22370 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY p�l
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Building Addw: V -
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CITY OF CUPERTINO-BUILDING DIVISION
CornanarsName: Lie.Na APPLICATION / PERMIT / 1
BUIIAINGELBCTRICALILUMBINGMCCHAMCAL CATEGORY CONTROL#
ArcM1kecl/F glnser. IJc No:
QTY ELECTRICPERMIT . FEE BUILDING PERMIT INFO
Add. PERM TISSUANCE ❑ �ECI 11
❑ •❑
LICENSED CONTRACTOR'S DECLARATION
I hereby•R4mthatlamllcenaeduMerpr Wmsof Chapler9(mmmm APPLJANCESRESIDENIAL J BD CRm1 FN
IngwlthS on7ODD)ofDlvblm3oftheBudrcneand Pmfea Code,andmyr LgV'C�e I�VPe7�
(leer.is in full deffect. PANELS
Lkerisc RCf Li -5767V
• I V m V 1 n
Dale Comractor e4G
AmeH R E public ION 201"1000
^ AMPS
%] ]urdentand my phns WB)used upublicremda 'OVERIWOAMI'S / SQ.F^f.FLOOR AREA f/9U.rFi� -
Kapr �j Llmnaed Pmfesbnal SIGNSEISTRICAL 1\eY1Q.�aes jam'
OWNER-BUILDER DECLARATION t
> � Ihereby afflrmthatIan,e. rognfmntheCoMradoriro
Lknelawfca he
foBSrFfULCRCUT/MSC �F ex ml
6R owing reason.Sectlon7MIS,BuaNmand Pml.io.Code:Any dry.,
TEMP.MEFR OR O�INS.
K� muntywhlchmlulmaperm Wmmt Malter,Impr ,dem h,orreplr2-0
06
q�a[[ anyatrunun prbrto lb buanceaborequlmthsrpp0ant forwN prMtto POWER DEVICES
V
t,5 ct file a signed statement that he b licensed pursuant to the provisions of the
3u. Contrad.e.license Law(Chapter 9(mmmendng with Section 70(10)d DM- VALUATION
eon3oflheBus esrrndProesbroCade)orhatheeexemptherefromandBDUNGOO.EECRC I
yl the Neb for the alleged exem)xbn. Any Wdallon of Sedbn 70715 by any
appllunt fora permit subjecvtherppBcanttos civil peruhy door morettan OIJTLETSSWfTCFiETi
.. five M1undred dollars(5,5001. FIA1 - _ .
I,u owner d the property,or my employees with wages u their sole N'EW RESIDENTIAL O ' dT. LS TYPE CONSTRUCTION'
compensadm,wW dothe work,and the drudun b"intended or offered for 4 a
� ale(Sec 7(K4,Buninna and rmre�lons Code The Contnctols Llcew Lw
t3s>8 dm wt such torn imuerdpmpertywho ocropl yeea,ovn o,ithnandDATE C.GR RES,UNITS
P0.. who domeuch work hlmrelfathwghhb vwne.11,howeVr thebuihrt such '
improvemedarrerotintended earofcdyly it,h er-n Bder dbgve iQTAL
hnprovemembwldwhhlnomyurofcomplelbrat)owmerbullderwlll)ve -.
,burden of proving that he did r.n bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZDNE AM
Lj L as owner of the property,am exclusively omtracdng with Ikmsed PERMIT ISSUANCEmors uo,to construct the pmjed(Sec 7DW,Bushes and Profmbns Code..
The Contndor's Llcerae Ijtw does nor apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
buuda or Imprwrts thereon, and who contracts for such p,j<N with a
cWj(Mar(e)hotrned pursuant to the Cmtndds Liam.Law. RACK FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec B k P C for this reasonQIlTq-r FEES
. Owner Date DRAINSFLOOR ROOF,AREA,GOND. SAFITARY Y_ N_
WORICMAN COMPENSATION DECLARATION RECEIT
If
�I-��I#1 hereby affbm that I have•certificate d cmmnt to self-hwre,ce a FWD.IRES PER TRAP SCIi0OL TAX Y N
cErtttiate d Warkm'C«np..rmatlm Intursnu ma certified copy thertof(Sec. RECEIPT
If
3800,pol�y, /OQ�bcJ .}y�— -///J( GAS Fw.sYSIFA/.1 INCROUI'I.EIS rARK FFI YFNe_
Y / `�' GAS.EA.SYSTEM-0VFR4(EA) BUILDING DIVISION FEES
C,pP�]pC+ertified ropy b hertbyth the en d. GREASE/INDUSDIL WASTE INTERCEPTOR PLANCHECK FEE
�Certl/led ropy b flied with the dty Impedbn dlvWm.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE g}yFRy7MTnAy-SroRM pw llaa-1. Date Recel [k
(This ion need rad be completed Lithe permitb fm one hundred dollars
ret 00)mlm.) WATER HEATER w/vnvr/E1,0.'CR ENERGY FEE Y N_
I certify that N the perforouneeof the work forwhich this permit Is Issued,
I shall na employ any person N any owner w u to becomesubject to the WATIRSYSIFM/TREATING
Worken'Cmrpenaatmnl:wsaf CGbfmda. Date PAID
PP NEW RESIDENTIAL PLMB. SQF7.
A Brant
Z Q NOTICETOAIsub)CAM:R,sherov*Com erCtion,pto,sons theLyou Dale - OTA [aY
F U) Codedbero ustlot with eu Worken'Compewtbnprovbbnsdthe adl TOTAL:
cc Code,d r vo a lartM1wdh comply with such provlsbv orthb prod(shall be E
Uj > deemed revoked. I
CONSTRUCTION LENDING AGENCY SEISMIC E
ll Z (hereby afRrenthrtt)reb A;"idlm ld Se,397,C f.C.)pr(ortn- TOTAL ELECFRICFEE a�
.� once of the work for which this pvmh bbsred(Sec 3097,CW.CJ
02 Ie de,.Name ' PLUMBING FEE Ug
LL ~ Leeder'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
In
OW 1certlrytM1atl)vt read thbrppllatbnrnd natethattM1c above ln(am�dlm
N Isco ed.lagreetocomplywithandtyaM omn(y ordWnmand vUtelaws PERMITISSUANCE FEES PAID: m4
relaum
ngtobulldingmrudMMae
tim,and ebysuthmimmenbtt otafthis y�
F o-me
Z dty to enter upon the abavntbrcd property for WpecHon purpose� ALTERORADDTOMDCK
(We)agree to sac,indemnityMes an d keep harthe Clty of Cup mo Date Reeei t#
V agawt liabilities,Ndgmnta,m as esp .which mylnanywayaonrue AIR HANDLING UNIT(TO 10,000 CENT) SUBTOTAL•
sgalnst aalIIep,In qac of gra ring of this /eO
AIR HnNDulvc ulvrr(OVER 7a,000CFM) CONSTRUCTION TAX
Sig a App orb or — Date E Use.HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDDUS MATERIALS DISC SU E
Will theappllant or future Wilding.pitrd.wnearhandk huartdous DATING UNIT(70 100,000 BMDate Reeel NI '
matcrlel as de0ned by the Cupertim Muddpl Code,Chapter 9.12,and the
[all Yesd SafetyCode o 25532(a)2 HEATING UNIT(OVER 100000 BTU) TOTAL:
Til the applla bu0ding oaupant use equlpmntwdevicca No
VENTILATION FAN($INCLERFSID) ISSUANCE DATE
which eMt havrdous air conUMvnb as deRrcd by t)Bay Arca Ab
S r_1
_ y,, nagemenc IX�r�f,1d BOILER-CtJMP(3M'OR 1001IXU BTIn
Ihavc read the havrdous materials requ lnmenb under Cha 6.95 of ROB.ER-COMP(OVER I LKLOOD B'�U)
t)Califomla HoAh h Safety Code,Sect tons 75505,25533 and 25534.I
undrntard that if the buildlog does not armntly haves tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. ,
responsibility to edify the oecuprd d the rqulrcmcrds which must be met _
prio/r to �anmd ril t pray.
Cb4tlNar auto agent to ISSUED BY:
IOTAI,
OFFICE COPY