25722 _-
U1111,U1N'G ELRCI'NICAI. PERMIT NO.
11Y OF PLUMBING•MECIIANICAL""" I •I AC��A
jL BUILDING urvSsioN. - _APPLICATION/PERMIT IBUD,U3N4PROJE mRNITi'TCATIGN{, G J L
. . -. -
�/ I, SANITARY NO. APPLIGTION SIIBMTITAL DATE
13UILDI�N,OY,AI)DR1US.;
II GUl1U..,yVA�I 1i I'GG.IU� UNIT MPC/fO/R$� LOTH ! .. I I�LM•►bIl 'ti
I�IVSIJAMM�_ I�I��k1iTTZt� PITON&. 'CVrV� U v LINO:
NC CONItROLM b.I
IIIC GNG LR L ° 1-
.i7�.►J"
CI {a'T'(f J"p s�y�+lt Pla4tYjlT�rq{pHOtjE: t eek'( a 1 m E nrz: 3 -
titP,DIc� t ) sl ' VN Q ELECT• MB I SMECH
1r' CNlS 3 o 19�Za '
' ,,11.41r A:,I, LI Ir•Ir„ ,{I fa 6 I � 1 I "Ur eeRMITlssunrtcE:-:I�":' Id . � : � ..: :o •'1 . �')t�
i•[rr i;Fi;* LICENSED CONTRACTOR'S DECLARATION ..\II APPLIANCTiS-RPSIDENTW, ' 4 .P7%'1' i 'fl'.'1'�4i ,TOB DESCRIPTION '
L! yl'.I hereby affirm that l Am licensed underpwvssionsof Chapta9(Commencing with* -
JO❑ Section]OOo)of Drvison3 of the Uuvnus and Profeniom Code.and mylacnwnim ' PN4EIS 14 " {�' '\1� t j
JU
full fora wdcff«t... .1..,._.... .��:._._ ...__ _..
UPT0200 AMPS
L x CI s Lm As I 1 1
it H D t Conuactar _ T i .. 201 11000 AMPS
�Z� iv II^ It 44ARCNi'IECTS
DECLARATION it- !T CL .I I' OVER IOOOAMPS SQ FT.FLOOR ARG 5/SQ FT. `
tart su deny plena¢hell be mcdupublcrt redo: -f
s SIGNS ELECTRICAL JI{�?//�1^LED
'p^�'
L sell Ro(evronil . ..• .•- 4' TI ' II V 0 p V Y {. 1
. ouyl^ , OWNER GUILDER DECLARATION �� ) SPECIAL CIRNIT/MISC i-
iF tI..1 hereby affirm that 1 mo exempt from the Comactora License Lew for the
n -
rn following...(Section 7071.5,Business and Profesvom Code:Any cry m..my �SEMP.METER OR POLE INST. J�,
n Y,
which requires a permit to construct;alter,impmve,demolish,or rcpa any--ou,
POWER.DEVICES -• _.. _.,_ , f
prior re les I....alwreci.i.the appluant fm such permit CO file a signed aummcnt h
T p that he is licensed pursuant the provisions of Ne Contractors License law(Osspser
�� T SWIMMING POOL ELECTRIC VALUATION
^ 9(commencing with Section 7”)of Division 3of Ne Business and Professions Code)
or that he is exempt therefrom and the basisfor the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
-w v
,Y Section theft ysoydre do[]],m S5W).Permit subjects the epplicwlroacivil penalty of
CO nm more than five hundred dollen(5500). ,!• NEW RESIDENTIAL ELCCIR _SQ.FT SrORUS 1 IYPHCONSIBUCII014
willdo the work,And the m will Professore Code:Thctureis of undededoes no apply(Sce um,Basin n,
Licens
_ ,❑ I,nowrrcrofthe t oris to ceswithwa umtheirwlec
mad
pP Y wan owner of
property whobuildsorimprovesther«n,end whodoCesuch work hinotaforthrough his OCC.GROUP _ RFS.UNITS
ownemplo mI.WovidcdtlntsuchimpmvcmcntsarcnotintendMmofferedfm Me.IL' I i
" however,the buildingor improvement is wldwithinane yew ofcompletion,the owner- I TOTAL:
builder will have the burden of proving that he Nd not build Or improve for porpow of
"GAP
R Y r3T4J-bi%a%V. r', .9tYr a
.^ Q _ PLUMBIANC;PERMIT�y .. FEE �` FT.00D ZONE I ATN
'❑ I,ss awnefofthe property am exclusively o uaaung withlmenud conawton to µ, a AaAG•.b n•m'41'.4:
cmrswd the pwl«t(S«.ounc merofp and ywfa¢iom Code)Tin Conua,And PERMIT ISSUANCE -
wcemrc Lew dos not apply menownerof proper)whobestids m impwvca thereat,orrd
whoconwcu fon«h projecuwiNewntnctor(a)licereed pursuanuolhe Contnaor's • r' •,
Licenw Law.- r _ ALTER-DEIN&VENT-WATER(G) ?w•;ryNBB SUMMARYs.;, f .,yP!0;
e f❑I,1 atm exempt under Sec. .B&PC for this mason BACK FLOW PROTECT.DEVICEO TUE ES
SANITARY.. ..._ N
IR "
.._ RECEIIT p
Owner• Dme DRAINS-FLOOR.ROOF,ARG,COND. ,.
