20911 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmjear ldenri(1¢dan PF7tMITNO.
Bp i973a oMkE COURT PERT/NO m 950/4 20911
� V/ Srj' Q 0-,03 I/CITYOFCUPERTINO-BUILDING DIVISION M.mD� D LIRN N973
C nda'sName: Lk.Na APPLICATION / PERMIT
BUILDING-ELecrRICAI.PLUMBINGM HANICAL CATEGORY CONTROL a
Arohlted/Fngl^ser: Lk,Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address, PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
Thereby ant thatlunkl .n d.Md rprovmoneofChapler9(.n APPLIANCES-RESIDENTIAL JOB VINCH11IMN
ingwitliner.
Sedum forme and
effm o(the Buelceoand ProfnelomCode,and / vW /�����
Lirs. le In file loom and died. PANELS
L^" CIa� Lk.I
Date Contndor
ARC'HITECPS DECLARATION1-1000
q�q�aa�%tQ IundersterdmyplatuehaBbeused aepubllc ria OVERI"AMPS SQ.Fr.FLOOR AREA f/SIU.E7.
F, T' LI¢nsM Pnafe®foral SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCIRCNT/M6C
E., G Iherebyafflrm that l am exempt from the Contranor'a Lkenee Law for the
pp following rearm.5q m7013,Bushes and Profession Code:My dryor
671 nq TEMP.METER OR POLE INST.
K5 •y countywhkhrequbnaper tomru Malter,Impmv de=Whormpalr
S X73 anyetm=mpA tolbbeuan¢,aL requlrntheappbmntfineuchpermdtto POWER DEVICES
66 c. file a dgncd statement that he b Ilacnaed pursuant to the proWbru of the
0� Cortr oea LicenseLaw 07hpler9(mur
mendng with Sn on 7000)of Dint-
p�0� alon3afths Buelnessamd ProfmbmCpde)arthohebemmptthe¢fmmaM gWLW✓dNG Il70L ELECTRIC
VALUA710{�
•��tt the Web for the alleged exemption. Any violation of Section 7013 by any Da
p�
ppU.nt for a permit sub),v theappllont to a dull penalty dnot more than e OTfIk�SW1TCHESSFU[ITJRLS � f
n�u as ed owner
we r of the property,
ro
I,asowKrefthePmperty,ormyrmpbyenwNhwagnulhetreole NEW RESIDFNI7ALELFt7A'Y `$Q}7, ES TYPECONSIRLCTION
penaaHm,wlll dothe wok and thetimaure Isnot Intended or offered for
p aals(Sr,70µBudness and Pr fessbrs Code:The Corrado,'.License Law
don not apply to an owner of property who bulkb or lmnpro,es thereon,and
E: whodons &.,k hlmselfmthrough KI...empl gees,pmvitt that such OCCGROUIe R UNITS
ov
Impremeres are not Intended proffered for oak.If,however,thebudding or ( T AL
Improvement b add within oKyearofcompletbM the owner-bullderwlll have
I ndemof proving the he did not build or improve for Purpose of saie.). QTY. PLUMBING' RMI FEE FLOOD ZONE APN
�I,v awns of the property,am exchutwely mntracdng wkh Ilcenssd
mntractons to mmat.d the projed(See 70K,Business and Prufessmst Cade: PMJMpT ISSUANCE y` /� 32_0/
Ths Contadoes License Law dm not apply to an owner of property who ALIIIt�DRAW 4 VENT- ATFR T-10/ II 4 1!'
