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28630MW oo aVF t4 U Lea z °52- A a ' OWU awl"' 0AWCe 0 FAQ �xA .1. o a�� Z ~� H aA UO OF Ha Uz APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICA BUILDING ADDRESS: OW4TE12'S NAME: J J , w PHONE: I I CQAIJRACTOR'S NAVE: �' ,�LIC�NO:: S -Y7 v PHONE: u LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. ❑ Consultant Fees Paid by Applicant (Initial) License Class Lic. # Date Contractor ARCHITECT'S DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER - BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not buildor improve for pur- pose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- rense Law does not apply to an owner of property who builds or improves thereon, and QTY who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: 'Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compen- sation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct I agree to comply with all city and county ordinances and state laws relating to QTY. building construction, and hereby authorize representatives of this city to enter upon the above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICA T UNDERSTANDS AND WILL COMPLY ITH AL NON -POINT SO CE L ON� Signature of Appli ant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fornia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP TO 200 AMPS 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUITIMISC. �t�, TEMP. METER OR POLE IN - f POWER DEVICES DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTR SQ FT. TOTAL: PLUMBING PERMIT PERMIT ISSUANCE I h r ALTER - DRAIN & VENT - WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS - FLOOR, ROOF, AREA, COND. FIXTURES - PER TRAP GAS -EA. SYSTEM- I INC. 4 OUTLETS GAS - EA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER - SANITARY - STORM EA. 200 FT. WATER HEATER W/VENT/ELECTR WATER SYSTEMIIREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT MECHANICAL PERMIT PERMIT ISSUANCE C'�F ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER - COMP QHP OR 100,000 BTU) BOILER - COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE TOTAL: � � Iz-" PERMIT NO'28630 SANITARY NO. AP CATION SUBMITTAL DAT ct-K ,qt; N/C CONTROL # BUILDING PERMIT INFO J Cry kLEC P M� JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL a , ❑ KITCHEN REMODEL ❑ ADDITION d ❑ PLUMBING RE -PIPE ❑ M-UNIT ❑ STRUCTURAL MODIFICATION ❑ CHIMNEY REPAIR !a,M ROVEMENT �90 ❑rB "ATH'REMODEL/REPAIR ❑ DEMOLITION ❑ OTHER cri / Fr, COMMERCIAL: W BLDG /ADDITION ❑ DEMOLITION PLJ TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER SQ. FT. FLOOR AREA $ /SQ. FT. 3 1 I kV40__,' STORIES TYPE CONSTRUCTION OCC. GROUP APN SIGN FEES GRADING FEE O.W SOILS FEE PAID Date R t# TAL: BUILDING FEE FEE SEISMIC FEE ELECTRIC d PLUMBI MECHANICAL FEE CONSTRUCTION T HOUSING MITIGATION PAID Date Receipt # � O A ISSUANCE DATE ISSUED BY: P1rr LIlrHIV 1 1 V rILL im mruruviAi IVIV VV l n11V nMLO LIIVMO' LOOM OfiLL rV1114 1 rr-114 VIYLi CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: 1 Q l STeVR,I't S CV, 4M[� Z, V OWNER'S AME: PHONE: CONTRA TOR'S NAME: LIC NO: Da v eewz`e- 40 a gS OS2 3 r ( /� t, /Z�lo2� 'S�vs /ENGI C UouKe �NO: O0 ADDRESS. 111 l �I'L S-f TILAJC_ CA 9 /063 CONTACT: PHONE: 02,001A� `_,& r ❑ Consultant Fees Paid by Applicant (Initial) LICENSED CONTRACTOR'S DECLARATION 1 6 J QTY. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing W0 Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is xW in full force and a t. t`4 1 d U License Lic. # U J Y aF a PWn Date Contractor ARCHITECT'S DECLAR ON Z1 understand my plans shall be used as public records WLicensed Professional a OWNER - BUILDEP DECLARATION yi W Q I hereby affirm that I am exempt from the Contractors License Law for the A. U following reason. (Section 7031.5, Business and Professions Code: Any city or county C")- y which requires a permit to construct, alter, improve, demolish, or repair any structure aprior to its issuance, also requires the applicant for such permit to file a signed statement �. that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 A(commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of F z not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, [� A will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for pur- pose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and QTY• who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: �I have and will maintain a Certificate of Consent to self- insure for Worker's Compen- on, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Work6' ' C onjpensano Insurance carrier and Policy nt�bg LA 14 SW Carver:-j C.G Policy No.: (� "1 (�9 7 CERTIFI TE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compen- `Z, sation Laws of California. Date .0Z C) Applicant . H rA NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should E" t 0-4 become subject to the Worker's Compensation provisions of the Labor Code, you must wA forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY U O I hereby affirm that there is a construction lending agency for the performance of w H the work for which this permit is issued (Sec. 3097, Civ. C.) O U Lender's Name 0 U Lender's Address a I certify that I have read this application and state that the above information is HV) correct. I agree to comply with all city and county ordinances and state laws relating to QTY. U Z building construction, and hereby authorize representatives of this city to enter upon the H above- mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT U ERSTAND AND WILL COMPLY WITH ALL NON -POINT SOURCE RE IONS. Signatur tca on c Date AZAR OUS MATERIALS DISCLOSURE tll the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes Will the applicant or ture fu building occupant use equipment or devices which hazardous air contaminants as defined by the Bay Area Air Quality Management ict? ❑ Yes No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fornia Health & Safety Code ections 25505, 25533 and 25534. I understand that if the building d n currend ve a to it is my responsibility to notify the occupant of the re me lu stA4et prior to issuance of a Cer ifiWe of OccupatIc y. ELECTRIC PERMIT I FEE PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP TO 200 AMPS 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL JOB DESCRIPTION FhRMI i NU. 30514 SANITARY NO. APPLICATION SUBMITTAL DAT. .ZL -'SAS N/C ❑ % COON`TROOLL## �! /v �.J ,INFO BUILDING PERMIT BLDG ELE PLUMB MECH JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEUREPAIR ❑ DEMOLITION ❑ OTHER P Al 0 SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE IN COMM ❑ EW BLDG //ADDITION ❑ MOLITION XTE y Ur tUetjpfffiQtp SERVICE IMPROVEMENT Ar El POWER DEVICES SWIMMING POOL ELECTRIC O TLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTR SQ FT. ft SQ. FT. FLOOR AREA _ i� V - _L1 O` 1996 $ /SQ. FT. TOTAL: PLU FEE PERMIT ISSUAN ALTER — DRAIN & VEX A R( A) Q VALUATION N� PEC I I . BACK FLOW PROTE D DRAINS — FLOOR, ROOF, AREA, COND. IIVO V TYPE ONSTRUCTION FIXTURES — PER TRAP ` GAS — EA. SYSTEM -I INC. 4 OUTLETS OCC. GROUP APN GAS — EA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR BUILDING DMSION FEES GREASE TRAP PLANCHECK FEE SEWER — SANITARY — STORM EA. 200 FT. ENERGY FEE WATER HEATER WNENT/ELECTR f GRADING FEE 7� WATER SYSTEM/TREATING SOILS FEE WATER SERVICE PAID Date Receipt # NEW RESIDENTIAL PLMB. SQ. FT. TOTAL: TOTAL: BUILDING FEE MECHANICAL PERMIT FEE SEISMIC FEE D' p PERMIT ISSUANCE ELECTRIC FEE ALTER OR ADD TO MECH. Z PLUMBING FEE AIR HANDLING UNIT (TO 10,000 CFM) MECHANICAL FEE AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX EXHAUST