22387 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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—}— q 4 I'FLLMIT NO.
e.Bamg A.d : - �V V l+ J ► e .� 22387 -
e arc: o e:
CITY OF CUPERTINO-BUILDING DIVISION
Cmttrad.rsName: Lk Na APPLICATION / PERMIT Upw7-2- C?
® Mchltect/Ggl�uer: Lb.Na BUfI.DINGF].ECTRIGV�1'LUMBINGMOCHANICAI. CA Y CONTROL.
QTY ELECTRiC PERMIT FEE .BUILDING PERMIT INFO
Addrtaf:
PFRIATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
I hhSecuo 700D).lamlkmaefuMB.M .b dP fCha.0(mmmenc API'1]ANCESRF9DEM7AL DESCRIPTION
Ingwith5ectbn N00)of itvfect, ofthegutltrsewdProfeselauCodt,and t
license b In full d dlM. PANELS � I r
Lloeeiyt C�IJCN SOK '393 G
Date GTy ComnaooJjQ(�P�/Lr�./�G 12
-
AROIITECTSDECLARATION 201-1000AMPS U
�gvpR7 I uedeutaed my plaeu shall be rued u public movda. OVERIOOOAMPS FT.FLOOR AREA S/SQ.FT.
Fi f: Llmued Pderbvl SIGNS ELECTRICAL I ��Cn`
< OWNER-BUILDER DECLARATION SPECIALCIRCUIT MRS. IL�l `�J
7F, � Ihemby.M.that lam exempt from the Contractor'sLkxnse law for the / '�".�J�
pp foOowing rtason.ISedlmi7mlS,Business and lhofeubeu Code:Mydty or 1 �rml
6 Z TEMP.MEYER OR POLE INST.
P�p —y urechkh niorto abauance,mrutwuilmstheaprne,demsuch,armilt w
5t�< anyrtructurtprlertolbbuanee,sboreyuirnsuant t Bthe for such preeemof to ]OWER DEVICES -s-i
0.V fileCo a signed strtemeLa ( he b Bcen.ed pursuant rt the proalbru of the
331�i I- Comnct.fs Llceroelaw(Chapter9(mmmendng wbh Section 700D)of Dld- SWIMMING POOL ELECTRIC VALUATION
OJ don3.!lht Business and Pedeeebm Code).rthrt he6eremptthert(rom.nd
OUT
...]]] ' the bask for the alleged exemptbn. My vidatbn d Sectbn 70415 by any
<^ lee huntforapllars% bjcRstheappllcanetoadvll ptvHy ofnd rro¢tlun 'LAS �}�}1K['(JRTS
p Ilve hundred ddlva(L+OU4. NEWRES16WHALELECTR SQXT. CONSTRUCTION .
❑I,u owner of the property,or my employee with wages as their sok
comptneatice,will do the svork,..d theatrumum b not bm dedor offered for - T
tale f.,70K Bu lnessand Prd¢eloeu Code:The Comnctole license law 1
does not.pply to an owner of property who W ids or Improves themon,and OCCG 1)P
66 who doe much work himself or through hie own employee,provided that ouch rG p ��
lmpevsemtmeart nor lnlended proffered for uk.
14 however,ihebuldbgor TOTAL: DATE ` .1i�i
Improvementbsdd Within.rcyear.fcompleH.n theowever thderwW love
en of proving that h,did t build or Improve for purpose of ule). Of Y. PLUMBING PERMIT FEE
�bre
1 u owner of the property,am e.loswdUm
.,d
contracting with Bneed FLOOD ZONE APNt
contractm.tocorWruct the project(See.70K Buflnessaed Profeaelom Code: PERMIT EiUANCE .
'ie Com metoe.License Law does not apply to an owner of property who
builds or Improve thereon, and who mmracta for such p5ejecta with a ALTER-DRAIIV&VENT-WATER(EA)
C17�ctc,w llrenied p.rauant to the ConaadQ.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII .m exempt under Sec B& P C for this mae.n
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA.COND. SANITARY Y N
Owner Date RECEF'
WORgNAN COMPWSATION DEMRATION FDn1JRE&PER TRAP SCHOOLTAX Y N
lam[Fereby affirm that I have.oenl/iute d conemt to rB-Lwrt,a a REC IPT a
380D,
3800 S F.A.
to of WorkeriC ST
ptvatlanlruuran¢ma¢niflad mpythertof(See GASYSTEM..INCA OUT[MS PARK FEE Y 'N
Tab CJ MGgL/
RETIED.'I
Cn nv Ae.4e.� / CAS FA.S1'SIF1(-0VFRI(FA) BUILDING DIVISION FEES
5CertNed ilco rthehed.