build. or Improve thereon,and who mrrcnda for aunt pSojects with a =i eJ
orW
rued Pursuant to Cmtedo's Lloers'Law. BA
TtL W PROTECT DEVICE FEE SUMMARY
I
y
B 4 C for this moon
r Dsh DRAINS RRC)DF,rARES,�ND., SANITARY Y_ N
KMAN Q� e SATION DECLA R�F71'T I
❑I he m that IY ry a certiflof comer m rU-irwrc ora 1R'P ) 14 LTA% YNo lntmi Compersatlm lraunnce as certified copythereof(Sec. a RFGmITa
38W,Lab C) - GASEA. -1 WCIOU'E.ETS P FEE Y N_
Pol
Comm any �`S n -0VFRCEA) 'I BUILDING� DIVISION FEES
I ICertNed copy b hereby furnished GREASE/INDUSTRL WkSlli 1NTFIkE'TOA 1� PLANCHECK FEE
Certified mpybfiled with the city,Inspection division. y o
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP 4 hI V�V 1 PAID
COMPFNSATIONIe'SURANCE SEWER-SANITARY-STOORM EA Date Reccl tH
(rhia aedkn need not 4 completed tithe perNt b fe ora hundrtd dollw
(SIM)aless.) wnTFR iFA7FJ wivENr/ t T ENERGY FEE Y N
I mn fy the ti the performance of the work for which this permit la issued,
1 shall not employ any pecan In any manner m ae to become wbjed to the WATER SYSTFAf/TREATItxG
Workm'Compx.tbn Lawao(C.W.dt. Dee PAID
O Z AppB¢nt
Z z NOTICE TO APPLICANT.If,a flan making this Certlfkate of Exemption,you NEN'R DFNT1AL FLMB. SQ.FT. Date Recel tk
PN should become subkd to the Warks,;Compenaelm provisions of the Labor TOTAL:
2 (A a syr mftf«hw hmmp"thsuchprov orth6perm 6&libe s,0
adi
,oked. BUILDING FEE
W O CONSTRI/l'FION LENDING AGENCY ISMIC FEE
CL Ih,mby.fflmthatthereb.mmtsudlmlerdingagenmyforthaperform ELECTRIC FEE
7 Z once of the work for whkh thisa=b Issued(Sec.3097,Civ.C.) TOTAL:
02 I.eMer:Nam PLUMBING FEE
LL1— L,nderaAddree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O IU 1cert lfythe I have read thbappendan anal state the the above lnformatlm
hon M-I agreetocmnplywfthel cgy and muntyoMWnoeand alien,laws PERMIT ISSUANCE FEES PAID:
- d mleing to Wilding mmtsudlm,sM hereby..thcxl reprexntatNn of this
F N city to enter upon the alcove-mntbned property for lepedo purpose. ALTERORADDTOMECH.
Z (We)ogre to save,WemNty an d knp harmiess the Cfty of Cupertw Date Reecl tit
V tWbWtka,Ndgments,dstaard npenan whkh mylnany wayapwe AIR HANDLING UNIT aro 10,000 CFM) SUBTOTAL:
.gal Id City inns quence of the gra n}4 dtw permit. Ito b �HAN,3NG UMT roVEt II,00 cpv) CONSTRUCCIONTAX
rreofA t/cmhado, C DG-LAUST HOOD(WI DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM E IS 01SCLOSU RE
WBlthea Ilona Ww¢bulldlng pentatorcorhaMkha nJous HEATING UNIT(TO 10,000 BTU) Date RCCCI tit
nrwerbl a deflmad by th,CupeM.Murdpal Code,Chapter 9.17,and the
IWIth and Seery Code Sedim 25537(1)7 HEATING UNIT(OVER IO ,020 BTT!) TOTAL:
❑Yn No
Wllitheappllnm or ore Wlldingurupea.seequlpment mdevl¢s VENIILATIONFAN(BINGLERESID) issuPNMTr
whkh emit hares...elf contamLume 1e defined by the Bay Are.Ab
Quality Management Dist d7 BOILER{OMP OFiP OR 1W,IXA B1Tn
❑Yo No OCT
t) 99
ihavcrea lieaBh& pus mterleercquUcmenb 533an 2SSU..95 o1 BOfLER NMP(OVFR IO,000 BTU) �/VT 1v"O
Calffxmthemtandt tlfth kSadin Code,Sedb 25505,75533and2431. 1
u�dcntendy to rally
the icdosa of taumentlyhavcatenanl that 1,e mry NEW R}9DENTIAL MEIN. SQFT City o1 Vu(a�asala,
,io, 14111 rc a.Ctheacvpa mafth, dmmema which cwt be omen 4U
-rkmsones a(s Certll Gte of Occup
Pwnaaauth gem fA/6aa
TOTAL: ISSUEDIM • �N� GL
OFFICE COPY