the work,and the structure is not intended m offered for sale(See 7044,Business OTHCR
a m and Professions Code The Contractor's License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself an Wmugh
his own employees,Provided that such improvements are no'intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however,the building or improvement i,sold within one year ofcompletioq the SQ. ' OOR AREA $/SQ.ET.
owner-builder will have the burden of proving that he did not build or improve for pur-
Push of sale).
0 1,as owner of the property,am exclusively Profession,
with licensed contractors m TOTAL:
,nsnua the project(Sec.7(004,Rosiness and Profcssiooe Gu1e:)The Connadar'e Li-
seLaw does not apply to an owner ofpropery who builds or improves thereon,and QTY. PLUMBINGPERMIT FEE
who contracts for such projects with v conlmner(s)licensed pursu:mt to the Contractors
Liam,Lvw, PERMIT ISSUANCE
I am exempt under Sec. ,B&P C far this reason
Owner ALTER-DRAIN&VENT-WATER(EA)
Date VALUA'T'[ON
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby vf0rm under penalty of perjury one of the following declandi,ns �� I Q r 1.-
❑I have had will ntainlaina Cenifieseof Comm lo,alf-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES _'/TYPE CONSTRUCTION
tore,,us viacd for by Section 3700 of the Labor Code.for the performance of the
work which this peter'is issued. FIXTURES-PER']RAP
r have and will mainaln Worker's Compensation Insurance,as required by Section
J00 of the Labor Code,for the performance of the work for which this penni'is issued. GAS-EA.SYSTEM-1 INC.4 OUTLET'S OCC GROUP APN
MYwiP�OMi%271 erlerana Pminy roe t,.
Carie PIONFRO WORKER F1IaAf1 GAS-EA.SYSTEM-OVBR4(BA)
CERTIFICATE OF SAI IO INS FROM WORKERS' -
COMPF,NSAI'ION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This section need not len completed if the BUILDING DIVISION FEES
p permit is for hundred dollars l$IINp GREASETRAP or less') PLANCHECK FEE
I,any pehat nce
Wa performanymannce erofthework for which this Earthe ed WrkesuCompn SEWER-SANITARY-STORM EA.200 Fr.
not employ any person in any manner so as become subject to the Workers'Compen- ENERGYFEE
O ,Z Applicant
pliain nws of California.Uetc WATER HEATER W/VENT/F.LECTR
Applicata 1 D 0 GRADING FEE
atiNOTICE by APPLICANT:rs after making this wisimeute h E otnptinn,you should WATER SYSTEM/fREA'1'ING
hwhmo subject m the Worker's Compensation provisions of he Labor Cale,you most SOILS FEE
W forthwith comply with such provisions or this permit shall be Deemed revokal. WATER SERVICE
Q
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FII PAID
I hereby affnn that there is a c,nsaveti,n lending agency for the performance of Data Rweipl#
the work for which this permit is issued(Sec.3097,Civ.C.)
0 U Lender's Name TOTAL:
W Lenders Address TOT
6t I unre
unify that 1 have ad this application and slate that We above information is BUILDING EGB
Te. crrreh.1 agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE
Uz building couswdion.and hereby authorize representatives ofthlsclty to entert,ma the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the Ci ly of Cupeninn against PERMIT ISSUANCIif �'. ELECTRIC FEE
linhilitieajudgmants,teas and expenses which may in any wayaacrueagTi:ssald Cily ALTER OR ADD TO tG 1. -
c�nsequenceofWa TTba y this pertnil. PLUMBING FEE
APPLICAN'1'UN tSTyIEU. ANO WII 'O 1'LY WITH ALL NON-POINT tl '.t
S AIR HANDLING UN T CI O 10,000CIM).SOURCP. Gly rl rc n MECHANICAL.FEB
I/ /1]��/ AIR HANDLING UN TI{OVE@ 10 )CFM) �� CONSTRUCTION TAX
Signa o ppbc Canna Dale EXHAUST HOOD( UCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE ""[[��,,��'w'
Will the applicant or future building mceuparla car handozv
the hrdntn material HEATING UNIT('1011 m/,
011 )BTU
as relined by the Capetian,Municipal Gude,Chapter 9.12,had the Health nod Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yes ONo
VENTILATION FAN(SINGLE,RESID) PAID
Will thea Iicant or future building Date Receipt If _
pp l occupant use ea Air equipment devices which BOILER-COMP 31IP OR 100,000 BTU)
mit hazardous air ,enntxminnms as dehned by the Bay Area Air Quality Management (
District) TOTA.
❑Yes E:]No BOILER-COMP(OVER I(Xl,gq BTU)
I have rervd the hozwdnus mumnals 4u men under Chapter fi.95 of the Cvli AIR CONDITIONER ISSUANCE DAT
fomla Health&Safety Coda,Sectiwts^ O5,25533 end 2594.1 umkrsmna Wal if the NEW RESIDENTIAL SUCH. SQ.FP. �• 2_ 9
huilding does not cunen'ly hive SI
W ,Wal it is my respnnsibi lity trionary the occu'un /
of the requirements which must Ed,rgfu.dSsuenae nfa Cenitienm of Occupancy. —/mss
Own ran aulhonzed agent � ) Ilnfe TOTAL: ISSUED BY: /
OFFICE