`./r.b ,WORKMAN COMPENSATION DECLARATION SCHOOL TAX IY N
Ilurebyafnrmthat lhave oraceniri cones to asf(Sec re,ora AbC) hiChte of FlXTURFS-PER TRAP RBCEIPiq
Camperenion lmunnce ora certified copy thu«f(Scc.7g00.Lab CJ which PARK FEE 1RECLIPTg N
' "ollcmployee's under this permit.', : "' GAS-G.SYSTEM-IINC.4OUTLETS --'BUILDING Clam FENS'
l:Policyg .,
'Company' " GAS-G.SYSTCM-OVER 4(EA) PLANCI HECK PER I
` ICI.Ccnlfled copy is hereby furnished. :] ' v '" - -- -
,�,Certified copy is filed with the city impcction division. - ORGSEANDUS]RL WASTE INTERCEPTOR GRADING FEE , I
CERTIFICATE OF EXEMPTION FROM WORKERS' ' GREASETRAP SOILS FEE -• "
:i. '•,'.hit- '• COMPENSATION INSURANCE
4: (This section need not he completed if the pcorm is for one hundred dollars($10)(B SEWER-SANITARY-STORM GA.20OFT. ENERGY FEE_.
or less.) :,t_•,.•.ri
I,xm(Ythn i.,hCprsforMceof the work for which this permit is Issued,Ishall WATER HEATER W/VEN171ELECTR 1 •- ..YI
not employ any;person in any manner so as to become subject to the Workers' PAID`—"_'-"""-'r""
Compensation Lawsof Califnna:.D.taWATER SYSTEM/TREATING Uem ' Recciptp j5
z 'Applicant -:+
--i APPLICANT:If.ofmrmakAAgthi.CIn Rc.m'f Exemptidri;youshould NEW SID LP M0. SQ.IT. ° �. TOTAL: t om)i
Q Ncome subject
APo she Wmkces Compensation provisions of the labor Code,Yau mus \ ••
I becomes}jmtw the _
"' amply with such provision or this permit shell b<deemW rtvokM. _ - -- c - - ^•- OUILDING IEE 4. ,_
• SEISMIC FEE \ I !:
r forthwith I hen ' i CONSTRUCTION LENDING AGENCY...L_._..._... -
- by affirm that them is a construction lending agency forthe peffewousence e( TOTAL: FT V CBIC FEE j
O: the work for which this perm,a usucd(Sec 3097,Civ.C)+I ! t �
Lenders Name e - r tTTga ^^`T fa MV .y ,, '""^ PLUMBING FEE r •,
F Lender'a AddressMECNANICA4 PERh6'I" PEES ,
U. I cent,)that I have rend this application end erre that the above informations 'Lp ..4*as v..Ts..wet xra s.rt+rnSL -_ - 1;J
0.< correcl'Iagree to complywth ell city and county ordinances andnne laws relating to PERMIT ISSUANCE
MECHANICAL FEE..1,
vuave-mentioned property fm inspect ion purposo, this mcnterupon the CONSBUC110N TAX •'
B a by au P L. .... ALTER OR ADDTO MECH... ............. ... ...__..,.:._:- I's
building I agree to coand here Ihodnre resaurives of
We f to save,indemnify d keep harmless Y wet - - -o against
."( ) gree Y p uyof QAgaN00id City s.a
Irvbdnra) dgmcros,cases anJ res which me nen Yeccme Against said City AIR HANDLING UNIT(TO 10,000 CFM) pp
to corse C..fdu,,mMw&.fthiI,nML. 1
AIR HANDLING UNIT(OVER 10.000 CFM) -5X
S gnamrcof APPlmanl/Comnetm r ...._... I Dte _� 1±• tGXt1AU5T HOOD(W/DUCT),. .. ,,•�.+ a 1 PAID a \ tt •. ) fit'•.
