23070APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY.
Building Project identification -
Building Address: t en coo Ltd 66 tic o � -
PERMITNO.
23070.
where >� Get e.
CITY OF P T[N6BUIL IN TVI§ION
APP CAT( N PffRMIT
l 1
G°nr '-N S m
CATEGORY
C
BUILDIN ELECTRIC GING-MECHANICAL
Arch / gineer. Lm. Na
QTr ELE I PE IT FEE
BUILDING PERMIT INFO
Address:
T15SU CE i�am
LICENSED CONTRACTOR'S DECLARATION
Ihereby efirenut70 that lam M1 30ihIlAuMrovidonsa/Cnapler9de,aAd ,
Ingwlth SeMon7f10%o/DiWslon3o/th usiriessand ProleWonsC-ode, and1
license Is In full force and effect.
AN L
pro] 9DESCRPDON
—�
P
Lice n Class LION
Dat Contractor'
�� �V
281-1000 PS
ARCHITECPSDECLARATION qI
1. entan y plain shallbe used as public records.
OVER I
SQ. FT. FLOORR AREA $/9Q.FT.
v
Licensed Professional
2
SIGNSE TRILL
OWNER -HOLDER DECLARATION
I hereby a(Orm e
that I am exempt from the Contractors License Law (othe
SPECG C1RClB7/M1SC
AJ L E f
�p ETER OR POLE INST.
following reawn.(Section 70315, Business and Profession. Code:Mycity or
county which exquinat a permit romh
tuuct, alter, improve, d,.I, .yd%lr
A e T a..�
any.tructimpriertolreb.uance, also requires the applicant for such permit to
file a signed statement that he Is licensed pursuant to the provisions of the
DEVICES16�
.
u I IE ,�••(l
NG IDOL ELECTRIC
QAXrslon3ofthe
OUTLETSSWH'CHESFIX'MtES
Conlradne. License Law (Chapter 9(mmmentlng with Section 7000) of DIW-
Bu.messand Profemimu Code)orthatheisonmptlhemfromand
ins bash for e alleged exemption. on. My violation o(naltyo 70315 by any
the bcant fora penNged exe prion. p0 MyaciWl penalty of notv,tany
ON
NEW RESIDENTIAL ELECTR SQFf.
five hundred dollar. ($.500).
Lan owner of the property, or my employees with wages as their sole
STORIES _
TYPE CONSTRUCTION
rompan.atlon, will do the work, and the structure isnot Intended or offered for
sale (Sec 70K Business and Professions Code: The Contractors License Law
dace not apply to an owner d property who builds or impravm thereon, and
whodoch
Improvemenb arenot mtelf orhroghhifone If,yees, provided
whod°ementswork hlm lfodoroughed owns. If,ho however,
tsuch
buildingor
/1
� � U
E R
improvement i. oldwithinomyearofcompldlon,theowner-WiWerwill have
tl
t1�urdenofpmWng that he dm real build orimprove for purpoacofsakd.
U L as owner of the property, am exclusively contracting with licensed
contractors to mrutruct the projrd(Sec. 7014 BuslnessarW ProrksMs Cade:
QTY, PLUMBING PERMIT E
FLOOD ZONE
TE
APN
PERMIT ISSUANCE
7 D
5
The Contractors License Law doe. not apply to an owner of property who
builds or Improves thereon, and who motnae for each pkojects with a
cgRlPdorW licensed pursuant to the Contractor's License Law.
LSI am exempt under Sm. B k P C for this mason
ALTER -DRAW & VENT - WATER CE A)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTS I DE FEES
RNNS RRODF, AREA, COND.
SANITARY Y N
RECEIPT# '
Owner Dine
WORKMAN COMPENSATION DECLARATION
❑I hereby .fibro that I have a certificate of consent to self -Invert, ora
celtlflcate ofWorkeri Compensation Insurance or a certified ropy thereof (Sec.
3800 Lab C.)
Pat
FO(.IVRFS I'fR.DtA[s '�^
SCHOOL TAX Y_ N_
RECEIPT N
GAS F.A.SYSfEM-1 WC60ITCLETS
PARK FEE Y N
RECEIPT#
M Y / /C i ♦ f
GAS EA. SYSTEM -OVER
BUILDIN (VISION FEES
rtlBed ropy Isnem fuMeFed.
Certified copy a filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
SE/I USTRL WASTE INTERCEI'TO r�
PLAN I C 2Q .a�♦.a
I iL
PA7dl'
GREASE TRAP
COMPENSATION INSURANCE
(TMssecilon need net be completed lithe SpermitURA ls Perone hundred dollen
` a Re i t#
SEWFRSANTfARYSIORM EA.200Fr.
WATER ];EATF32 W/VENT/ELEGTR
ENER Y N
're
PAU
(g100)oless,)
1 crellythat m the perfomenmof the work forwhich this permit Is (wed,
I shall not employ any person In any manner w a. to be.. subject to the
Workers' Compensation Laws of California. Date
WATER 5YSTFM/TREATING
ApplicaNOTICE
NOTICEco MPLICt agar nuking cate
Date R cel t#
NEW RESIDENTIAL FILMS. SQFT.
should become subject to the Workers'
to pe ation provisions°f the Labor
n provbis of,
BU �'
such provisions
Coda you rtwat forthwith comply with such proaltom orlFls permit shall be
p
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hereby affirm that them Isa mrotmdion lending agency forthe perfomr
ELECTRIC FEE
ance olthe work forwhtch this permit Is Issued (Sec. 3097, Clv, CJ
Leader's Name
Lenders Address
I mitifylhatl have read thlsappliallonand snrelhaltheabove information
bromed. l agedto complywitn all cityand muntyordinances and pate laws
PLUMBING FEE I
QTY. MECHANICAL PERMIT FEE
PERMITISSUANCE r+
MECHANICAL FEE ^
FEES PAID:
relating lobullding rorawNon, and dm representatives of thio
d toenlerupt the abovcme Property (o mpecilon purpoo.
a7 a .ave, Inch fy an d keep harmle Inc Clry of Cupedmo
ag natli Ilties, dgmenn, (tea expenses vela hmay in any wayamue
Date Receipt#
ALTER OR ADD TO MECH.
AIR HANDLING UMTfI010,OW CFM)
SUBTOTAL:
a Lite City a on granting Is Permit.
AIR HANDLING UNIT (OVER IB,BDOCFM)
CONSTRUCTION TAX
Signature (Applies /Contractor Data
E)(HAUSTHOODM/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CM 100,000 BTU)
Will the applicant orfuture building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 9.1Z and the
Health and Safety Cade Section 25532(a)I
��"'jI Yes r] No
4fli
Date Recel
' TO
-
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESIM
ISSUANCE DATE
the applicant or future building occupant use equipment or device
which emit hanurdeu. atr romamtmnn as defined by the Bay Ana Air
silty Managemcn[DisMct7 -
ve ❑ No
of
luveread thalth&dfety Code, Sedeons 255nb5533 and 25534.
Code, otWme75505,ve a amass, that I
the California at if the building
understand that ity to notify the occupant not erequiyhavea hick teatb met
pdorioibuance face eiateontofthe Tequlmmenbwnich rwsl be rrel
prior to Issuance ole Certificate of Ocmpancy.
�� Q AI
raa i! 902
CITY M
V'r fl l`
Uf GUrCTilll.y
ISSUEDB
(LER-COMP OHPOR 100,000 BTU)
BOILER -COMP (OVD2100,000 BTU)
NEW RESIDENTIAL MECH. SQFfrespons.
Ownermauth mired agent Data
_—e
OFFICE COPY