Certified ropy is filed with the d[y lvM
peon divlelmW
. GREASE/ DI15I'RL WASINTERCEPTOR 74RCQ'lDR PLANCHBCK FEE
Y`' CERTIFICATE OF IXFM MON FROM WORK ERS' GREASE TRAP PAID '
COMPENSATION U:SURANCE �yplygAh,H. Y-BIL�RM et aTaFT Date Recd tit
(This section need out be completed If the perrnit b for one hundred dollars
($100)orless.) WATER HEATER W/VENT/EI.ECTR ENERGY FEE Y N
1 certify thrt b the perromunceof the work forwhich thlmUt
e peb issued,
I.hail not employ any pe.in any canner an as to become subject to the WATERSYSIFM/TREATING
Wmkerf Cmnpensatbn Law.d UlBmnb. Date - PAID
O Z Applicant - NEW RESIDENTIAL.'LMB. SQFT. Date Recti tic
Z O N'OTICETO APPLICANT':If,after trukingthla Ceniflnteof Exemptlon,yw
F N should become aub),t to the Worker:Comperoatwn previsions of the labor TAE:
_ Code,you must forthwith mm ply withsuch provWou orthis permit shall be
W > deemed revoked. I
W
o CONSTRUCTIONLFADINGAGENCY EISMIC -E
I hereby affirm that then b.construction knitting agency for the pedorm
ELECTRIC FEE".
7 = an¢ofthe work(or which tial permit hlfved bee 3097,Civ.C) TOTAL
U O Leteer'.Name - PLUMBING FEE
LL H 1<Mer'e Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iced Bythrtlhave¢ndthbspp"k ..rdmatethaltheaboveinformdlm
bcorrtct.Iag.t.cornplywfth Wcdyaedcounty.edlnancee.ndtl tel.w. PERMIT ISSUANCE FEES PAID: Y1
} N rdming to bu llding coneuuctice,andere
hby authoube representative.of this
F (n dty to enter upon the abovcmentbned property for inspection purpo.ea. ALTFRORADDTOMH:H. Date Recef tit
(We)agree to seva,Ind ernmfy.n d keep harmless the City of Cu Perrino, _
V
galore llab5ate.,Itdgmema,cons and expenses which cony N any way.., AIR HANDLING IINIT(IO IO,ODO CFM) SUBTOTAL:
agabuts C i qu t granting dthls pemJL AIRHANDLING UNIT(OVER IO,ODOCFVO CONSTRUCIIONTAX
� � �/�/9/ CONSTRUCTION TAX PAID:
Sl�iufAppBgq Cmtrx IXHAIJST HOOD(W/DI1CI)
2irfutum SMAng cmupant momRIALS O UR
Wbi Cheap nedby the urc building o¢vpantstort h ptedk ha and
HEATING IINTT(IT3I00,0006I1J)rnaterDate Recci to
Health la Safety odthe Cupertino tion255MutddpalCode,Chapter 9.12,and the
Health and Safety cede Section 7S532(a)7 HFA7lNC:UNIT(OVER tOD,IXA BIT!) TOTAL:
Ya Sj No
Will tht•ppllae�(yf(0wreinlitabuilding oaapaedby the Bay Are.
devices VENTILATION FAN(SINGLE RFSTU) ISSUANCE DATE
which eMthaerent airriaMnemaas dtOrud by the Bay Aren Ak
Quality hhnagemem IXs ct7 BOIIF.R{OMP OHP OR I%000 BTU) ,
OYe No
ve¢ad'he h am sash requirerocons under Chapter 695 of BO Q{OMP(OVER 100,0008
the C Ivenh Health&Safety Code,Sectle.Te505,75533and 2:534. 1
urdceetand that it the budding dna not currently have a tenant,that it h urry NEW RESIDENTIAL MECH. SQ.FT
m,poeulbllit tonally theeme not orbs requlumew which rtwR be met
prior to -ensue Ce fire off"Fancy.
w!h agent Dae ISSUE
TOTAL: — —
OFFICE COPY