HOOD (W/DUCT) HOUSING MITIGATION FEE HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) PAID VENTILATION FAN (SINGLE RESID) Date Receipt # BOILER — COMP (3HP OR 100,000 BTU) TOTAL: BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER ISSUANCE DATE i1 NEW RESIDENTIAL MECH. SQ. FT. t ISSUED BY: OFFICE APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION //�� 7 PERMIT NO O �T 1 O BUILDING ADDRESS: / l o S7ERv5 4a=7< &_V6 . SANITARY NO. APPLICATION SUBMITTAL DAT OW'S N!' , f PHONE:' O� CONTRA TO$'S jjAM�: LIC NO: N/C El CONTROL # ;RCHITECT/EN INEER: LIC NO: I ADDRESS: j p � �� (..I 1iV G �' CONTACT: PHONE: ��i / 1 �• p1 �.. r �� /y i •7 ❑ Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG ELECT PLUME MECH El /Cat ❑ ❑ \� z W C 0 H r= W F. U P zd W LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000 of Division 3 of the Business and Professions Code, and m license is > y in full force and effect � , License lass Lic. # Date Contractor QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ADDITION El PLUMBING RE -PIPE ❑ MULTI -UNIT []STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEUREPAIR ❑ DEMOLITION ❑ OTHER PERMIT ISSUANCE APPLIANCES — RESIDENTIAL F- �D V) O w z Ca AR ITECI"S DECLARATION I understand my plans shall be used as public records PANELS UP TO 200 AMPS F W a W � O W W U W O to ap.ior (.t� �. y A p,i o 0 W, to z y, 5aJ-' F A 4 00000 Licensed Professional OWNER- BUILDEK DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for pur- pose of sale.). F1 I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. , B & P C for this reason 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METE OR POLE INST. COMMERCIAL: ❑ NEW BLDG /ADDITION ❑ DEMOLITION El TENANT ❑FOOD SERVICE IMPROVEMENT ❑ OTHER PO VICES SW POOL ELECTRIC ETS TCHES — FIXTURES N RESIDE CTR SQ FT. SQ. FT. FLOOR AREA Alin, 6! aa E 96 $ /SQ. FT. 1 QTY, PL1N� G PERMIT FEE PERMIT ISSUANCE ALTER — DRAIN & VENT— WATER (EA) ZZ O Z 0-t ; WA V O w H O U � CA V Z ~ Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self- insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Wor 's r e i n Incty�ace�ard and Policy number are: Carrier: //VJ G�ii Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any per o to any manner so as to become subject to the Workers' Compen- sation Laws Date Applicant VALUATION BACK FLOW PROTECT. DEVICE DRAINS — FLOOR, ROOF, AREA, COND. STORIES TYPE CONSTRUCTION FIXTURES — PER TRAP GAS — EA. SYSTEM -1 INC. 4 OUTLETS OCC. GROUP APN GAS — EA. SYSTEM -OVER 4 (EA) GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DNISION FEES GREASE TRAP PLANCHECK FEE SEWER — SANITARY — STORM EA. 200 FT. ENERGY FEE WATER HEATER WNENT/ELECTR GR FEE NOTICE TO APPLICANT: If, aft ng thts iftcate o Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name WATER SYSTEMlfREATING SO WATER SERVICE ate Receipt # NEW RESIDENTIAL PLMB. SQ. FT. TOTAL: Lender's Address TOTAL: B ILDING E I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above- mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. QTY MECHANICAL PERMIT FEE MIC FE PERMIT ISSUANCE TRIC E BNG E %CHAINICJL ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) FEE AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRU ON TAX Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fomia Health & Safe Code, Sections 25505, 25533 and 25534. I understand that if the building does rren[ly have a t , that it is my responsibility to notify the occupant of the m hich u e rior to i suance of a Certificate of Occupant . �• EXHAUST HOOD (W/DUCT) HOUSING MI IGATION FEE HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) PAID Date t # VENTILATION FAN (SINGLE RESID) BOILER — COMP (3HP OR 100,000 BTU) TOTAL: BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER ISSUANCE DATE -, ISSUED BY: NEW RESIDENTIAL MECH. SQ. FT. TOTAL: Owner or aufh6rized agent Date OFFICE ArrLIwA1v I I v rILL Iry mrvi-t Ivim Ivly vvI 1 MIN neu LIN= - ux DALL rvIN I rMN UNLr CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATIOT BUILD I` I) V e," < c L OWNER'S NAME: k PH NE: CONTRACTOR'S NAME: LIC C /3 ^ ) I ,-t V121 2R An '7 9-t. & 111, 1-/-- V fill CCK: i.iL iV V. HLLKCJJ: e L +AR$Z(t 1 1 Z, 01 -ko' Dc"I I PHONE: ❑ Consultant Fees Paid by ADDlicant (Initial) AkZ_4'RDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fornia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date ELECTRIC PERMIT I FEE PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP TO 200 AMPS 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRICQ OUTLETS — SWITCHES — FIXI NEW RESIDENTIAL ELECTR PLUMBING PDP.We I FEE PERMIT ISSUANCE ALTER — DRAIN & VENT— WATER (EA) 4 BACK FLOW PROTECT. DEVICE DRAINS — FLOOR, ROOF, AREA, COND. FIXTURES — PER TRAP GAS —EA. SYSTEM- I INC. 4 OUTLETS GAS — EA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER — SANITARY — STORM EA. 200 FT. WATER HEATER WNENT/ELECTR WATER SYSTEM/I'REATING. WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT. MECHANICAL PERMIT I FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER — COMP (3HP OR 100,000 BTU) BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE PERMIT NO. 2 9 7 9 SANITARY NO. APPLICATION SUBMITTAL DATI N/C CONTROL # ❑ A . % le, BUILDING PERMIT INFO BLDG ELECT PLUMB MECH JOB DESCRIPTION r _ NLICENSED 4 C z -w- U U n Q WW Z CONTRACTOR'S DECLARATIO I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic. # Date Contractor ARCHITECT'S DECLARATION I understand my plans shall be used as public records QTY ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL WLicensed J X W Q 0.0 LO rj t }i Professional OWNER- BUILDEP- DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEL/REPAIR ❑ DEMOLITION A 0a (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of MW .� d 3 0 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of ICI property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for pur- pose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and QTY, who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: -. ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ,Jdy Worker's ensa w�lrrsurance c er and Policy nu Carrier: Policy No.: CIERTACATF S OF ETION FROM WORKER ' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall Z not employ any person in any manner so as to become subject to the Workers' Compen- cation Laws of California. Date C) 0 Applicant t.y A U O NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of w H O U ,� U the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Lender's Address a I certify that I have read this application and state that the above information is HrA U z correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the QTY. H above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. ) AkZ_4'RDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fornia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authorized agent Date ELECTRIC PERMIT I FEE PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP TO 200 AMPS 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRICQ OUTLETS — SWITCHES — FIXI NEW RESIDENTIAL ELECTR PLUMBING PDP.We I FEE PERMIT ISSUANCE ALTER — DRAIN & VENT— WATER (EA) 4 BACK FLOW PROTECT. DEVICE DRAINS — FLOOR, ROOF, AREA, COND. FIXTURES — PER TRAP GAS —EA. SYSTEM- I INC. 4 OUTLETS GAS — EA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR GREASETRAP SEWER — SANITARY — STORM EA. 200 FT. WATER HEATER WNENT/ELECTR WATER SYSTEM/I'REATING. WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT. MECHANICAL PERMIT I FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER — COMP (3HP OR 100,000 BTU) BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE PERMIT NO. 2 9 7 