21952 blandfkatim PERMIT NO.
BuildingAddres.:
f_- 4N G,In � 21952
7—6 WN C�
=woc ...............
I)t;,*, 4crIASK" 'CITYOFCIPERTINOLMLDINC DIVISION,
Contraftes No.,,
'APPLICATION /PERMIT
BUILD]Nr–ELECTRICAL,PLUMBINGMFiCliANICAL•'P CATEGORY I
Lie Nm,
t... W
Address: LICENSED CONTRACTOR'$DECLARATION PERMITISSUANCE 11� El El 0
lherebyffirm that 14m Seemed under provisions ofChapter 9(comment. JOB DFfixrriolsl
lng�thsecdon7OOMofDf�Igm36ftheBui�and PrulessimseCode,mcl my Y�l
7
PANELS
ll-rnelslnfullfonmmdeff�
Llcm.Claaa Llc.I
290AWS
Datk—Cmerector I -Mid
ARCHITE&S DECLARATION 201_IODOAMPS
OVERIODDAMPS -9Q.FT.FLOORAREA $/SQ.Fr.
z Imclarolmd" ne
plashillbiused"
Licensed Professional Is,
kGNS&SICTRICAL
OWNER BUILDER bkWATIbh�,–",
SPECIALCIF!CUIT;
Ilterebyiffirmflu foithe 1
following reason.(Section 70313,-Busines,and ProllessimiCocle:Anycltyor mTMAPAiE*OkW'IN9T.., t 1 i.I— .I
atywhichmqu[maperndtWw�c"tei,impro%i,dirhol6h,oiimpair I
nyMmftrepriartoltiinuako,,6orequimthiappHeintforsuckpirmitto
file a signed statement that he Is licensed pursuant to the pro Iona,of the
F. Contractor's License Law(Chapter 9(cencyromehig with Seiler 7000)of Dlvl- W W hia kc;i;O dy
VALUATION
f.3 ofthe Business and Pmhool6niCode)orthat he li iieript therefromind
the basis for the alleged exemption. Any violation of Section 7011.3 by any
appUmntforipermkmbjec6thiioplkuttciiiMloiitahybfiiimmtho. OUTLETS.EWlTCHES-FIXTURES 0 OrD
a md cloth. . J, NEW RESIDENTIAL IIII.Wi9�2—I' sopir.
1,as r of the 'or mnp'�- with wagei is thele sole STORIES TYPE CONSTRUCTION
near m,willdothevom, exult sbut .not Intended or offered forP " ,4j"M�, , '
.1. 7061,Buslnns ind Proferlohe Cmle�The Contractors lAcensi Law
does nor apply to an owner of property who build,or improves theme,and t v,
ass I
essuchworichlonselforthrmilthism" Icy OniWdecilluilsuch OCC.GROUP R M UNITS
666 whodo
Improwmarnimenci Intended d4offeredforule.1Lhow4veythebulidingm TOTAL. r-1,
lonprommentissoldwithinorwylkirtdi leticktheownii-locifidiiwill have
t"rden of proving the he did not bU79mlno ii for O.'rpose of ials.L, H� FLOOD ZONE -XI—IN
U L a owner of the Property,mh exc=9 Mfitrikilik With licensed
PERMIT ISELIANCH
contractors,to construct thepropd Oei.70K]Iushiesi and Pr;fmfmi Code:
ThaCentroom'sLimrselLawdoesnotapp toanaivnerbfpropiilyWho
bull"or Ion roves Bottom,Ana whi co"Llas,fi5i such Llnnas popJacti with a ALIER-DRAIN S,VENT=WATER WA)
BACK FLOW PROTECT.DEVICE
L.J I am ctor(seecopt ordeed r Sit." jhe - 8 P C&16 b," QUTSIQFFEFS
DRAINS.FLOOR,P:OOF,AREA,COND, I SANITARY y N—
Owner . M 1 – 1 1 RE-EPT 4
01 herebyWORKMAN COMPENSATION DECLARATION
affirwi that I have il certificate ofimsifit to self4m.,or i P&TURM PER TRAII SCHOOLTAX Y— N—
f RECE91F I
mpNate0 GAS.EA .1 INCA 4
380DIAbCj §YSTEM OUTLM PARK FEB Y— N—
RECEIPT 0
Policy I "I GAS-EA.SYETIM-OVER 4(EA) '-z BUILDING DIVISION FEES
CD
Rcaylfled copy 6 hereby forolahaid..
