21954 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PF TNO.
Building Address:
21954
/o goo lJ, n v Ova
TTWMs one, Tr
T� SI�_ CITY OF CUPERTINO-BUILDING DIVISION
Contractors Narrc Uc.No: APPLICATION / PERMIT
\14` AN2 SeAl�RcIFfL EAL6.�'o*75T ZA/SL/S BUILDINGELECTRICALI'LIIMBINGMC{IIAMCAL CATEGORY CONTROLI
Architect/Englexer. LIc No d
r;. lieELECFRICPERMiT j � 1�;PCE If t •�BUILDING'PERMIyJNFOarr,+tit:
x +�:7.
Addreee: gp,,W_'T..7/Z, I (�4 9 /0,5 PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam lkmscd under prwblms of Chapter 9(mnunen< AI'PIIANCESRESIDENIAL g
Ing with Sec0un 7000).![3hr.1 n3o11he Boslnmand lkofesslom Code,and try2Qp��
license Is In lull mad effect. PANELS �r
Llan.CC// b Lk.1 ZvSL/� /tom
Dne3. T Conran., N _ a Fee_ �I' O.IQIAD �[`It ��{!S
ARCHITECTS DECLARATION MI-1000AMIS
z- OVER 1000 AMTS SQ.Fr.FLOOR AREA S/SQ.Fr.
Ob
[J. I uriderelaid my plan Stull be need u puisne records.
(/ Lkcnud Profcmional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION 51'GCIALCBRCUIT/ML9C D IN A,
t, / Ih.rchy.!item that lam exemptfranthe Contractor'.License hwf.r the 'v
%(7 .0 following rrmon.(Smlan]m15,Buelneae and lio/cabns Code:An Nt r
F%p`Gy county which requlreea perndt tocomtmct,alter,lmpmve,demolbh,orrepalr 7U11'.METFRORI\7LE INS?.
2'y�J anyatructure pd.".It bouance,aWrequlres theappllcant f.rsuch pertntt to Nr UTE R
C�E 6` file a signed statement that he b licenced pursuant to the pmvtsbro of the IbWER DEVICES
��yyOu' Contrsctor'e license Low(Chapler9(mmnuencing with Senbn 70010).1 DIA.
W3 rn SWUIMINC IDOL T].ECIRIc p—[�ALUATION
X 05 he hIgi he for lla Ilrgw1 lxemptbn. Any violation
n of Section
7(Xiltherf by any DA _�� / /v
S" the basis for the alleged exemption. Any vldnbn ol5enlon J0315 by any .I
applleant I.,apertsubjets theapplkant to a civil peeuby d un u. OUIILTSSWITCIIISIIKTURFS
M
ftvc hundred ddhn(i50tn. NEWRESIDEJTALEIECTR SQFT. STORIES TYI'ECONSIRUCTMN
�Lasowrerodotbe weak
d my emturea wnhwdedor !fend fo
compenmtlon,w111dotM1e wmk and the structure b not Intended or offered for
�� sak(Sec]WA,Bueinem ud l'mlemloru Coda TM Contraaoh Gcemelr,w
E75$ Jose nIX apply to an ownerdpmpedy who builds or lrsspmves thereon,and OCGCROUI' RIS.UNTI'S
r,�.. whodueseuchworkhl.Uorthwghhlnownemploy.,prwidedthateuch
Improvements are not Intended oroffered for sale.If,however,the building a TOTAL:
Improvement bcdd within oneyearofcose lelbn,the owner-bullderwlll have ,
t1�r¢a rden of proving that he did east bund or improve for purpose ofask.). QTY.;.t,O'`PI:UMBING PERMIT4'$"Prl ""'-FEE'd FLOOD ZONE MIN
LJ L as owner of the property,am exclusively contracting with 1. PERMITISSUANCE
contractors to constmn the project(Sec,7014,Business and Profembm Code:
the Contractor's Llcerue Law does not apply to an owner of property who
Wilde or imprwea thereon, and who contracts la such pR.jects with a ALTER-DRAIN 6:VENT-WATER(EM 1
nor(.p
licensed Do the Contractors License Law. !V_/��i.';6'i'FEE'SUMMARY•tt `Yi"';r;t
7Wp Auer Se BACK FLAW PROTECT.DEVICE
IJ I am exempt ueder Sec, g 8 P C far lisle re
P stet Datc
DRAINS�FLOORROOF,ARFA,COND. SANITARY
RI- N
WORICMAN COMPENSAI ION DECLARATION IAf1JRFS PER TRAP SCI1001.TAX Y— N
ggrI hereby aid.that I have•ad10¢ve of consent to.U-Insure,.r. R_ I I_
certlflateaf Workere'Cwnpewtlmtlmunnce araartilkd ropy thenrol(Sec.38CO3;,I,C.) S F.A.
