20211 APPLICANTTO FILL IN INFORMATION WITHIN RED LiNES — USE �3�L�. r�;k!�a' ;>° #v, a: �°
r Buildin Pro'ect Identification �v� � PE7L'vIIT NO.
I Building Address: �O �� 1
�U`� �� �6�1.-� � � I
ner s ame: hone: A> O BMI AL DA
�j�� �-(.U��� 3�t,� CITY OF CUPERTINO-BUILDING DIVISION ( 1., ���-)�
Contrador's Ivame: Lic.IVo:
f. ` APPLICATION / PERMIT �t ''� t
�`�.1 BUILDING-II,ECTRICAIrPLUMBING-MECHANICAL CATEGORY CONTROL q�Z1 f�
Arehited/Engineer: Lic No: ����
q'rx ELECTRIC P�RMIT �g Bt1ILDING PERMIT 1NF0
Address: PIItMITISSUANCE � � � �
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- �'PI.IANCESRESIDENl'IAL JOB DFSCRII'1'IO \
ingwithSection7000)ofDivision3oftheBusinessandPro[essionsCode,andmy , �(],� � n `
license is in full force and effect. PANII-S L � ��`"l Q 0�-�/
License Clas9 Lic N ������
Date Contrador
ARCHITEC'I'S DECLARATION 201-1000 AMI'S '
�Z I understand my plans shall be used as public records. OVER 1000 AMI'S ' SQ.Ff•F[-OOR AREA $/SQ•FI•
O � �
��J V Licensed Professional SIGNSELECTRICAL QQ
t-¢•Q cW-, OWNER-BUILDER DECLARATION �,
N]� SPECIAL CIIZCUIT/MISC ,
E._, I hereby affirm that I am exempt from the Contractoi s License Law for the
�O`�..'�p following reason.(Section 7031.5,Buslness and Professions Code:My city or TFMP.METER OR POLE IIVST. �
�� a cwntywhichrequiresapermittoconstruct,alter,improve,demolish,orrepair i
���6 anystructure prior to its issuance,also requiresthe applicant for such permit to pp�,yFg DEVICES
file a signed statement that he is llcensed pursuant to the provisions of the
��w t-U• Contractor's License Law(Chapter 9(comcr�encing with Sectton 7000)of Divi- —
3 O Q sion 3 of the Business and ProfessionsCode)orthat he is exem therefrom and SWIIv1MING POOL EI,ECTRIC ! VALUAT'ION��y�:
���� the basis for the alle ged exem p tion. An y violation of Section 7031.5 b y an y ��{ C/� r` �-C./
OUTLEI'SSWITCHFSFI�CTURES � 1. G
applicant for a permit subjeds the applicant to a civii penalty of not more than J �
a�o� f've ndred dollars($500). SQ.FT.' STORIFS TYPE CONSTRUCTIOI�
Fj�� � IVEW RESIDENTIAL ELECTR
Q I,as owner of the properiy,or my employees with wages as their sole
5z� m nsation,will do the wor15,and the structure is not intended or offered(or
�O sale(Sec.704Q,Business and Professlons Code:The Contractoi s Llcense L.aw
�r3°� does not apply to an owner of properry who builds or improves thereon,and OCC.GROUP RFS.UNITS
whodoessuchworkhimselforthroughhisownemployees,providedthatsuch , ��
improvements are not intended oroffered for sale.If,however,the building or TOTAL:�
improvement is sold within oneyearofcompletion,the owner-builderwill have
th rden of proving that he did not build or improve for purpose of saleJ. Q1'y, �IMBIN�G PERMIT �� N'[,ppD 7ANE APN
�I,as owner of the property,am exdusively contracting with licensed PERMITISSUANCE '�1 �Y1
contractors to construct the project(Sec.7044,Business and Professions Code: J.��,��
The Contradoi s License Law does nd apply to an owner of property who pLTFR-DRAiN&VENT-WATQ2(EA)
bullds or impravea thereon,and who contracts for such p�jects with a F6E SUMMARY
co t actor(s)licensed pursuant to the Contractor's License Law. gp��pyy PROTECT.DEVICE
�I am ex m under Sec. B&P C for this reason 1
�n DRAINS FIAOR ROOF,ARFA,COND. SAMTARY RECIII'1'q
ORKMAN COMPENSATIO EC RATION ' �.�s�.I.�� SCI30pL TAX Y_ I�f
I hereby affirm that I have a certificate of consent to self-insure,or a RECIII''T N
ceftificate of Workers'Compensation Insurance or a certified copy thereof(Sea G EA.SYSTEM-1 INC.40U'I[.ETS PARK FEE Y N_
3800.Iab CJ � RECIII'I'N
Pdicy# _ GAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cam any
�Certified copy is hereby furnished. GREASE/INDUSIRL WASTE IN1"QtCEI'TOR PLANCHECK FEE
Ceriified copy is filed with the city inspedion division.