C c rItEASE/INDUSIRLWASMINTERCEPMi 1- 4.,, PLANCHECKFEE
m1fled copy Is filed with the city inspection division.
CElT6TGTR 6F-604,PTiON FROM WORKERS' 1CREASETRAP PAID C%
COMPENSATION INSURANCE
ostbecconplelvdifthioeimit Isformehundred dollars p SEWMSANffARY-STORM PA.2DOPT. Date Recti t#LD, I
(Thissectlonmed n
(sincelosaj tt I — ENERGY FEE Y N
Tomtrythe this jormit is lowed, WATER HEATER W/VENTIELECTR
I shall not employ my person in any rnih�ii id ft W becoica,suiblecli I.the
Workers!Cbsopmutlm,JAM ofChimik.Dgtj�rl.4A�,e!�,. WATER SYSTEM/TREATING PAID
d = ApplicantNOTICE TO APPLICANT.If,after no this Certificate of axe lon,yod NEWRESIDENTIAL"0. qQpr. Date ReCeiptill
Z
should b..wb)ert W the Workers.Cbmpariatkii priAilalons ionrl,a Labor TOTAL:
Ccde,y.0 mot forthwfth comply with ouch proolskmamthli pewcashall be
Uj > deemed revoked.. BUILDING FEE
CL CONSTRUCTION Illki)IN bL� -1 -r,
CV!Oki- 0-1� SEISMIC FEE t 4-14ZI
ih,reby.fil p i
that them to acovermclion letulligagency foitthe pmfomrn� ELECTRICFEE
MZ *amofth...,kmforwhichthleimnfiftiiisiued(%c.3097,Clv.CJ ,ta TOTAL
Lmd.,.No PLUMBING FEE
LL t- Lmder'sAddms MECHANICAL FEE
O td I ceftflythatl havered this I?pHationanddaftthatthemboveinfo�tim
I ' od county PERMIT IsgJANcE FEES PAID.
CL �affimd d ya'by a�"0�sa re
w or 'a'de
d"lcorrect I "S comply"balln ba� ALTER OIiADD TOMT�H.
l'y4tt.g.'ot the L— -thosol!T for no Date R�fpt#
(We) r in "' -d P cast
.8.1ma'It. M ZILY. . Pmers. ch; AIR HANDLING UNIT�]O 10,001)CFM)
;dg nl� and which SUBTOTAL:
loatesidC con he granting
ftial.
go oJ,In �-=-fr
AIR HANDLING UNIT(OVER la,D*CFM) CONSTRUCTION TAX
Sigrahme.l[Applicam/Contran,tor Date DCHAUST FTOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0000 STILL Date Rete) t#
material as defined by the Cupertino Municipal Code,Chapter9.IZ and the
Health and Safety Code Sedion25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:I-A JLS
RYes tNa
ill the applicant or lure building occupant use equipment or devices VENTILATION PAN(SINGLE REBID) ISSJJAWATE
za
t which emit hardous air contaminants is cleared by the Bay Area Air
T;fity Management%ad the b.gement District? BOILER-COMP OHP OR 100,000 BTU)
9 u materials
Nooterials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 1991
(he California Health It Safety Code,Sections 25505,25533 and 25534.1 NEW RESIDENTIAL MECH.SQ.FT 1AAR 9 1
understand that lithe building does nor currently have a tenant,that It Is my
responsibility to notify the occupant of the requirement@ which=at be mart City of CUIJ,4:nj
prim to Issuance ofaCertificoteofOccupancy.
Owner or authorized agent Data
TOTAL: ISSUED
OFFICE COPY,