24253 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pm ect Identification PERMIT N
Building Addrev: � � cc ` Y 2 4 2 5 3
"��ts2_
are. W L s one. CITY OF CUPERTINO-BUILDING DIVISION le
Gn ra r%� _]}� Lic.No: APPLICATION / PERMIT
LjdlaBUILDING-ELFCTRICAI.PLUMBINC.MECHANICAL CATEGORY VV
CONI�Isd�
Architect/Engineer. Lie.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
A�.�
Add. PERMITISSUAtNCE i� MI I'Llell 1
11
LICENSED CONTRALTOR'S DECLARATION �ON L-R
Ihereby
ion70that lamsion3 Theunder Busiessand provisions ofChapter9(mmmm AIsIsIlANCESRE9DENTIAL �p!�
Ing with Section 7000)0/Division 3 o(the Buelneasand Pro/nslonsCode,and my
Isome Is 1.
Limosecims force and effect PANELS Is
Date- Clave it.p T 1 Y�/ •'r►�iii
Date Conlmctor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-IODOAMPS
µQ�9O zz I understand my plata shall be used as public records. OVERIIDOAMIS SQ.FT.FLOOR AREA $/SQ./FT�.
E ly Licensed Professional SIGNS ELECTRICAL -X/�ara<� �3sYi
«<< OWNER-BUILDER DECLARATION SPECNLCIRCUIT/MLSC VVVV VV ��VV
zF. I hereby affirm that l am exempt fromthe Contractors License Law for the
p following reason.lSecHon 7031.5,Buatess and Pro(essiona Code:My ctty or
FZ H TEMP.METER OR POLE INST.
ceuntywhich requlreaa permit to mrutmcL alter,Improve,demolish,orrepair
enystructure prlorto Its Wuance.alm repulreatheappllcant forsuch permitto t �g�d
Ofib a signed statement that he b licensed pursuant to the provisions of the TOWER DEVICES
µ,l• Contractor's License law(Chapter 9(mmnnnc itwithSection700D)ofDivl-
Blon3oftheBusinescandProfesseonsCole)orthat he la exempttherefromand SWIdMINC POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any Lo !1 A
UTLETSStVITCFtESFIX'IURESco
applicant fora permltsubjerotslheapplicmttoa civil peoaltyo/nat nn.than div `
five 1,a.o ne,dolof he W). NEW RESIDENTIAL ELECTR SQFF. STORIES TYPECONSIRUCTION
�n ❑Lasownerll otproperty,or my employeeswith wages a their sole
compensation,CSoc.7Kwill Bothe work and the structure Th no Intended or License
for
O vie(notapply to an ow and Proopert oCode:The Contracture thereon law
does$$ whodot such loan owner ofporthropertyo builds owneporees,prvided thereon,and OCC.GROUP RES.UMTS
whodoements am not himself Intended reoffered
Neow or ale.lf employees,provided that such
Improvement.red within
pleb the o nveg deer ilingoe 7 L: 1
Improvementbwld wltFln orwyearo(completlorytheawnerbullderwlllhave
ljZIIuBm of pmvlog that he did nabuBdorlmpmveforpurpoeeofsale.). QTY, PLUMBING PERMIT ]SEEFT.OpD ZONE APN
a.
or of the property,am eachWvely mntrecting with licensed PERMIT ISSUANCE s�
foot on to construct the project(Sm 70K Business and Professions Code:
The Contractors License Lw does not apply to an owner of property who ALTER-DRAIN 4 VENT WATER(EV
builds or Impresses thereon,and who contra /or such plojeR - •
s with a
.1114actor(s)licensed pursuant to the Contradoei License Law. FEE SUMMARY
lJ I am exempt under Sec. B 6 P C for this reason BACK FLOW PROTECT.DEVICE 00TRIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
•
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP �r SCHOOLTAX Y N_
[31 hereby affirm that I have a certificate of consent to Belfdneure,or a RECEIPT 9
certificate ofWorkeri Comperuatlon Insurance ora certified mpythereof OSec.
