23979 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY n
Building Project Identification PERMITNO. '
Building Add ren:
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nesse ante. pp ,,,, one: p
AAlI CE RUG✓-5 00 Y9/-73S�J CITY OF CUPERTINO-BUILDING DIVISION
can ctm' Name: Lie,Na APPLICATION /PERMIT tr��
E2 SoA1 a U S.� 4N BUEWING-ELECnUCAI PLUMBINGMECHANICAL CATEGORY CONTROL
Architect/Engineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ MWH❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chap(erg(comment, APPLIANCMItESIDENTUL JOB DESCRE'RON
ingwitIt...h .null forces Dlviect. 1he0uelnessand Pro(eWonsCode,and my
Brenn b in full!orae and err.. PANELS 6�'•6V/J��a`�C��—/�
Limns Cks Lk.N
Date Contractor UP TO 200AMIS,
ARCHITECPS DECLARATION 201-I000AMPS
µQ!.9W ZC Iuralerstand myplaceshallbeused aspubllerecords. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E (/ Licensed Pror.F.t SIGNSELECTRICAL �. n
<«<�6 OWNER-BUILDER DECLARATION _ SPECIALCIRCUIT/MISC F `
y � herebyafOmlhal]amexempfromtheContr.oriLlmnssLw(mthe `lI J e
Op following reason.(Section 7011.5,Business and Professions Code:Any city or
TEMP.METER ORPOLE INST. /
P muntywhare requarsa permXromrutrunlreathalter,bnpmvgdennWh permit
tto �A
q any atrocorre priorto statement
that
he
aW rcqu pursuant
forpro suchhpeof the ['OWER DEVICES XV
E5 O file a elgned w,m eLa that ha t licensed pursuant it the provisions of the _
G613µ C.nlractor's Gcerue lsw(Chapter9(commenMgwXhSenlon7000)ofDlvl-
�OS stoo3 oftheBuslacseand ProfB.WmCede).rthat hela exempttherefroma" SWIMMING POOL ELECTRIC L VALUATIO
6 the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWIT'CHESFTXTURBS / 6/l�/�
applicant lure permit subjecbtheapplkanttoadvil penalty of net morethan ( 666
five hundred dollars(5500), NEW RESIDENTIAL ELECIR
�. ❑L as owner of the property,or my employees with wages as their sole —e'QFf. STORIES TYPE CONSTRUCTION
compenntion,will dothework,andtheftructure is not intended or offend for
0 ask Tc.70K Business and Prefesohns,Code:The C.atran.Ys Lt..IA.�s� does am apply to an owner of property who Wilds or Improves theremi,and OCGGROIII' RES.UNITS
don such work hurcu forthrough Ms own employees,provided that Batch
improvements are not Intended oro(fercd for sale.If,however,thebuilding or TOTAL:
improvement ksold withinomrarafmmpletlorttheowner-butWerwlll have
OW-burden of proving that he did not bund or Improve for purpose o(ule.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
l_I 4 as owner of the property,am exclusively contracting with licensed -
commerce,toconstruct the project(Sec.7064,Business and Professions Code: PIRMITISSUANCE -
The Contractor's License Law don net apply to an owner of property who ALTERDRAM&VENT-WATER ffN
builds or Improves thereon,and who comment for -
for such p(o)ewith a FEE SUMMARY
egeiractor(s)licensed pursuant W the Contractor's License Law. BAIX[TAW PROTECT.DEVICE LJ I am exempt under Sec. B k c
P C for this reon
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby alfirm mW that I have a rtiRcaof consent to self-Insure,ora RECEIPT Y
certificam.M.rken Compemtionlemonce me certified copy lh.eerf eco GAS EA.SYSTEM-1 INCAOUTLETS PARKFFE Y N
3800,Lab C.) RECEIPT N
ccP. Y GAS.EA.SYSTEM-OVER!(EA)
Com any BUILDING DIVISION FEES
cc
copy b hereby hems city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE L1 6rY
Certified copy k tiled with the city inspection division. �7
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE ShWFR-SppFR.T•pRY-SroRM EA xroPr Date Recef (M
(This section need not be completed lithe permit isforom hundred dollars
