27712PY OF CUPERTINO APPLICATION/PERMIT
BUILDING DIVISION
,DING ADDRESS: a.21,35- �+hfct auhal
.Upel iAO, CQ•c15-41 r
ERS NAME e OAR SHRHRijf01 E 996_ &Sx
CIIITEg/ENGINEER: LIC NO:
✓I IYUJI 4SaSSON R4�abl
CI'� PHONE:
LICENSED CONTRACTOR'S DECLARATION
C]m'z, I hereby affirm that l um licensed under provisions ofatinar9(commencing with
�00❑ Secticar 7") Of Division 3 of the Business and Professions Code, and my license is in
a�U fullfame and effect.
FZIw Lit s>Class LiMg�:
p
yay n CzON? Of fOzd s a ypl s
G'4�;
.3 LIc o, rom"r al
a,yWBOWNER-
UIL DER DECLARATION
�q(i(5OyF I hereby aff t that 1 am exempt from the Cmaracmr's License Law for the
6 Cade:a++3�m falnwing reason.( action 9031.5, Business and Profanions Ce: Anm y city county
which requires a permit to construct, alter, improve, demolish, or repir any structure
prior m ha issuance, also requires ate applicant for such penoiuo file a signedstawaent
SC Q o that he is li¢nsed pursuant to the provisions of the Cmilommus, License Low (Chapter
o u. 9 (commencing with Section 7") of Division 3 of the Business and Professions Code)
to or chat he i s exempt herefmm and the basis for the alleged exemption. Any violation of
>¢Section 7031.5 by any applicant for a permit subjects the applicanuo a civil penalty of
yZ
ran
more Iran r, Ne hundred dollars O50T.
1"o ❑ I, as owner fthe property, or my employees with wages as their sole compensation,
will do the work.ind the structure is net intended or offered for sale (Sea 7044. Business
and Professions Code: Um Comb com s License Law does not apply t. an owner of
property who buildsorimpreves thereao,andwhodoes such work himselfenhroughhis
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one yearofcompletion. Ilse owner -
builder will have the burden of proving that he did not build or improve for purpose or
sale.).
❑ I. sommarofthepropeny, emexclusivelyconuacting with licensed commucmmto
conswct the project (Sec. 7044, Business and Professions CMe.) The Contractor's
License Law docs not apply to an owner of pmperty who builds or improves Hereon, and
who contracts for such projects with a connotations) licensed pursuant to Contmcmrs
License Lms.
❑ 1 am exempt undtt Sec. , B & P C for this rc on
Owner
*IORKKMAN COMPIlJSAT10�D: LARA' ON
�❑ Iw l huveucm.cansennowf(Sn rgobC)iwhich-I—orotanifiMtwpy thereof(S3g00LabCJwhichcovmn'a ""permit.PolicyCmpa❑Chcrebyl ishcA❑Cfiled, thjeLk c n vision.
or less) '1/
Ic<nifyttia in theperromtanceoflhe wy fo I1 Ihispermilisiss I It
nn, employ any a son in any :;;5
m nal us dye u ysb' t W ars'
Z Compensation sro(Califomia. a5
Applicant
C) C NOTICHTOAPP ICANT ,cit gHi t Fano(Exemploryoushould
F' become subject to efs a adon p to of the Labor CMe, you must
hnthwiH comply with aneIt provisi iso this] vit shall he deemedc,mmil.
a
Cla CONSTRUCTION LENDING AGENCY
7 z I hereby affirm that there is a construction lending agency for the performance of
V O the work for which this permit is issued (Sec. 3097, Civ. C.)
V. yr 1<ndels Name
1�' Ieadea Address
{Uf cenify that f have read this application end xtate that the above information is
LY. coma. I agree ma comply with all city and county ormasurcesind 11.1. laws relating 10
U) building conauuction,and hereby authorize representativesof,hiscity hummer upon the
V z .hove- dpropeny for inspection purposes.
(W�i re to save, indemnify end heap,, hertnle%%%��f the City of Cupertil. again',
liahili,ie, dgmems,ev ande)penseswhQhmayirtyty waynccruetnirki said Cihy
m copse of me nrand Ih s oenn�I 1 I
HAZAR90US MATERIALS DISCLOSURE
Will he applicant or future building ae.,am, some or handle harmdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and flue Ilcahh and Safety
CMe, Section 25532(a)'1
❑ Yes ❑ No
Will da spdiana,or future builJingacupanf useequipmentordeviaswhichami,
haramMus air contaminants as defined by the Bay Arca Air Quality Management
YXii
I ❑Yn El No
I have and the himMous materials requirements under Chapter 6.95 of the
California health & Safety Cud,,, Sections 25505, 25533 and 25534. 1 understand that
tl'thebut Wing Jawsnotments yhaveust he mat it ismy insurance
bfa Cionotify the
occupant of He requirements which must tc met prim to ivuenm n(a Cenificate of
Occupancy.
Owner or ammnai d agent Date
0
TY. ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS �k
UP TO 200 AMPS
277121
SIGNS ELECTRICAL
11
/ O�
L
I oD ZONE
LCIRCUIT/MISE.
TEP.
M
TI!MP. METER OR PULE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
V7A�IlUATI
gTORB?S 9'vpF.fnNCTt
OUTLETS . SWITCHES - FIXTURES
NI?WRESIDENTIALELECTR _SQ.FT,
PLUMBING PERMIT
FEE
I oD ZONE
APN
PERMITISSUANCE
ALTER- DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
SANITARY
Y N_
RFCEIPrMSCHOOLTAX
DRAINS FLOOR. ROOF, AREA, COND.
Y
RTiCE1PTN
FIXTURES-PERTRAP
PARKER?E
,oVuJ.qTNc)yQAION
PLANE P .
Y N_
ECEI M
PERS
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - EA. SYSTEM -OVER 4 (EA)
GREASUNDUSTRL WASTE INTERCEPTOR
G A Fi?GREASHIRAP
SOIL HodSEWER
- SANI'T'ARY - STORM EA. 201?NERGY
FEENUWATER
f1A
HEATHS W/Vfi/RLECTR
rA1DWATER Dal
SYSTI?M/I'R[ATING
NEW RESIDENTIAL PLMB. SQ. Pr.
a MECHANICAL PERMIT-
PERMIT' ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
IXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU) 1
HEATING UNIT (OVER 100,000 BTU)
VENTILATION PAN (SINGLE RPSID)
BOILER - COMP UI IP OR 10000Th BTU)
BOILER - COMP (OVER I(IQ000 BTU)
NE?W RESIDENTIAL MECH. SQ. FT.
PER
PAID
Data
SEP ti 419gs
y Ut i"urtHflNO
ISSUED
"NIPPii,
9