9 SANITARY NO. APPLICATION SUBMITTAL DATI N/C CONTROL # ❑ A . % le, BUILDING PERMIT INFO BLDG ELECT PLUMB MECH JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEL/REPAIR ❑ DEMOLITION ❑ OTHER COMMERCIAL: V ❑ EW BLDG /ADDITION [I DEMOLITION CANT ❑ FOOD SERVICE ❑ OTHER SQ. Fr. FLOOR AREA $ /SQ. FT. aabt ION Q S1Mk(Escrj 111yu11 TYPE CONSTRUCTION P4ULMO DIVISION FEES ENERGY FEU J X66 GRADING FEE SOILS FEE PAID Date cey # TOTAL: BUILDING MECHAVW,AL FEE CONSTRUCTI TAX HOUSING MITIG ION FEE PAID Date eipt # TOTAL: ISSUANCE DATE ISSUED BY: WOO W F U �ZW. °z4- A WU 3wH �Od Va ttrry� � q�o�,/ F'Z Q x � A x�o APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL I PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: 19110 Stevens Creek Blvd. The Roasted Coffee Bean OWNER'S NAME: PH CONTRACTOR'S NAME: LIC NO: renant:Jared Carlson �5 -1919 ProCon Construction 49041 P: �CHITECT/ENGINEER: LIC NO: ProCon Construction CONTACT: PHONE: Tim Healey 247 -1444 490413 ADJ�M DeMille Dr. SJ 95117 LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class 4 80413 Lic. # e l a s s Date Contractor ARCHITECT'S DEC On I understand my plans shall be used as public records ❑ Consultant Fees Paid by Applicant (Initial) QTY. ELECTRIC PERMIT FEE PERMIT ISSUANCE APPLIANCES — RESIDENTIAL Licensed Professional OWNER - BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner o property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for pur- pose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and QTY who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: .. 17 I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as required by Section 00 of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy nu b are: i n:746 Cartier: Policy No. : ea ER OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compen- sation Laws of California. Date C) Applicant . ,t ,Lo� NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should (~ " become subject to the Worker's Compensation provisions of the Labor Code, you must wH forthwith comply with such provisions or this permit shall be deemed revoked. A Z CONSTRUCTION LENDING AGENCY U O I hereby affirm that there is a construction lending agency for the performance of L7~ H the work for which this permit is issued (Sec. 3097, Civ. C.) 0 U Lender's Name ��A��T�� U Lender's Address a I certify th I h 4aa 1ppr! cat' nE4t= thW above information is H(A correct. I agree top �j ei r unt Q iynces �l J elatin to �.i Z building constructRfn�ifdher b a tl(otizebresen7ali'ves of this cy �ot�er upon the Q H above - mentioned SUri be pcg2b2p2poses. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLI ERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGU AT S. Signature o Appli Contractor Date AZARDOU ATERIALS DISCLOSURE Will the a l an[ or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑Yes -0 No Will the applicant or future building occupant use equipment or devices which ::mit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes -*No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fornia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authorized or authorized agent rate PANELS UP TO 200 AMPS 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUI TEMP. METER O O INST. POWER DEVICES SWIMMING POOL EL IC) OUTLETS — SWITCHES — F NEW RESIDENTIAL ELECTR SQ FT. PLUMBING PERMIT I FEE PERMIT ISSUANCE ALTER — DRAIN & VENT— WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS — FLOOR, ROOF, AREA, COND. FIXTURES — PER TRAP GAS — EA. SYSTEM -I INC. 4 OUTLETS GAS — EA. SYSTEM -OVER 4 (EA) GREASE/INDUSTRL WASTE INTERCEPTOR TRAP SANITARY — STORM EA. 200 FT. WATER HEATER WNENT/ELECTR WATER SYSTEM/TREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT. MECHANICAL PERMIT PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000AIR HANDLING UNIT (TO 10,000 