r. . ! _,. NGTWG UNIT(TO 100,000 BT11) ,-,_ a x Date- v. ac rp �6'tr
HAZARDOUS MATERIALS DISCLOSURE - s
-I-
Will the applicant Or future budding o«upnt some or handle hawdous materielHGTING UNIT(OVER I00.0008TU)k; I� t ,m}nl1 t" FII
defined by the Cupert no Municipal Code,Cbapmr 9.12.and th Health and Safety T 9'e I k
Code.Section 23572(u)] s ' "'� VENTILATION PAN(SINGLE RFSID)') ) L
E)Y. 0 N ' • .IISSUANCEDATEd, 1 „
BOILERr COMP(3HP OR IUUOW BTU),�, it 1
4y?4' l Will lhcepplicantorfuwwbutldmg«cupontuseuupmentodevicawhnhcmt f F - 4 1 r ',' t;{A'
0, Jam air contaminants m defined by We Bay Asea Ar Quality Managementj j,; BOB.ER-COMP(OVER 100000 BTU) _
IFSr t:
I ❑Y..'N" ❑N I I NEW RESIDENTIAL MCCH SQ IT. t P A I Q , r •^.
y lr 1 have rcvl'shc hesardom matmals rc mnmenu under Charm,695 of th r r '•
9 P ,. f,l- II V., ,,,, ,Iae.,•..: ,•,.,;:.: DEC 22,19
C I fomla Health&Safety Code.S«Bons 25305 25373 end 23574 1 undemand th t
,f the budding does not currently have a mrunt,that it is my responsibility lm aorfy IIIc
occupant of,the requircmenu which must be met prior to issuan e Ora C rtificam of
Oaupency..,b, .. illi:•f,. f:• ) r r;v.t r ' 1 I: I t f i' I 1 1 t r., i" I Cjl I V•' 1'IN
Owner or authorized agent Dau ) \I I,:( TIL I'; \I I'• 1•;']tTOTAI.: ISSUEDBY:
.. Gns• 'glo, 'l ,�. t`-.rt'•Sr t a:b _ _ ..s .'`..- __�'' '
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -19 AIrW
CITY OF CUPERTINOUILDING—ELEUrRIC-Al, PERMIT'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: _ SANITARY NO, APYLICA'DON SUBMITTAL DAIV
AD a UNITxbtz
I 1,'x 5a
OWN': AME: PI10NE: CONTRA. R'. NAME: LIC NO: NIC COMB Lx
qq
.pF1JGINEER: LICN : ADDRESS: El O
i � -VI M1V
WNTACT: PHONE: BUILDING PERMIT INFO QTY. ELECTRIC PERMIT PEE;
C /1 aMs� /k BLDG ELECT PLUMB MECII
J g�YYJ� {I �\,I� PERMIT ISSUANCE El El El
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL
OCZ Ihereby affirm that l tion ns
n liceed 9
underprovisionsofCluipttt (commencing with JOB DESCRIPTION
¢00 Section 7000)of Division 3of the Basimesstnd Professions Code,and my license is in PANELS
FEF. Fall romantic!effect.
<U L) UP TO 2M AMPS
FZt License Class Lic.M
.<, Data Contract. 201-IOW AMPS
F-yZ ARCHITECTS DECLARATION SQ.Fr.FLOOR AREA $/SQ,FT.
Z O'n I understand my plans shall M used as public records. OVER 1000 AMPS
�ytw SIGNS ELECTRICAL
Licensed Professional
�yKQ OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
�xx'06U I bercby affirm that I am exempt from the ContramoO,License Law for the
W 3 a y following mason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
1'"OQ which inquires a permit t.consumer,nhcr,impose,demolish,or repair any mm mm
' Sairs issuance,also rc Ibea licca lin such no Ile used neJ sentiment
Q POWER DEVICES
prior quires pp permi g
dioKThat he is licensed pursuant t.the Provisions of the Contractor's License Law(Chapter VALUnT10
9momnrcncing with Sonon 0000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC �N O�
W=y or that heiseaempnm
heefemand the basis eallegedexemprion.Any violadonof OUTLETS-SWITCH[S-FlXTURFS D)y )
F_Z Q m Section 2031.5 by y applicant for a Permit subjects the applicanuo a civil penalty of
KF not mom man five hundred dollars(SSW). NEW RESIDfNT1ALELECR -SQ.Ff.