3810,LbCJ S FA.CASYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
Policy Y GAS EA.SYSFEM-0VER a(EA) RECEIPT 0
Com any BUILDING DIVISIO FEES
CCeAMM copy t herebyth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ed
Cedllled copy b(Ikd with the city inspection division. as �
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID_ gi.r
I
COMPBNSATONINSURANCE '
(Thleeection need CnotO be eompl
COMPENSATION
epermit t/or am hundred dollen SEWER-SANITARY-S'NRM F.A.200Ff. Datetjt ems #
($10D)or ler.) WATER HEATER W/VIiNC/Q.GCTR ENERGY Y N
I cert)/ythat In the performance o/the work forwhlch this permit is Issued, O ��
I.hall not employ my person In any no
Bo yJp b�, (rye su�tet�toyhe 1 WA.I.PR SYS.IFA1/.IRFA•DNC
Workers icam_mp ...jr E�t�'�j(I(o�i ia. atelim_y_7 R p\B PAID
O Z Applicant 4 / '\\ IC ISJ�6 V NEWREADENITAL PLMB._SQ.FF. Date Re i _
2 O NODCETO APPLICANT.If A mating ap. �if qpI IAB; U
H ahouldbemmesubje.z.Warken'C°m4tfAn fyov b 'BAh@L'$ol 1
W Code,you must(wish mmplywithsukh pro Mid-ort t a 1
W > deemed revoked.
cONsrI�47{qI LEND A� —/ SEISMIC FEE
0. Iherebyat(Irmthattherllfi Mise form, ELECTRIC FEE
Z ,..fthc work torwhich this permit t issued(Sm.3097,Clv.CJ T
V O Iandere Name PLUMBING FEE Q
LL F Lender'BAddresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imdi/ythatlhavereadthlsappRrati°nand Btatethattheabovelnfomutlon �w
1 boome%.Iagreetocomplywethallcityand muntyordi.mccamd smteiaws PERMIT ISSUANCE FEES PAID:
} relating tobuildingmtutructiory and herebyautherhompre ,...xs of this w '
I— Z citytnenterupontheabove-mentioned prerperty for pectlen purposes. I ALTERORADDTOMECH. aa�
lWe)agree to Inde a d ken ss the City o/CupertNo Date Reeci t#
V ag.,utllab Bit. d ex vee ithmaylnanywayaccrue RHANDLINcuNrrcT010,ODOCFM) I" SUBTOTAL'
agal aid Cl 1 the gr tin o/thbpennit.
/ AIRHANDLING UNIT(OVER I0,000CPM) CONSTRUCTION TAX
S sea reofA� cant/Contnctm Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
Hk R USMATERTAIKIDISCLUSUILE
Will the plcantorfutumbulldlogpant Blomor handle hazardous HEATING UNIT(TO 100,!00 BM r' Date i
terblas eflmd by the Cupertino Mu tlpal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,!100 BTU)
❑Yee No
Will the applicant Rome building occupant use equipment or devices VENITLATIONFAN(SINGLE RESID) r ISSUANCE DATE
which emit haaardous air contaminants v defined by the By Area Air
Quality Management District? BOILER-COMP DHP OR 100,01'0 BTU)
4 Yee rl No
havereadthe th&SSi ouematedab requirements under Chapler6.95 of BOILER-COMP(OVER 100,000 BTU)
thecmta ndtatifthAildin Code, otcure2tly have a tend,that
(A p p
nepontandthat notify the ocupard of t erequire encs tcnanl,ihal It try NEW RESIDENTIAL MECH. SQ.FT Y'• G9 (I
rnporolissu to notifytheoccupanto/the requirement which must be met
prior to issuance of a CertlBcatc of Occupancy.
R
Owner or authorlacd agent Date ISSUED B
OFFICE COPY
CITY OF CUPERTINO
INSPECTION DIVISION
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APPLICANT TO FILL IN IN FON MAI ION Al If II HED LINES-USE IIALL POINT PEN ONLY
_ 4o.o.o1FCTTT,T1PRX'(iT— PERMIT NO,
CITY Ur,CUPERTINO APPLICA'T'ION/PERMIT PLUMING.MIrCIANICAL
BUILDING DIVISION BUILDING PROIRCT IDENTIFICATION -9
BUILDING ADDRESS: SANITARY NO. I APPLICATION SUBMIT TALUATE
i
ONO I LOT If
OWNITIS NAME; PHONE, I'ON'I RACI OR:S NA Mli: LIC NO: NC CYINIROLX
ARlllfll!CIJUNGINEER: LIC NO: ADDRESS: ri
C— FOIACT: PHONE: ' Y J"ffl fCf)INd FLiiMrt INFO
N
Q'tr9i , eLLsf,li �fliikl" 1. �. din a1
DLDG CLEM PLUMB MLCII
PERMIT ISSUANCE -(Ju 0 O ❑ E
LICENSEDCONTRACI'ORlS DECLARATION APPLIANCES-RESIDENTIAL IOD DESCRIP'T'ION
Oyy fberehyaffrrmHis,on'ReenaeJ rrnd<rinuvisimnnfrhans,9(cammencing will,
L300 $alien 7000)n1 Division Sof @c 0nsineas sed Profession.,Carle,eMmy license Iain PANELS
lywC full(maned drat.