CFM) i AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCf) HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER — COMP (3HP OR 100,000 BTU) BOILER — COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. nFFIC;E 1 FEE SANITARY NO. 3 N/C CONTROL # ❑ eV S2.1 BUILDING PERMIT INFO B KC UMB EC JOB DESCIAPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR. ❑ CHIMNEY REPAIR IMPROVEMENT ❑ BAT ., LIREPAIR(�❑ DEMOLITION El OTH 6�T -IQ COMMERCIAL: W BLDG /ADDITION ❑ DEMOLITION NANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER SQ. FT. FLOG AREA $/S FT. L-kvc, tk . VALUATION ` STORIES TYPE CONSTRUCTION OCC. GR( BU PLANCHECK FEE ENERGY FEE GRADING SOILS FEE PAID Date Receip TOTAL: BUILDING FEE SEISMIC FEE t ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Receipt # ISSUANCE DATE ISSUED BY: TM00— APPLIGANI TU FILL IN INFUHMATIUN WI IHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING DIVISION APPLICATION/PERMIT BUILDING - ELECTRICAL PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFICATION PERMIT NO. 30135 BUILDING ADDRESS: PANELS UP TO 200 AMPS SANITARY NO. APPLICATION SUBMITTAL D ATE 110 V T Lee—(c kvo (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through IC^�28"toz OWNER'S NAME: .AACIE=/ENGINEER: PHONE: LIC NO: I CONTRACTOR'S NAME: LIC NO: N/C ❑ CONTROL # ADDRESS: - g CONTACT: I �.1a7`u4 ❑ Consultant Fees Paid by Applicant (Initial) CZ U )-,4 p, Uy 0 t� n��111 LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full face and eff � License Ck. Lic. # 57 S 8 Date C3S'S Contractor 4i�+� 96N ARCHTTECPS DECLARATION I understand my plans shall be used as public records Litxed Professional OWNER- BUILDER DECLARATION 1 I hereby affirm that I am exempt from the Contractors License Law for the following reason. (Section 7031.5. Business and Professions Cork: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prid('to its issuance, also requires the applicant for such permit to file a signed statement that he is hceymsed pursuant to the provisions of the Contractors license Law (Chapter 9 QTY 5� APPLIANCES - RESIDENTIAL ❑ MULTI -UNIT PANELS UP TO 200 AMPS APN 2 ❑ INTERIOR OVER 1000 AMPS AC o .�'. Z C 3 .. c co t. .r (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through 5tra. ot SPECIAL CIRCUIT/MISC. GRADING FEE TEMP. METER OR POLE INST. POWER DEVICES his own employees, provided that such improvements are not intended or offered for SWIMMING POOL ELECTRIC PAID Date sale. If, however, the building or improvement is sold within one year of completion, the NEW RESIDENTIAL ELECTR SQ FT. owner-builder will have the burden of proving that he did not build or improve for pur- pose of sale.).. " ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li- ..t :,, tense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's l.iaau Law: " ❑ I am exempt under Sec. B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: have and will maintain a Certificate of Consent to self -insure for Workers Compen- as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Worker, �mpensation Insurance carrier and Policy ntwfber gore: Carrier:. 51iiT� FUN 0 Policy No.:. SSKK CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Ibis section need not be completed if the permit is for one hundred dollars (S 100) or less.) . I certify that in the performance of the work for which this permit is issued, I shall ,7.., O O .Z.0 Ij f y ; w >" V O 44 H V .4 LO J z not employ any person in any manner so as to become subject to the Workers' Compen- sation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should becon* subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION L.EMING AGENCY w,.', herelW affirm that there is a construction lending agency for the performance of the a; ,� 7cF hich this permit is issued (Sec. 3097, Civ. C.) Lender's Name tenders Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the QTY m--c above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE RE ULATIONS. Signature of Applicant/ClOb6actor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑ Yes ❑ No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- fornia Health & Safety Code, Sections 25505. 