C. ❑ I,asownerofrhepropeny.ormyemployeeswimwagesasthelrs.lecompensati.n, Q ti" RIES 'TYPE CONSTHUCI'ION
pU,3� will do the work,anJthm'vunurc isnm intended or
off..oruraule(SecJrl4q Business
and Professions Cole:The Contractors License Law Jces nor apply man owner of
property who builds or improves demon,and who dors such work himself or through his
own employees,provided that such impmvememsam not intended.rofPorcdfasale.If, OCC.GROUP RES.UNITS
however.the building in improvement is sold within one year ofeempletion,the owner- TOTAL:
builder will have the burden of paving that he did not build or improve for purpose of
seam.)' MBING PERMIT FEE
❑ Las owner nfrhe pmpeny,amexdusivdy, contracting with license)contractors QTY.e
ors to FLOOD ZONE APN
rnsruct the project(See.006,,Business and Professions Code:)The Contractor's
License Law does not apply to an ownerofpopony whobuddsor Improves thereon,and PER;I1TISSUANCIi
who contracts for%nab projects with a commmoge)licensed pursuant to the ContractorsgLFfER-DRAIN&VENT-NT
FR O]A) FEE SUMMARY
License Law.
❑ 1 sen exempt more,Sec. .B&P C for this mason lEACK FLOW PROTECT.DEV IC OUTSIDE 'S
SANITARY YN
OwnttRECEIPfp Dam DRAINS.FLOOR,ROOF.AREA,CO
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
yI hereby affirm that l have a cenificam of consent to selGim onraccnifca¢o FIXTURES-PER TRAP Brad PTx
Written Compensation l marame,or a certified copy thereof(Sec.3g00,atab C.7w ' PARK FEE Y N
covers ail employee's under this permit. GAS-EASY -I IN 'f.,TS RECEIPI'a
• Poli<yx BUILDING DIVISION FEES
Company GAS-FA. -OVER (E ) PLANCHECK FTE
❑
Certified copy is hereby famished.
(3 Certified ropy is fled with me city inspection division CRFA US TL INTERCEPfOft GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' TR J, SOILS FEE
COMPENSATION INSURANCE
Urisseninn ncednm M complcmd ifthe permit is Jerome hundred dollars($IW SA Y-STORM EA IIT. ENERGY FEE
m tecta.)
Icmify mat miss,Performance or the work for which this permit is issuW,Ishall WA EATER W/VENT .CTR
not employ any person in any son, as to Irccor a subject to me Workers' PAID
Compcnsmionlnwsof Califomia. Dam WATER SYSTEM/OR ING Data Raxiplp
'Z Applicant
7� 0 NOT ICE TO APPLICANT:If,after making this Cenificam of Exemption,you should N RESIDP IAL PLMB. SOFT. -TOTAL: ^^
Ter ; secomesubjectto the Worker's Compensation provisions of the Labor Code,you most BUILDING PF:E afa{.J
fnrlhwilh comply with such lowskiomor this permit shell be deemed revoked.
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
2I hereby affirm that them is a construction lending agency for the performance of
U 0 m work for which this Permit is issas!(Sec.3097,Co.C.) TOTAL ELECTRIC FEE
I andees None PLUMBING FEE
U'' F Lenders Address QTY. MECHANICAL PERMIT ITE
L) I calmly that 1 have mad this uppliwrion and stare that the native informmion is MECHANICAL PEE
IJ.1 correct.lagrceloconrply with all city andcounty mdinaneesand marc laws relating m PERMIT ISSUANCE
I" building coushuetion,and hereby audience rcprcsentativcsofthis city to came upon the CONSTRUCTION TAX
I..I Z tib se-me honed progeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree no save,indemnify and keep harmless the City of Caliendo.agmnot
Iiabilities,judgmerns.costs and expenses which may in any way science against said City AIR HANDLING UNIT(TO I U.OW CFM)
in consequence of the granting of this permit.
Aift HANDLING UNIT(OVER 1(L000 CFM)
Signumre of A,hemit/Cnammm Date EXHAUST HOOD(W/DUCP) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
Wllltheapplicam-wefuture building occitmasmrcor handle haurdous material TOTAL: e�O
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Cale.Section 25532fo? VENTILATION FAN(SINGLE RFSID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant mature a og occupant use equipment ordeviccawhich emit BOILER-COMP(3HP OR 100,000 B1'U)
ocous air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100,000 131 U)
v ❑Yea 0 N NEWRFSIDENTIALMECH. SQ.FT.
L have mad the haurdous materials mquirtmcn.under Chapter 6.95 of the /
CaliforniaH & de,calth Safety CaSeetions 25505,25533 and 25534. 1 understand mat /
A
if rM1e building Docs not eurtcntly havicemnunL mal it is my rcsporeihility to notify the O�
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owner or authori agent Date TOTAL: ISSUED BY:
OFFICE _ ,