'-Zw I.1,c cClass Lief UP TO 200 AMPS
H7. Date Cnmmmor 201-IWO AMPS 50.IT.MOOR AREA SISQ M. r
I"'Z ARCBITECl-S DECLARATION OVER 1000 AMPS
Dorn— I mndersundmy Plan I'allheusnl as p^hliemrmda. �� [{3 �L.. 3�
04-0l
�_rnkw SIGNS CLECIRICAL 120, 3y
i0 Livnrnvl l`rnfusiannl
OWNER-OUILDr:R UI!CLARAIiON SPECIAL CIRCUR/MISC. _
3is,-u I hereby arrant nrnl I mar escmrl front;lire camra<m,n noose Law ror me p 20_b�
W LL~N fnllnwingrcrinn.(Scc(iorr2O)LS,Uusine%antull`rnfessinr+s Cmlc:Mnycityorennrrry IRMP.MLTRRORPOLE INST.
F_sy ON which m9mirea n prmnh to tonins,miler,intparve,do oolieh,or rePnir any auadure
5§> prinro;lelaen:nme.nlxnm then rJicanl fur such nnfilenni reed mmenent POWER DEVICES 7 J
u{�� t 9nlms tI pcmJ p
wpy 0 Thal he It Ocnrseel Terminal to]fit p
rrovia^^.a or oro Contractor's License Law ill
da0y,
9lSWIMMING POOL ELECTRIC VALUATION
YC mm�nrndng wide Strikes nn ROfglnf Division)olihc nminean and l`rnresions Cml<)
pI_y orlhallieBrernnn@erehomandlliebasisforlheRllegnlriemptinn.An,sialntionoT OmanSWITCIIPS PIXTURPS a 73
k
Set Ilan 71115 hynity applicant for a Penangn mO
anhjeclire applieo n civil Penshy of
nil meal 11rnn Bvelmmlr<d ddl...(3{1X1).
O
� ❑ I,mnwnermftlreprnprny,nrmy nnpiny<uwillswnpemnstmirsolealnrpnnmlrnq NEW RESIDENTIAL ELECIR SQ.17. ��O- � .'OlS "YI'iCUNS1N IC-1 IIN
iwill Jo lire wank.rod lie sbncmreis not Intended looferml for male(Sec.Ill4,Onslneaa
and Professions Caste Un,Cnmracmr'n License Law does not artily to an owner lir
proMoy who hmildam hoposea daemon,and whodoem ench work mmaelror ennui,his
OCC.TillOtll' TUIS.UNI lS
hoerermieen,Tmai or that nveloarTmvmnnreart rrm hear ided orcmpicilod for owner
wevrw IT havedinenrlcinof mein imhsaid wilid lo(oild or
for mnawnaa" TOTAL:
Innun<r wIu haat fire hrnden lir Ina„erg arm Int girl rent I+sun lir hrnpnnve ren prrrpann ar
sale.).
❑ )
a.00nzG I: nrN
LmnwnernrmeT.sled,,.erearwa1.clyranvacmrgwhhuerm.nemroortarilt, Qr .
I,mnaect she Project(Sec.70,14,Business and Prefmsiona Cnum,1 lot Cantrmer's pERMI'r ISSUANCE
icenvel iwdorvmtapplymnn^wncrnfprnperiywlinhoilntnrimprmcalhcrc^n,n^d
who Oanmms for sedh pmjecln with nc larc us)licernalpmamanI mthe Corns,no's I
Idcrese Law. ALTER-BRAIN k VENT WA WIT(RA) FEE SUMMARY
❑ 1 ass evmpl inner Sec. ,R A P C for this reamer GO I- TUE vmutP'
BACK FLOW PROI ECT.O11 SANITARY Y_N
• Owns Dmc RECIiIPI X _
UItA1N5 FLOOR,ROOF,AREA,COND.