GASYSTEM-I INCA OUTLETS PARK FEE Y N
Policy I RECEIPT I
�
Com S any GAEA.SYSTEMOVER 4(EA) BUILDING DIVISION Fr,ES
certlncd copy Is hereby tarnished,
eeGREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
dlnea ropy Is mea with the dry impenbn aivlel.n.
CERTIFICATE OF FJ[pVI"ION FROM WOR KERS GRFASETRAP PAID f
COMPENSATION INSURANCE SEWER -STORM FA 300I"I'. Date R tp o��8
iThb.edion need not be completed If the pared!b for ane hundreddollars
$100)ones3 ENERGJ� Y
I mdlfy,that tithe perf.rmana of the work four which this permltb Issued, RIOTER LICATFlt W/VENT/FLECTR �ee —
I shall not employ any person in any manner an as to become rubjcd to the WATLRSYSIFM/UIEATIt�
Worker?Compensation Lawaof California. Date
PAID _
O Z Applicant NEW RESIDENTIAL PIMA SQ.FT. Date R 1 111
Z NOTICE TO N'PLICANT:If,after nuking this Cenifkate of K emptlon,you
should beeonnsubFct to the Workers'C.erpensatbn pr.wlons of the l,.bor TO L:
CC (n de,Coyou rroeUforthwith coroply with such provbloes or this permit shall be I -311
III j deemed revoked.
a90
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b.comtmnlon kedingagency for the perform TOTAL ELECTRIC FEE
7 Z ante eftheworkforwhkh this permit b lenued(5cc.3097,CIv.C3
U O Lende'.N.me rte, PLUMBING FEE
LL Lender.Address QTY. h;r;`«'MECHANICAL,PERINITI:,�p Tw—rEE s
O W Ianifythatl havcreacithb.ppllotbn.M.blethA theabovelnf.rmatiou - MECHANICALFEE
bcoorr.lagree to<omplywlth aUcityaM manly ordinanaeand kale laws PEehtrrlSSUANCE. FEES PAI D:
T N relming to WlMing comtrvnian,and hertbyamhorlxerepre.ntativnofthb
I'- na M
Z city loaer upon the oe-co.tbK p.pedyfo L.pectl.eNpoms. ALTTRORADDTOMECH.
r .gree to avg IalemNfy an d keep harmlem the City of Cupenlon Date R ceiptlif
U aga Iabilitics, d,d enb i rdeexpensen whkhmayinanywayaccrue AIR I IANDING UNIT RO 1g00o CFM) SUB OTAL:
.gal Id ///,r/ g sting ofthl.er p.
L AIR TIANDI1NG Iffier(OVER 10,000CITD CONSTRUCTIONT X
sIBNwre.f/ pueant/c.ntraetor Date ED IAusrI iom(W/DUCT) CONSTRUCTIONT XPAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplka nl.rfutu re build Ing occu pa of slum or ha nd k hanvlous I MATING UNIT HO 100,000 UM DatC R CI tic
.tc,UI as den ned by the Cu peril.Mu NdpaI Cade,Chapter 9.13,and the —
W hand Safety Code Se�ction 8532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yea fL—.I No
Ill the applicant or future building occupant use equipment or devices VEN ILLATION FAN(SINGLE RFSID) ISS> ATE
which emit hazardous air contaminunts as defined by the Bay Area Air s� ���u'F
Quality Management District? BOMiR COMP(311P OR 100,0010 BTU)
❑Yo ❑No
I hnvcrrad the havrdws unaterlab requlrerrcnt under Cha pier 6.95 of BOILER COMP(OVER 100,000 BTU) telt t ,I IJJI
the Cellfooda health A Safety Code,Sections 8505,75533 and 75531. 1
understand that if the building does net currently have a town,that it Is my NEW RESIDENTIAL MECil. SQ.FT. I, yI�s�
rop.miblllty,to notify the occupant of the req dime m
er D which must be Wy rum f B11
prior to issuance of a Certificate olOceupa ncy.
Owner or authorised agent Date TOTALISSDED BY:
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProIdenti(Irati® PFRMATNO.
Building A 9 00 �. T ,, ��a— - 21954
sorra ante: one.
+(� CITY OF CUPERTINQBUILDING DIVISION
Coritraaors Name Lk.N¢ APPLICATION / PERMIT l
Am �/{C/FTG EAt6,t-QrJ�' 29t5Z/5 . BUrLDINGMB
ELECTRICALPLUINGME{TUNICAL CATEGORY CONTROL/
Archkel/Engireer. Lie.N.
Me,.2TA X C S/'/9!6 BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
PLUMB 91=1
Add. 6.pPA+G TW k, SF C4 /0 PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I herby dfirmthat l son
Lkena licensed underprovWnroof Chspter9AITLIAN
C6RF9DEMIAL
Ingwlth Section 00)divdmOo(theBuNvemand Profea ¢uCode,and nyy
Ibevalirfull rad effect. PANELS 6-poVL5tfR-
Its
t
m
. Zf�.r Z.yJ
Dae rd —�LieCordnac" N 'C_ P-"('I t Sr
ARCHITECTS DECI_Mt TION 1-1 AMPS
mOZ Iunderstand my plaroahal be wad as public record& OVERIl100AMPS SQ.Fr.FLOOR AREA f/SQ.Fr.,
CO SIGNS ELECTRICAL
U L1¢nxd I'ro(embrol
OWNER-BUILDER DECLARATION
zed, IherebyaffirmthatIamexemptfromtheContranor'sLkerbeLawfeethe SPECIAL CIRCUIT/MISC E D I N
OO following rtason.(Sectlor�70115,Basin®and Profmbro Code:Mydty or
O Z^ T138.METER OR['OlE INST.
r'N ¢YA.w chnequlre+ape .,.I rgai altth, .pU.tfe .Ch;ormpairto u T E R
any atroaureprbnsentt.iL&unoa,licensed
t the rovuiopeof to ppkypR DEVICES ydn fibs oedstatementw( kbr9(m pursuant totheproWbrodthe
3t`t� Contraaora lJcenae law(CWpler9(commencingwkh 5actbn 700%of Divi- SWIMMING POOL ELECTRIC n,TE t. itALUATION
BOJ the basis for
o Buanem and lidmbro Anyviolhahe L exempt therefrom and
...7777 the Wal&!orthe alleged vemptbn. Any WaLtbn of Section 70315 by any OUfLETSSWITCHSFIXI'URBS
aPPlesntfora pemdt eubjeas the appllunt too doll peroltydna morethan
five hundred dollars($500). ,
..�n ❑I,as ownerof the property,yr my rmpbycn wkh wage astWbsok NEW RESIDENTIAL E.ECTR SQ'FI'' STORIES TYPE CONSTRUCTION
C7a a'n7nenaation•willdothework.endtheMmdurebmt Wended or offered for
s O sale Cee 74Z Busbasa.nd Prefabro Code:The Contractors Lice.Law
don not apply to an owner of property who builds or improves thereon,and
�$^ who don such wark Mmaelf or through his own empbyces,provided that such OCCGROUP RES UNTIS
Improvements are not Intended oroffened for sale.If,however,the building or TOTAL:
improvement baold within one yearofcompletbn,the ownenbuilderwW have
FLOOD ZDNE MINE
of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
"b I,as owner d the property,am exclusively con.,won I. pEthDT 156lIANCE
contractors/o construct the project(SecW,70 B ulnen and Pralmbns Code:
The Comnaar's License law dm not apply In an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
bu M. or Imwn ,
prthe e and who commas for such pa tijects with FEE SUMMARY
ogN(+rtor(a)B¢nsed punuw to the Contractor's Licence law. BACK FLOW PROTECT.DEVICEtJ I am eaempt under Sec B 4 P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Dae RFCFL'[&
WORIGHAN COMPENSATION DECLAMOON FIXTURES PER TRAP SCHOOL TAX Y_ N
1 hereby&Ilan that 1 have•certificate d cannot m opy thereof(S a
certificate IAb CJ orken'CampemaRm lmuran¢aa¢retried copy thereof(Set. RECmrT;/
3600,Lab CJ GAS FA.SYSTEM-1 WGt OUTLETS PARK FEE Y_ N_
RECFTPTT&
Policy& GAS Fw.SYSTEM-0VER (FA)
Com ray BUILDING DIVISION tE FS
ECedMB .pyLfLL-dyfuM.hed. GREASE/INDUSRtL WASTE INTERCEPTOR PLANCHECK FEE
N. copy b NedwithtW styIvpectbn dhiaoR
CERTIFICATE OF"liMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gEWFR-gAM7ARY-STORM E.A.XIOFf Da[e R [k
(ITL sectbn need not be completed tithe permit b f¢one hundred doBary
($1 WE or les&) WATER HFATEt W/VEJT/ELELTR ENER�a Y
I¢rtify that N the perfonrunce of the work forwm<h this pemdt L laced, 1 C
I shall not employ any person U any manner,so n to becomeER subject to the WATER SYSTEM/TREAT!NG 1,
Workcrs'Compenaatbnlaw.d C.W.1a.Date PAID
Z Z NOAppTICE
NEW RESIDENTIAL PLMR. 9QpT Date R til
0 NOnCEcroneAPPLICANT:eWafter orakingtwsattonuteofoumpheLabor
you
F N slImICode,you
surthwit the ply with
it Comp rovisinprovhwurmit s Lab he TO*L.
CC
de,cmdr revoked. BUILDING
withsuch pnvvLloroorthbpermit vhdlbe E t
] i. deemed mvo4 d. -
Ljol
W _eI CONSTRUCTION LENDING AGENCY SEISMIC FEE .O
lk Z i I hereby alfirnn that then b a construction lending agency forthe perform, ELECTRIC FEE
7 Z y an¢of the asvrk(orwwhthb pormftbbsued Cee]OYI,CIv.C.) TOTAL
U O . lender.N.me PLUMBING FEE
LL ~ Lender.Addnm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢dlfy thatl have read twappllatbnand+atethhe abw fornvtlon
att
IL bmrnv.Iagrntocomplywkh.Bcky.M.w tyondbanccnandwtelaws PERMIT ISSUANCE FEES PAID.
>. relating to building mrotnualon,a"hereby authorlre mpre.enlatfwa o(thL
r Z [aEEga
y to enter upon the abase-mentbned property for inspection purpu ALTER OR ADD'ID MF�ti.
e agree to cove indemnty an d keep hamdes the City of CupertinoDate R i tli
V LbWdimtles,jnd w eape�.whlrylnanyway... AIR HANDLING UNIT(IO 10,000 CFM)ni aCity bymingdtw pern SUB OTAL:
3l2/ / AIR HANDLING UNIT(OVER l4aoo cEM) CONSTRUCT[ONTAX
sigvtu¢of puant/Contra I, Date EXHAUST HOOD(W/DLC) CONSTRUCTIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futu¢Wlidinga¢upaot.toreor h Odle harardous HEATING UNIT(TO 100,000 BTU) Date R el til
craterial as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
lea hand Safety Code Sealon2S532(a)t HEATING UNfT(OVER 100,OOD BTU) TOTAL:
Yn rNo
Illtheapplfa
....r futu¢bullding oavpant ase cyulpnrcm¢devim VENTILATION FAN(SINGLE RESm) Ir+�2hNR¢ITIA'I'E
% whkhendt hod.air contnmfine
lrums as defined by the Bay Arta Air r`-AL
Quality Mm
anagerm District? BOILER-COMP OTm OR 100,0(9 BTU)
❑ yes NoIOO
I have read the harardoua nuterlab nNulremenL under Chapter 6.95 of BOILER-COMP(OVER 10),01a)Bn1)
the U11fomla Health k Safety Code,Sealoro 75505,5533 and 2S5U.I
undeotnM that if the building does not currently have a tenant,that It L my NEW RESIDENTIAL MECTI. SQ.FT t
reporoibilky to ratify the occupant of the requbemema which wart be met ;m
prior to Lc.uan¢d a C.I ifiaw of Occuparuy.
Owner a mUeTOTAL;
thord agent Date ISSUED BY:
OFFICE COPY