CERiIF7CATE OF EXEMP'I'ION FROM WORKEAS' GREASE TRAI' PAID
COMPENSA7'ION INSURANCE SEWF.R-SAMTARY-STORMEA.20oF1'. Date ReCelpt#
(This section need not be completed if the permit is Eor one hundred dollars
(5�00)or less.) WpTFR I IEATER W/VENT/II.ECTR ENERGY FEE Y_ N_
I certi(y that in the performance of the work(or which this permit is issued,
I shall not employ any person in any manner so as to become subject to the y�rp�TIR SYST'EM/TRFATII�IG �
Workers'Compensation Laws of California.Date PAID
0 Z Applicant NEW RFSIDENITAL PLMB. SQ.FI'. ' Date ReCei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Fxemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
� � Code,you must(oithwith comply with such provisions orthis permit shall be � BUILDING FEE �
deemed revoked.
W � ,
CONSTRUCTION LINDING AGIIVCY SEISMIC FEE 1
a � I hereby affirmthat there is a construdion lending agency Eor the pedorm- ToTAL: ELECTRIC FEE ti�
� Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) , �
() O ixndeisName PLUMBING FEE `��
LL 1= Lender's Address QTY. MBCHANICAL PERMIT �� MECHANICAL FEE '�„GG'
OW IcectifythatIhavereadthisapplicationandstatethattheaboveinformation �
a is correct.I agree to comply with all city and county ordinances and state laws PERMTT ISSLJANCE `� PEES PAID:
} � relating to building constnidion,and hereby authorize representatives of this
ci to enter u on the above-mentioned ro e for ins ection u ses. ALTE�OR ADD TO MECH.
~ ? ry(We)a�ee to save,indemnify an d keep�mless he City of Cupertino Date Receipt#
V against liabilities,judgments,costsand expenses which may in anywayaccrue AIR HANDLING L)NIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit. C�NS•I•RUC•I•I�N•I•AX
AIRHAIVDLIIVG U[�IIT(OVER IO,OOOCFM)
Signature of Applicant/CoMractor Date �a-�a.us r xoo�cwiDUC� CONSTRUCTIOIV TAX PAID:
HAZARDOUS MATER[ALS DISCLOSURE
Will the applicant or Euture building occupant store or handle hazardous ��1TTNG UMT(TO 100,o0o s'r[.J) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.72,and the
Health and Safety Code Sedion 25532(a)? I IEATING UMT(OVER 100,00o aT� TOTAL: � Q
�Yes �No
Will the applicant or future building occvpant use equipment or devices VEN"IILATION FAN(SINGLE RESID) j$S[�1\�/�'TE
which emit hazardous air contaminants as defined by the Bay Area Air - �
Q�lity Management Distrid? BOILER-COMP(3HP OR 100,000 BTLn
pYes No
I have read the hazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVIIZ 100,000 BN) t� ,
the California Health&Safety Code,Seaions 25505,25533 and 25534. I
understand that if the building does not currently have a tenaM,that it is my IvEW RFSIDENTIAL MECH. SQ.FC.
re&ponsibility to ndify the occupant of the requirements which must be met
priortoisguanceofaCertificateofOccupancy. f�.+� {`;'� �'.lfY1Pf'����,i
�� �, ��
ne or authoriud agent Date �y.� I��p gy.. `��.-'��tl.kJ--�C.i�
TOTAL: : �..�J
OFFICE COPY
.��'��.������•�a�L� �`���3�] ��l���i���.��.���� �����'�1�� �a+� ��i���� -- ��;:�� �:��� '�^�;�1;°�� 9�J'� ��i 1L��'
8uildin Pro"ect Identification 1 PIIi1�QTN0.
Building Address: ' � ���� �
� ��� '�J�.3..9 ' ���� ��Z
u� ner s ame: hone: N 5 A A
� �� �� � �,,��, ����..� �ITY OF CUI'ERTIN�-BUILDING DMSIOTI �'`��
..;ntrador's/[Y.a�mi'r.` . ' Lic.Na. fA p p L I CAT I O N / P E R�I IT � �`+ i�
r- V�.! BUII.DING-II.ECIRICALrPLUMBINGM'ECHAMCAL GAIEGORY COMROL f'�
�� Architea/&tgineer. Lic Na � v
,a�-,�� Y�--- .._n- �� ._, - - �, �.•.