25533 and 25534. 1 understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. Owner or authnrimd agent Date Y ELECTRIC PERMIT RESID ENTIAL: ❑ SFDWL PERMIT ISSUANCE 5� APPLIANCES - RESIDENTIAL ❑ MULTI -UNIT PANELS UP TO 200 AMPS APN 201 -1000 AMPS ❑ INTERIOR OVER 1000 AMPS IMPROVEMENT SIGNS ELECTRICAL 5tra. ot SPECIAL CIRCUIT/MISC. GRADING FEE TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC PAID Date OUTLETS - SWITCHES - FDCTURES NEW RESIDENTIAL ELECTR SQ FT. TOTAL: PERMIT ISSUANCE ALTER - DRAIN & VENT - WATER BACK FLOW PROTECT. DEVICE �/ DRAINS - FLOOR, ROOF, AREA, COND. 'e FIXTURES - PER TRAP GAS - EA. SYSTEM -1 INC. 4 OUTLETS GAS - EA. SYSTEM -OVER 4 (EA) GREASFANDUSTRL WASTE INTERCEPTOR GREASE TRAP SEWER - SANITARY - STORM EA. 200 FT. WATER HEATER W/VENT/ELECTR WATER SYSTEMI BEATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ. FT. TOTAL: MECHANICAL PERMIT FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT (TO 10,000 CFM) AIR HANDLING UNIT (OVER 10,000 CFM) EXHAUST HOOD (W/DUCT) HEATING UNIT (TO 100.000 BTU) HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE RESID) BOILER - COMP (3HP OR 100.000 BTU) BOILER - COMP (OVER 100,000 BTU) AIR CONDITIONER NEW RESIDENTIAL MECH. SQ. FT. OFFICE TOTAL: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH El [k F-1 ❑ JOB DESCRIPTION RESID ENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL APN MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ENERGY FEE ❑ BATH REMODEL/REPAIR ❑ DEMOLITION ❑ OTHER GRADING FEE COMMERCIAL: ,❑�EW BLDG /ADDITION ANT IMPROVEMENT ❑ OTHER ❑ DEMOLITION ❑ FOOD SERVICE SQ. FE FLOOR AREA I $ /SQ. FT. VALUATION BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Receipt # TOTAL: ISSUANCE DATE ISSUED BY STOM0 TYPE CONSTRUCTION OCC. GROUP APN 207 °r :.,BUILDINGDIVISIONFEES , '. PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Date Receipt # TOTAL: BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Receipt # TOTAL: ISSUANCE DATE ISSUED BY WOO QW U 'U PQa FON z�z VFW a OpWU 3wH COQ :C Q W 0 FZ� He R. oz z° (~ � (3a H Qa A UO OU U E" Uz ArrLH -ATV 1 I v rILL ITV IIVrUFIIYIAI TUN VVI I nIN ntU LIrvC.7 - U,t DALL VVIN I F rN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL BUILDING PROJECT IDENTIFIC. BUILDING ADDRESS: NAME: PHONE: I CONTRACTOR'S NAME: CONTACT: / PHONE: _ Air-vfi _1x91.. LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and efffj.. r License ss Lic. # Date —i ARCHITECT'S DECLA RATION I understand my plans shall be used as public records Licensed Professional OWNER - BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a perihit subjects the applicant to a civil penalty of 11 1 not more than five hundred dollars ($500. [] I, as owner of the property, or my em Ioy"s with wages as their sole compensation, will do the work, and the structure is not intend d or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's Lic rise Law does not apply to an owner of property who builds or improves thereon, , d who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for pur- pose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the ro ect (Sec 7044 Business and Professions Code) The Contractor's Li- ivty � SANIT P LIC NO: N/C El Consultant Fees Paid by Applicant (Initial) QTY ELECTRIC PERMIT FEE PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP TO 200 AMPS 201 -1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTR SQ FT. P J cerise Law does not apply to an owner of property who builds or improves thereon, and QTY, PLUMBING PERMIT FEE who contracts for such projects with a contractor(s) licensed pursuant to the Contractors RESIDENTIAL: AIR HANDLING UNIT (OVER 10,000 CFM) License Law. ❑ I am exempt under Sec. , B & P C for this reason ❑ KITCHEN REMODEL PERMIT ISSUANCE HAZARDOUS MATERIALS DISCLOSURE ALTER - DRAIN & VENT - WATER (EA) HEATING UNIT (TO 100,000 BTU) Owner Date as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety BACK FLOW PROTECT. DEVICE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ SWIMMING POOLS DRAINS - FLOOR, ROOF, AREA, COND. ❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the I FIXTURES - PER TRAP work for which this permit is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management 3700 of the Labor Code, for the performance of the work for which this permit is issued. GAS -EA. SYSTEM -1 INC. 4 OUTLETS My Work's Compet sation Insurance carrier and Policy um r/ AIR CONDITIONER Carrier:}` Policy No; / O.2 / 13 GAS - EA. SYSTEM -OVER 4 (EA) CERTI CATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE er o onz ag [ ate GREASE/INDUSTRL WASTE INTERCEPTOR (This section need not be completed if the permit is for one hundred dollars ($100) or less.) OFFICE GREASE TRAP I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so to beco�mejuN ect to the Workers' Compen- SEWER - SANITARY - STORM EA. 200 FT. WATER HEATER WNENT/ELECI'R sation Laws pf g alijomia. Date �% r��/`�/ %r Applicant - __l�Ft r� r NOTICE TO APPLI�If�ng this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must WATER SYSTEM(fREATING WATER SERVICE forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ. Fr. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Lenders Address TOTAL: I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the QTY MECHANICAL PERMIT PERMIT ISSUANCE above - mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against ALTER OR ADD TO MECH. liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. AIR HANDLING UNIT (TO 10.000 CFM) APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. PERMIT NO. S 0614 NO. I APPLICATION SUBMITTAL DA7 BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ❑ LIT ❑ ❑ JOB DESCRIPTION RESIDENTIAL: AIR HANDLING UNIT (OVER 10,000 CFM) Signature of Applicant/Contractor Date ❑ KITCHEN REMODEL EXHAUST HOOD (W/DUCT) HAZARDOUS MATERIALS DISCLOSURE ❑ MULTI -UNIT HEATING UNIT (TO 100,000 BTU) Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety ❑ INTERIOR ❑ CHIMNEY REPAIR Code, Section 25532(a)? ❑ SWIMMING POOLS HEATING UNIT (OVER 100,000 BTU) ❑ Yes ❑ No VENTILATION FAN (SINGLE RESID) Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER - COMP QHP OR 100,000 BTU) BOILER - COMP (OVER 100,000 BTU) District? ❑ Yes ❑ No AIR CONDITIONER I have read the hazardous materials requirements under Chapter 6.95 of the Cali - NEW RESIDENTIAL MECH. SQ. FT. fomia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently ha a tenant, that i is my responsibility to notify the occupant of r• irements which st be met p ' o issuance of a Certificate of Occupan er o onz ag [ ate TOTAL OFFICE PERMIT NO. S 0614 NO. I APPLICATION SUBMITTAL DA7 BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ❑ LIT ❑ ❑ JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ ADDITION ❑ PLUMBING RE -PIPE ❑ MULTI -UNIT ❑ STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT ❑ SWIMMING POOLS ❑ BATH REMODEUREPAIR ❑ DEMOLITION ❑ OTHER COMMERCIAL: ❑ NEW BLDG /ADDITION ❑ DEMOLITION ❑ TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER oe i SQ. FT. FLOOR AREA $ /SQ. FT. OCT 2 7 RECD CITY Ui- �Iur h I INO VALUATION STORIES TYPE CONSTRUCTION BUILDING DIVISION FEES PLANCHECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Date ceipt # TOTAL: BUILDING FEE FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FE PAID Date Receipt # TOTAL: ISSUANCE DATE ISSUED BY: APN