WORKMAN COMI'CNSATION UECLAIIATDN SCHOOLTAX Y_N
❑ Ilicrclnymff'rorlhmllmveacemi0entenlemnsreitti sd roominncarilicnle til RECEIITX
Workrrd Umar flan losarancanr a testified urn rhrrrof S<c.igal l.ah CJwhidr PI%'I'I)It ES PER'IRAP PARK PER Y N
Prmo I Y 4
awon all rrnpinyrc'n rrrWcr thi.pvrnJl, GAS EA,SYSTEMI INC,4oil TLET3 RECEIVI0
Policy N BUILDING DIVISION ITIS / cI
CmnP^r0' GAS.PA.SYSTEM-OVER4 THAI PLANCIIECK MIT �V,O6
L) Citified copy is herehy furnished. _
❑ Ccllnrncnpy ie filed with theclly innpcc0ondiv6Inn. OREASPgNDUSTRLWA3'rEINTERCEPfOR GRADING R!II S15-:OF
CrITIPICATE OP EXEMPTION FROM WORKERSORHASEIRAP SOILS FEE to 00
COMPENSATION INSURANCE
OLla xaian seminal lc cornplNcJ ifthc lxsmit is ler not adreldoll—Itllo) SEWER-SANI TAR Y-S I OR M IIA,2mrr. ENERGY THE 3 0
mlcsmd
I artily Char in the perfommnce of rhe work far which this permit is lsamu(I short WA'I FR DEA PER WIVENTR!LEMIT
nil mnpinY any Person in tiny manner so as to baleen subject In the Withers' PAID
Z Cnmlennntinn lawn ler Cnlirnrnin. Dote WATER SYS"11!M/EREI'IING On. Recdpi4
7 nririenrn
0 NOT ICE 10 APPLICANT:It, fit,nutria,do,Certificate of T:ncorl+llan,yn^mcohl NEW RESIDENTIAL PLmn. SQ.Ter. TO FAL: 21$nab'
.Q V) Tern(sobjecl to he Worker's Cannpensarian lnnvlsimrs of Tic Labor Cane,ynoor I '—
� , fnnhwirh cmnply will moll provldonsmlldn to..n0'half hedveneal rrvnkcA, BUILDING FFEi
W
CONSI'RlICT10N hI!NOINU AGENCY SHISMIC TRE Q
J z I lrachy affirm don there is R construction lnulieg agency lm the Trdnrnnnrr til
UO the work for which this permit is issued(Sec.J042.Cly.C.) TOTAL: yD r:1.ECTRICFGE J,
It W.None lir r a
U.. PLUMBING FRE
t� 1<mltdnndnre,a 7ev. . . , t.�ciinNi'cnLncnf�ii: `: ��:' ' SIO _
0 V 1 ccdiry That I hove read thin it,liemimr and notle rho the almva infennmirm it A1E:CI IANICAL FET- 0d
?e w carrel,Iagree incarplywmrnndlyold eoaalyordinances and state lawardmdngtn PimmirISSUANCE bs'
h”' MrilAinp anran¢rian,and hereby Rmhndae mpremenmOvo of Chia eirymonv nrym de CONSTRUCTION TA%
U z alxwemenlioned propcmy row no irelian purposes, ALTER Oft ADDTO MECII.
(Wei stare In nave,inde neify Rod keep Innmlcss the rhy lir Conciliar ngvimr
Iiuhiliri,,joar.rncnis.rom,ralcolon"'wlrlrinmry inonywnyarro..y;ninnt said Cir, A Ill I IA NDLING ON II'U O 1 ItNXI Cl M)
;."r e.npenre of tfit gmndng of this permit
Alit IIA N DIA NO UNIT(OVER 10,000 CI'M)
Sq,mdnre or ATTnerrm/Comramnr Dae EXnAUST I GOD(WIDUC)
_ rn1O
IIAZAR0O0S MATERIALS DISCLOSURE BEATING UNIT(TO 101L07IfI TITO) Date Receipl0
Will toe apir or hnnre huilAinp acctrpanl more or lonelle bacndova inalerlald
as denied by tan Op Linn Mi ieipal Cod'.Chnper 9,12,nod the IIi and Safety BEATING UNIT(OVER IIMI,gp Ill U) TOI AL: Q
Coil'.Seellmt25512(,)? VENT I LA'I'ION PAN ISI NOTE Il a g
1)Y" 0 No ISSUANCE DATE
Will0enpplicnrnne hnnrc hnilAingampamuaupriprncmar Jcvicn wlrichnnit DOILRR-COMF(lllp OR IIXI,(XIO TITO)
Immnlom ole rmunlaintm,m defined Ey the Rory Alta Air Qealily Maavpemrnt BOILER.COMP(OVER Iflq(%10 IT TO)
Dtmien
` ❑Yen ❑No NEW RESIDEN'T'IAL MECII, SQ.PL '
I have maul lire hmmaloos amtmlala rcgnlronm6s trader Chvpler 0.95 of lire
Collfmnla l lerllhRSnfely Code,SeOImB25505,25511 a 12551d. Itrndemund that
if file 1,01,14orelne1 nal cnrrcmly Imve rr mmol,ellen h ix my remlvnaihillly In notify the
rnpanl of It "non"which nrnsI Iv are Prior In lean.....of o Ce rifirme or —_
O"oP.mty.
eTvrwnm aaluni'd.'r l Onaa IOTM: ISSUFO DY: