S 0282 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECOUCAL PrRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0282
BUILDING PROJECT IDEN'IFICSIION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMOTAL UNE
I b562 A) ivid
ON' ERSNAME: 1 PIONL �� CONTRACTOR'S NAME UC NO:
O V — NIC CONTROL,#
'ARCHl1ECf/ENGINEER: I I LIC NO: ADDRF_SS: ❑
)NTACr: PHONE: NU BLUING PERMIT INFO
❑ ConsW It Fm Paid by AppliCarH(Inidd) BLDG _ /fa
ELECT PLUMB MECCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMR FEE r8#lC/ y'
1 Icmby tfhmn that 1 am ran.drd
roofer Imoviaka.,of CI:II+a 9(cnmmei
mens JOB DESCRIPTION
OLX wiho Secum]IIEB)nf Division Jofthe xusircca olid Pmfaduna code.and mylicetue i, R SIIF )FNTIAL:
WOO PERMIT ISSUANCE
Fes_ in full fat ad eHat ❑SFUWL 091CHEN RIiMODIiI.
6'UC~J Liccnw Chu Iia# APPLIANCES-RESIDENTIAL Chu -]ADDITION El PLUMBING RF I'II'C
F u: Dam Cor hr
Fly ARCHHECTS DECLARATION PANELS ❑AfULTI-UNrf ❑STRUCTURAL,
ZO` Iu^dcTsu^d myplara ofiol lc wvl as'Nic record MODIFICATION
OZ UP 1021X1 AMPS ❑INTERIOR C1 CHIMNEY REPAIR
F�FW Liam#PmfusimW ]111-1000AMI'.S IMPROVEMENT []SWIMMING PO0IS
�St:x...I OWNER-BUILDER DECLARATION (1VIiR T(M111AMP5 - ]RAI 11 REM(1DE1Ji(iP -
15 6 I Meshy all!.thm I en e.mnry from Ne Contractor's I.,tuse Law fur the
X 31 following tuson.(Section]011.5.Buxirtus vee Pofeasims Cmc:Any city m county SIGNS ELECTRICAL ❑OTHER
III
W W which myuires a pemlit to eommmCL deer,improve,demolish,or rrpai,any stratum /Vol 011 1
F v'OPrior miaiutaran.alsoreyui¢s the yFicam forwch pcmnah, SPECIALCIRCULUMISC.
Eby that Be is littnwd pas ,to doe lvovisions of ibs Cwtlranofs U.La.(Chager 9 ,
�50� Rommencing wish Section 9fM0)ol Division Jufthe Business and PratcuimaCmo)« TEMP.METER OR POLE INST.
d d y thm he is eaemq thmufmm am the basis for thc alleged cemnpinn.Any violist of O NEW BLDGIADDITION ❑DENIOIJTION
X^4 Sceim]031.3 by any til iranlfmapsmut aubja.the applicant r a civil Pa 'Y of POWER DEVICES
H mmac than fire humErd rkdlvx(SSf07� _
11 TENANT ❑FOOD SERVICE.F. Y IMPROVINENT
QI] La'--ftbe pmpeny.or my cmployecr with wages es their wlc cournensation, SWIMMING POOL.ELECTRIC ❑O111FR
Cp. will do thewM.amare.swemne is rot immided oroHeml fou stk(Sec.ltpy Bust.
W 3 and Professor;Cade.:The Cmmamm's Uccnw Use docs ml apply to an not rcr of OVILEfS-SWITCHES-FI S
,"o, hu Fnilde nr impmvu ihemn,and wlo dies such work humsnll or through I
hi%awn employee povidml that ouch impmvrnrn.art not interni or offined for NEW RFSIDFNTIAI.F1.EC1'R S IG'.
stk.If,hmvcvn.the bailing m irpmvemi is sold within otic yr.,ofcnrlgedon.tk SU IT.FLOOR AREA LSV FL
owner-bu kic,will hao,the hurden of proving that he dkl not Muildor Impmne fin pur-
powafaabt.). Ai n
I Lmowoe+mf do prWenr am exclunvely cmuatine with liceascd cmlReloAr TQT
n trod the pmjal ISa.]IHd,Rutinc.vr and Itofassimr Cmc:)Tic Cmtmdds Li-
cccnclaw dee.not apply to an owrrcr of pmpny who builds or imma trollagrpmvas durtrollQTY PLUMBING PERMIT FEB; JUL 1,a1 �CrnU
whocans for poja
such ts with aconuxmr(s)licev lquauanl to the Conaact�As
License Low. PERMIT ISSUANCE!
m
❑ Ise: np undcr5a. .B&PC for this ream,
Ow �e ALTER-DRAW&VFNf-WATER(EA) V I VF k, 1, I
WORKERSCOMPEN.S4fJOKDECLARATION BACK FLOW PROTECT.DEVICE
1herebyiliumuM prn lyofperjuryoreathefollwingdcchvatio
I have ural will maintain aCechfmmcof Conwnl msclf-insure fou Workcr'.s Canpcn- DRAINS-FLOOR.RODE AREA.GOND. - STORIES TYPE CONSTRUCT ION
as pmvidal for by Satirm 3700 of hoe IaM1or Cak,for the pMnmnmcc m1 the
w'mV;far w'hkh Ibis permit a i.sa c . FIXTURES-PER TRAP
] I have and will msinmin Worker',Cornrcnmlion Insurance.no quire)by Scdinn
JT(Ionf the lsdr Cak,for the perfonnvec of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS (ICC.GROUP APN
My Wod:efs Com senaaom hraurarxx carrier and Policy number oR
Ccdm Policy on, GAS-EA.SYSTI MOV OVER 41EA)
CERTIFICAI'1!OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE!INTI:RCPPII)R
COMPENSATION INSURANCE BUILDING DIVISION FEES
iaau4i.nmd lout FcrnmplmdiftMm
Pcdl is foronc hmcI dollars GREASETRAP
or nus.)(ThINANCIIECK hili
Ittnlrythv in lbcpMr.mOrc wcrrkfmw'hich rhispmmiti emend.Iahall SEWER-SANITARI'-STORM EA.NIO FT.
not employ,any'.in any marc,w m m hcmrrc,uhjm to tie Workers Cont TELERGY FEE
OZ .arson taws nr Cnldumia.Fare WATER HIA'IER WIVEN'IA!LECfR GRADING FEE
z AW vee
NOTICE TO APPLICANT:If,afar making thiv Cmilicate N Esernom,you should WATER SYSTEM/fRFATING
F ; Sous fl!li
mcanc mhject to Jou Worker'..Comsailn
penm oviei—of the Labor Cock.You ma
fmNwithcumply with such Protein.,acthis pertrdt shall be Jamul revoked. WATER SERVICE
4J Ca
z,
CONSTRUCTION LENDING A to uncy, NEW RESIDENTIALRESIDENTIALYLMN, SQ.PC PAIDIU
N
1 hmeny^Ron ert that Ihis s constant Bering egencY lir 1M perfonmrmc M
Dale. RceeiPl
U 0the work fa which thin permit 'is,uN(Sec.J 'Civ.C.)
V1<nddvName. T(TYAL: OTA1.1
I.emm's Address
IL I cenify than 1 have read Thu application and sem Ino the above infmmlion i, BUILDING HE
m cnncct.l agree to comply with all city and county ordinances imstar laws relating to QTY, MECHANICAL PERMIT FEE
U 'Z br ing mulrudinn and lcrtby auNoris rtfarenauva of thin city menti upon tk SEISMIC HE
shove-mentiouni popeny fm inspeeWn pueposa PERMIT ISSUANCE
(We)(We)arra m
to InaenUy and keeprm
balc,the City of Cupenioo againra R.F:CIRIC FEE
TwMlilks.jmgnxnls.ns trd cap:nscr which troy in anywayan:rse against std City ALTER OR ADD TO MECEI. PLUMBING HE
in nxsequrna M the graruing of this pemtit.
APPLICANT UNDERSTANDS AND LL COMPLY WITH ALL NON-POINT AIR DANDLING UNITGO I0.0f0CF1,)
SOUR �.RF.GULATIONS. MECHANICAL I�IiE
AIR HANDLING UNIT(OVER 10,M)CFM) CONSTRUCTION TAX
rto ApplkmVCmmrumr Iyam EXIIAUS'I1 IOOD(WNUCf) I IOUSING MITIGATION HE
fWTARUFUS MA IAIS DISCLOSURE
W 1l the app ic-onl m fumy beilding oceupam emxe«handkv
nanLrs material HPAUNG UNIT(TO 100,0k)BTU)
¢.mtinml M1y the Cupmim Municipal Cmc.Chaptm 9.12,am the Health and Safety
Calc.Salon) 532(e)'! HEATING UNIT(OVER 100.100 BTU)
Vcs ❑No
0 WN'i'ILp'1'ION FAN(SINGLERESIU) PAID Umc RaciplN
Will thc applicant or frac buiknng oml of use"'Pmcol an device which
t haaenkua air cmtamioonu as defr¢d by the Bay Arta Air Quality Mor agrnent BOILER-COMP(3HP OR 110,(W BTU) DUAL:
ehourct, B(III.ER-COMPIOVFR Id0.(MB'TU)
❑Yes ON.
I hmx read do hnvnnkwa monrriaH r .'order Ch,,,691 of(lel Cali- AIR CONDITIONER ISSUANCE DATES
q um rye,
fano Health&SafmY Code.Seniors 25505.251JJ am 2514.1 mm.lam Na if Ibe NEW RFSIDENTIAI.MECEI. SQ,IT.
Willi Ret nacartml,rt.1menl, itssmyrc ,p iliiylorwaifylMmc I
of mem.wthch muv eeMu Cmilieto lkcv
aiummor d tram Done TOTAL ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL PO1N�,PEN ONLY
BUILDING PROJECT lDENTIFICATION APPLICATION & PERMIT PERMIT NUMBER
gwLD1Nc
A0'�70 S ForTnLL
t4t 194VD BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 8456
OWNER'S PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE
ON&-DE-SSON>HONE257-$03
CONTRACTOR'S UTLETS-SWITCHES-RECEP 10.00/1.00
/J60 el '5f4"qAo5471y LIC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS APPLIANCES-RESIDENTIAL 4.00
208 W 1-,Uur ClRdiraGE Z5 2-Sod PANELS 10,00 DATE OF APPLICATION
ORRCHrtECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER /1
/r sec no, SIGNS TRANS. 3.00
ADONE.ENO' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
�1 ZIP TEMP.METER OR POLE INS. .20:00 /
APPLICANTS
ADDRESS MOTORS SEE FEE SCH. V
J
b ZO aS/LNUT �/ G'LE SERVICE CHANGE 20,00
o o LICENSED CONTRACTORS DECLARATION TEMP.POLE 'A 30,00
2 U 1 hereby aflims that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
(commencing with Section 7000)of Division 3.1 the Businessand
i Professions Code,and my license is in full force and effect t.lU I t 't- A i_ ) BLDG. ELECT. PLG. MECH.
z o'vj' - License Clas Lic.NumberEl
ax Dale Contractor p
¢ z i a OWNER-BUILDER DECLARATION Cls_ Of Cape<<IRO BUIL NG PERMIT
X
m 1 hereby affirm that I em exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
F LL o j Law for the following reason.(Sec.7031.5,Busin ssand ProfessionsPERMIT ISSUANCE 1�0. VALUATION S/FT.
Code:Any city or county which requires a pcOmit to construct,after,
SE 2 ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o ec oh flirts the applicant for such pemnt to file a signed statement that TOTAL PERMIT TO
A w $,A he is licensed pursuant to the provisions of the Contractor's License ��.
HiQ Low(Chapter 9(commencing with Section 70001of Division 3 ofthe /SMP
z 0 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Se H S the basis for the alleged exemption.Any violation otoection malty STORIES TYPE CONSTR.
T by any applicant for
veh hundred
subjects S500),he licanuoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mom than five hundred Jollan($51X1).1:
❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEV ICE 4.00 ---UEC.GROUP RES.UNITS
their sale compensation,will do the work.and the structure is not
intended or offered In, sale (Sac. 7144, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 5.00
Code The Contractor's License Law dao not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SEE FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
meetsare not intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose ofulc.LRES IND CON PB Other
❑ 1,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 30.00 1:1licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLER$- 1 INC 5 V.B. 600 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License taw docs not apply .
to an owner of properly who builds or improves Ihereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 �
contracts for such projects with u eontractons)licensed pursuant to
the Contract.,',License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea. ,B.&P.C.for the WATER HEATER W/VENT 6.00
om weOwnerer
Dam WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COM PE-NSATION D ECLARA'HON WATER TREATING EQUIP. 5.00
I hereby affirm that 1 have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.L
Policy No. Company
0 ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy is fled with the city ins Pection division. FIRE SPRINK ENERGY T-24
O Applicant MISC.- REFER TO ORD. Y E] N E] Yo NE]
CC CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE. PLG.CONTE, ❑C.NO. PLG.
0. Z (This section need not be completed if the permit is for otic TOTAL Y[:] IN - Y El NE]
hundred dollars IS 100)or los.)
L) O I crafty that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
0 f- mit is issued, 1 shall not employ any pecan in any manner so as to
U Due subject to the Warkcrs'compensation Wats of Califomie.
� a Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE: TO APPLICANT: IL after nwking this Certificate of Ex-
F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the tabor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO IO=OF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 6.00 SEISMIC FEE
1 herebyaffirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Gv.C.). HEATING UNIT(TO 700,000 B.T.U.) 8.00
Lender's Name
Lcadcr's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and an,that the above VENTILATION FAN (SINGLE) 4.00
information a correct. I s rel to comply with all city and county PLUMBING
ordinances and nate laws relating to building construnion. anJ BOILER-QONP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatrva of the city to enter upon the 2BER (Ower 100,000 BTU)SEE FEE SCH.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep hamlea the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in Consequence of the PERMIT ISSUANCE 10.00
gm ling of this pc a/1,�� MECH.CONT. LIC.NO. MECH.
v�J� .l
-7-7-05 TOTAL
SI alum of Applicant/Contractor T71Date/ T/ TOTAL
OFFICE COPY