•---�
. ._ ..,
,. �.�.: � _ ' .
.��"�-��s��''���"l�� a::,:�,.���.<�,,,�,,,_.�•x �...,.,` -
�N:�, ���:,�.y.:��-�..
Addxss: ��PERtvIITISS�JANCE ^. � � � �
LICENSED CON78ACC0&'S DECLARAT70N
I hereby affum tliat I am licenxd under provisioas of Chapter 9(mmmenc +u'1'L�N���EM'IAL J08
ingwith Section 7000)of Dtvfson 3 ofthe Buainoa andProfcsionsCode,mQ ��
licenx 3s in:ull fom and effea. P�S J� 1�U�-�l 1 l O N � O��
Licenx Glase Lie.1
Dabe Cor�ador
ARCHITECTS D6Q.ARATION �71-1000
O��FR 1000 AbII'S �Q.FT.FL.00R AREA S/SQ.FT.
�Z I understand ary plan+sEuII be uxd u public iemrds. �
�u�j Licensed Pr�esaicul SIGNS ELECIRICAL �vlJ
�N OWNFR-BUfLDEH DECLARAiION 9'E�IAL�CLR?/MLSC
� I hexby af6rm dut I am ocempt from the Co�rrdoYs Liceax Law far the
� loRawlag crasan.6���7U315,Busine�and Pm6es�ions�adC Any dty or TIIvQ'.MEI'ER ORPOLE INST.
E' rnuatywhieh requira a petauT to mnshuct,alter,impmve,dea+ollsh.a'rePair
� anysuuaurepdnrtotls�e,aTsarequlmstheappllrantfarwchpermitto I'04VFRDEVICES �
�U fik a agned statea�ent thaz he h llcensed pursuant tc the p:ovlsiom of the
a,� Consracbor s Lieeax Law lChapter 9(wmmeadng with SeCion fi00)of Dlvi- SWIivtIvtING POOL F1.E C ,
�� sion3 af the Busiar�a md Profesaiona Code)orth�he 3s axmpt therefrvmaod VALUAIION
Q,� the basis for the alleged exempeion. Any violatioa of Sedion 70315 bq any ��E.� � � �3 6 a �
�pplimnt!or a permit subjecb the appikant m a dvil paulty d not awre thaa �
ve dxed dapazs l�550�.
^ � � NEW RESID �r'4�.� SIi�RIES TYPE CDNSrRCJCIIOP!
z� I,u owner of ehe property,or my emPl°Yw with wagn as thelr aok
ai,willdo the war$.and the st:udure b not iatended or oHead for
�G sale l$ec 704�,Husiness and Prc�essions Coda 1'be Cc�aGo1a Lieesue I�vv -
c$$ does not aPP�y to an owner oE property wlw huilds or imprwe�thereon.and .. + OCG GROUP RFS.UMTS
who doo suehwodchimself orthmugh Ida own employW,provlded tlutsuch �
imprwemenes aze not intended ar oHered for sale.I�however,the 6uilding� � `'. tOTAL:�
improvemernissoldwithinoneyearofcompteHan.thewwer-bu�7�derwillhave _, ...:.._,.�,; ' ;,,�,�., _ ;;.�..�•:�;��-; -�,���,�:
th en oE pmving that he did not build or impewe for purpase of sale.� f��'``:�;�%-�' . _ ���„�:',°_' �.�5= . FLAOD ZONE APN
�as owner of the prapert};am exctusivety mntrxtlng wfth ll�xd PERMIT •�i ANCE,;. ��
emtru�xs Lo mnstrud the pmject(Se�7044.Businm utd Pr�essiamCodc
Ihe Contrdcro�s Lirense iaw does nd aPPi7'to an owner aC proQeriy w
build�ar Smpravn thereoM and who m�ads f�auch pmjeds wkh '�' & -WATFR�U � :��a��::�:>_rv,`��.���^�_�'�-:`-�-;y`f`i':
contracmr(s)liaensed punuant m the Contrador s License Law. BAC�C�iAW D � : ,..� "�.:..... -_�. � �
❑I am exemot under Sec B&P C for this xeascn • ' " -
� $ F � SAMTARY RECEII''f s
WORKMAN COMPINSATIO E I'ION � ' ' t �p�� y N
I hveby affum that I have a¢rtifiate of cansent to eelf-inaue,or a I RECEII'T N
certiSoke of Wodcas'Co�+ipensatton Insurana�a certif9ed ccpy theceof l$ec gyg�1 4 S� PAItK FFF � Y� N_
3800,Lab CJ RE�'I t
PolicyN .SYSTFM-0VIIt �E.
�m Y , BUILDINGD[VISIONFEES
�Certified mpy is hereby Curnished. GRFASE/INDUSTRL WAS'IE IDfPIIZCII'TOR ( PLAIVCHECK FEE
�Certified mpy v filed with tlu dty impeGion diviaion.
CERTffiCA7E OF DCEMYrIQN FROM WORKERS
��' I PAID
COMPENSAT1oN INSURANCE SE�vER SP,MTARY_SfoRMEA.20�,-r , Date Recei t#
(Ihis sedian need nd be ccmpieted if the pes�adt a for ane hundred dollus
csi am��a wnr��a�x wivErrri�crx ENERGY FEE Y_ N_
I certify that in the perforaanee of the wark forwhich tLis permit ia issued, �
I shaIl rtot emPloy aay perwa in any mannv ao u to bemme aubjea m ehe WATER SYSIFM!'II2FA'IING PA11�
Workexs'Compensation Laws af Ga]Ifarnia.Dm
A Hont
O NOP'IICE TO APPLICANf:If,aRu making tl+u CertlElcaee of Eumqtloa Y°u NEW RESIDEZ�ftL4L PLMB. 9Q.Ff_ a te ecei t#
shauld become aubject to the warkea'Compensatian p:vvtsio:n ot rhe Labor TOTAL'
y Code.you cuut forthwith aompiy wfth wch provisioiu arthis permit shall he t
� deemed ievoked.
� CONSTRUCTION LINDING AG}NCY • S SMIC
Z I hereby affirm tlut there h a mn9trudion knding ageMy for tlie perlomr �.$Cj'j�j��E
anQ af the wark Eor which this permit is tuued 6K 3097.Civ.CJ TOTAL: �
� Lenders Name ,;a»��.� �•,y-�=�•u=,•:4:,f r .;�:. - PLLTMBING FEE �i.��
h- Lendets Addiess , e;��,�����: :'4. , _ ����(.� ^
U IcertifythatIhavereadthisappilcationandAatethutheabovein(orauHort - i��
a ���c.ra�m�pty„��u a�y�na�y ma���,a�c�� r�ar rssv.yivcE `C� FEES PAIU
� relating to building mnseudioa,and hereby authodze tepr�utiva oE this
z dty to enrer upon the above-mentloned property f�'vmp�dlon purpoxs. ALTIIt OR ADD 1l�MECFi. o-dtE • Retei t#
— (W�agree to srvS iademnlfy an d keep hazmless t4te City of Cupertino
against Ifabilities,judgmenb,eo�s and acpen�a which aray in anyway:cave AIIt HANDLING UMT CTO 10,000 CFM) SL�TOTAj.:
aga4ut said City in wnsequena of the granting af thia pem+tt.
,�nt xnrmurrc unrtr ro�a ia,o��n,n CONSTRUCTIOI�(TAX
s���ar.e.�pu�,tic�aa� �� �r.avsrx000cwiDUrn CONSTRUCTION TAX PAID:
HA2ARDOUS MAtIItIALS DISCLOSURE
Will the applinnt or Eutuce bullding omipant soore or handle ha�rdous HFAI'!NG UMT(7'O 100,000 BT[J) 1}dte R2te1 t#
a+aterial u deFined by tl�e Cupertino Munidpal Code,Chapter 912,and the
Health and SaEety Code Sectioa 25532(a)? HFAITNG UMT(OVER 100,000 8T� � TO?AL: � Q
�Ye9 ��O VES(TILATZOiY FAN GSINGLE RESID)
Will the applicaat or future building ompant use equlpment or devices ISS��i�
which emit Euardous air aontaminaMS as de$ned by the Bay Area Air
QuaHty ManagemeM D�striG? . BOQ.FR-COMP�3HP OR 100,00�BTCn
4hav�e read the hazardau materials requiremeats underChapter 6.95 oE BOB.IIt-CO:vII'(OVII2100.000 B'itJ) - - ' �;. � 1:��:j
the Ealifornia?iealth dc Safety Code,Sectiom?550.5.75533 and 25534.I � .
undecsWnd tlut if the butlding doc not currendy have a tenant,that it is my �W R�D�L MECEL $QFf�
rsQonsibility W ndi{y the occupatu of the requirements which must be met �'+�,}�f �L t'+34�}'�i y���
priar to uance of a Certificate of Occupancy. L� i9 � �
�
or authoriz_-d agenc L�+te y�(�p gy; L _
20TAL•