($1007mWATER HFATFTI W/VENT/ELECTR ENERGY FEE Y N
I¢rtllythfythat In the per(omunm olthe wmk forwhkh this permit b Weed,
I shall net employ any person In any runner so as to become subject to the WATER SYSITM/TREATING
Wmkan'Compensation IA..f C bfomia.Date PAID
Pp NEW RESIDENTIAL PLMB. Q
Z NOTICE TO APPLICANT:I4 after making this Certificate of Exemption,you SFT. Date Rtumi tJi
should become sub)ect to the Workers'Compensation provisions of the Labor TOTAL:
I" N Code,you must forthwith comply w1thsuch provisions.,this permit shall be
> dneM revoked. IlUILDING FEE
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby d@m that there b e construction lending agency for the perfortm ELECTRIC FEE
0 Z anceofthe work forwhichlhis pe rm0)alseued(9ec.3097,Civ.CJ TOTAL'
0 O Ierderi Name PLUMBING FEE
LL I— Lender'.Add.. QTY. MECHANICAL PERMIT FEL' MECHANICALFEE
OW I certitythat l have readthisappllotlonand natethattheabovelnformation
f11 Incorrect.I agreelo complywlth all cityand county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
>. W reldleStobulidingcomtronloe,and herebyauthmiotrepresentativn.(this
F Z city W enter upon the abovo-mentlonrd property fee Inspection purposes, ALTER OR ADD TO MECH. Date Recei to
_ (We)agree to save,Indemnify an d keep harnJess the City of Cu perdue
against liabWties,Pdgments,mels and expenses which may in any way some AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agai sold In ronsequenm ohhe gnnlingetthis pertnll.
5��EC`=�i ��C4-.` A /4 / C— AIRHAnmuNc uNlT rovERio,000cEM) CONSTRUCTION TAX
g hereof AppO n ncr to-- EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZAItin)=MATERIALS DISCLOSURE
WllltheappB otorfuture building occupant store or handle hazardous PLEATING UNIT(T0100,WD RTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the Date Recei t#
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT
RYes NN.
ill the apperant orfuture building occupant use equlpment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COM?(3Fm OR 100,0(10 BTU)
4 Yea n No PAID have read the haze ouB materials requirement under Chapter 6.95 of BOILER-camp(OVE2100,000 STU) PA 9 D
the California Health k SafetyCode,Seatlon 25505,25S33 and 75536.1
understand that ifthe building does not currently have a tenant,that it as my NEW RESIDENTIAL MECH. SQ.FT ��
responsibility m notify the oampant of the requirements which must be met J�d 1� s,
Into W a
nofa Certi(Icateof Octmpanry. �/ �n
/t.Kl.(.aY q/Z
Ow.cr.r;utth0/m44gent V Akae ISSUED BY: , rCH I IIVU/ _
TOTAL;
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City of Cupertino
AdMIL Department of Community Development
• O
10700 Torre Avenue, Cupertino, CA. 95014 (408) 252.46/2
July ma
I
(DATE)
I am an adjoining property owner of 1 Mice JRvCKS
(NAME)
whose property is located at II S Holl L o LANIL CVF&n"p
(ADDRESS)
I approve (as per Ordinance No. 686, Section 16.28.040 of the Cupertino
Municipal Code) the allowance of a X ' foot high fence facing my - -
(8 MAXIMUM)
441 property.
SIGNED: NAME:
ADDRESS""s C WU N Se V
1153 1raNEAR LjJW6
Ct� PEkTiNo CA
City of Cupertino
Department of Community Development
10700 Torre Avenue, Cupertino, CA. 95014 (400) 252.4642
(DATE)
/ Q �7AntrCE
I am an adjoining property owner of �� 1 U«(�1 �(/�� 2 ��a P� v�ucres
e AME).
whose property is located at o Jo t �, ((S'7 trolly 4EAD Lnu
(ADDRESS) Cu P E,er,I o
I approve (as per Ordinance No. 686, Section 16.28.040 of the Cupertino
Municipal Code) the allowance of a SFr foot high fence facing my - -
(8 MAXIMUM)
property.
SIGNED: NAME: Td-taele
ADDRESS: f� i IlyiEw -311E T
� ,L
St�,.IItN���ERIINp