22847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
Building Prn'et Identification I I PIRMITNO.
Building Address: w A&5 - - 22847
C 'anO � LSS� Kd
neve ante: ne, - p
1 kr%aI 3 44` CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: - Lie.Na APPLICATION/ PERMIT 6
BUILD]NGELFCTRICAL,PLUMBING-MDCI IANICAL CATEGORY COYIROLN
Archltet/Engineer LIc.No:
-1 I ,t' BUILDING PERMIT INFO .
] ,^` QTv ELECTRIC PERMIT ii '.. FEE
Address. 14C Q�U f� J ut—
PERMITISSUANCE ❑ ❑=—IMIMI FLUME -❑
LICIiNSIiD CONTRALTO SU[CLARATION '
Iherebyafforothatl am licensed under provisions Of Chapter9(c mmon APPLIANCFSRFSIDENTIAL ]OB DESCRIPTION
ingwith Sect1on7000)of DiWsbn3ofthc6usinneand ProfesslonsCAdglndmy _ --
licenseis�lintfuB and effect MS PANELS /✓'}l..,L;
LI¢ Pur
Y �T''ii 77'' R.
DateContretor_3�
ARCHITECTS DECLAR TION EAMrs
07 Iundentand my Alam shall be used upublic records,
OV OVERR 1 1000 AMPS SQ.Yr.FLOOR AREA $/SQ.IR.
p°pu E.D.ly U Licensed Professional SIGNS ELECTRICAL Ai
E..se
pI���iuuu� 1 OWNER-BUILDER DECLARATION
X yp�y�3! ]hereby affirm that Ism exempt from the Contractor's License Law for the SPECIAL CIRCNT/M15C -
09,- -following reason.(Setion703)5,Rusin.and Professions Code:Anydtyor YTER
2.1- TCMP.METER OR]'OLE INST.
F� county which mryircsa permit tommtrut,alter,Mprove,d<mollsh,arrepalr / Q 6
m any structure prior to Its isvrance,also requires the applicant for such permit"'. POWER DEVICES
a file a signed statement that he b Ilrensed pursuant to the provisions of the
�wG Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWNtMING]VOL ELECTRIC
ai.0.(th.Buslnees.rd ProfeulomCode)orthet heleemorpitherefromand ' ; IDVALUA'DON
6 the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHES.FIXTURES
applicant fora permit subjects the applicant to a civil penalty elect more than
n. five hundred dollars(S500)., NEW RESIDENTIAL ELECTR
�n nL as owner of the property,or my employees with wages as their sok �'hT' STORIES TYPECONSTRUCTION
7 c mproeatlon,will doth work and thestruture is not intended or offend for
47 O sale(Sec 7011,Business and Professions Cede:The Contractors Umnse Law
�$ does not apply to an owner of property who builds or improves thereon,and OCG GROUT" RES.UMTS
<- who doessuch work himself orthrough his own employees,provided that such _
improvere,re are not Intended proffered forests.If,however,the building orTOTAL:
impm
roveent resold within oneyearofcomplelion,theewner-buildeiwili have - <
t rden ofpmving'that he did not build or bnprove forpurpose m mile.). CITY, .' " PLUMBING'PERMIT+' FEE FLOO ZO4 —APN
UL as owner of the property,am exclusively roma ...,with.sensed PERMIT ISSUANCE
rontratontoromtrut the project(Sec.7044,Bueinessand Profeniom Code:
The Contractors License law does not apply to an owner of property who
o mtALTER-DRAIN VENT (EA)
Wilds or Improves thereon, and who, for such plyi ds with a - - -
m"R(fator(s)licensed pursuant to the Contractor's License Law. PEE:$UMMARY
BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B&P C for this reason
Date DRAINS FLOG R00F,A SANITARY' Y - NOUTS I �
FE I'S
Owner - _i. R. AREA, _ RECEIPT# -
WORKMANCOMPEN$ATIONDECLARATION FIXTURES PER TRAP" SCHOOL TAX Y_ N
❑I he affirm that I have 1 mnNcate of consent to se141nsure or a
mAIRl to fWorken'Compensationlmumnmoramnified RECEIPT M copythereaf(Sec. GAS FA SYSTEMiINC.40I1TLE15
3800,lois C.)��/ /3/ PARK[FE Y N_
Coliryp W REG[]Pfp
Com r_[_ IJ GAS EA.SYSTEhf-OVER4(FA) BUILDING DIVISION FEES
enc copy b here fu the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
C fled copy is filed with the dry Impetlon division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP - PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM RA 200FT Date- Reeel t# -
Hhis section neetl na W complcted if the permit b(erase hundred dollam
'(f100mmifyt3
InBy tWATER HEATERW/VENT/ELECTR ENERGYFEE' Y N
that In the petormanreafthe work for which this permit la issued,
I shall not employ any person 1 any manner so pe�cynyyybjet to the
Workers'�pnp o alifornia. Date rJ Tas _`af WATER SYSTEM/TREATING PAID
.O Z Applicant
Z O NOTICETOAP LIC makingthb Certificateot Fxemptlon,you N6W RCSIDFN77AL PLMR. SQ,FT, Date _RCCCI t#
'Fshould become eubFt to the Workers'Compcmatlon provkioneafthe Lebo, TOTAL:
fD Code,you most forthwith comply with such provielom orthb permit shallbe
cc > dee dInvoked. BUIL12ING •-E
ap CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I herebyafRrmthat there isaromtructlon lendlegagency forth perform TOTAL: ELECTRIC FEE
ZO once of the work for which this permit le Issued(Sec.YK7,Civ.C.)
f1 <nder's Name - PLUMBING FEE
LL I— Lender's Address QTY. , MECHANICAL PERMIT.;,,' ;FEE,". PLUMBING FE FEE
MECL
O W Irenifythatl have read lhlsappBcatlanend s[atethat theabovc Information
1 ®rorrect.l agree to complywilh all city and many ordinances and state laws PERMIT ISSUANCE FEES PAID;
W relating rebuilding construction,and hereby authorize representatives ofthis
Z city to enter upon the above,mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V
.,at iaboil n,jad menti,carte and expenses which may In any wayaccrue AIR hfANDLING[NIT(TO 10,030 CFM) - SUBTOTAL:
a 1 I e uares of the granting of this Peron. r
AIR HAINDLING UNIT(OVER 10,Mo CFM) CONSTRUCTION.TAX
Slgnatu Applicant/Contractor Data EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applica nt or(utureb ng occupant store or handle hazardous HEATING UNIT 100,000 BTU) Date - RCCCI t#
materui as delimd by rheC kine MunlcipalCode,Chaplcr 9,12,and the _
Health and Safety Codr 1on25532(ai - HEATING UNIT(OVER IW,"BTU) TOTAL:
❑Yes No
Will thexpplicant or st
tore ding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUW9E DATE
whichemithamodot airm minanteas dellned bytha Bay Arca Alr' "Rs—i�ryAl#I
Quality Marugement )is aI' - BOILER-COMPUIIPOR 100,000 BTU) D .a '
4 Yes No }
havereadthehaze pus materials requircmentsunder Chapler6.95 of BOILER-COMP(OVMI 00,000 BN)` OCT
fj rOg)
the California Health&Safety Code,Sections 75505,25533 and 25534,1 !
understand that It the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
' ly to aft ih panto! erequirementa which must be"m�,e,/t
frelo.r'
cCeate til - G� lCity OGICIIftliIR/Da oiled age.,
- Date j'(C`i ISSUED BY;ZO5 I,
TOTAL:
OFFICE COPY