23953APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEW ONLY
Building Project Identification 2� P��
Budding Address:
PITtMITN23953
nes one:
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� ULLEW
CITY OF CUPERTINO-BUILDINGDIVISION
APPLICATION /PERMIT
BUfLDING-MECTRICAI PLUMBINC-MECIIAMCAL
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Contractor's Name: LL(ISOaN:
Li
CATEGORY
CONTROL#
Archhect/Engineer. Llc. No:
QTY ELECTRIC PER FEE
BUILDING PERMIT INFO
. \
Addrai I -S IJN
PERMITISSUANCE �
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapter 9(convnenc
[i.e.1,1.fan formafdefelon3o(the ButlsssandPro(esslonsCade,and
Timms bIn(uB fors and
APPLIANCES L
]OB DFSCRIPHON
�n _sus, rs.J EL
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CVs Lont
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DateLiOm
Date Contractor
ARCHall be used npu DECLARATION
I understand my pias atoll be used upublicrerorda
LI..ed Prcdosai uil
-1000 AMI
O ERt
.Fr. FLOOR AREA 'E'f9�FT.
3jb l
4VELSVTRICAL
TALCIRCUIT/MISC
OWNER -HOLDER ra DECLARATION
T hereby alOrm that I am from the LARActorb Lianas Lew for the
_
d Y/ ob
TEMP METER OR POLEINST.
POWER DEVICES
following reason.(Sectlon 7031.5, Business and Profusions Code: Any city or
county which requires a permit to commuct, alter, Improve, demolish, or repair
anyatructure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provisions of the
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® �,7 �p IV t B
Etl 4V/ YN\Vtl
SWIMMING POOL ELECTRIC
lia^
OUTLETSSWITCHESFIXTURES
_
Contractor's License Law (Chapter 9(communeing with Section 7000) of Dlvi-
slan3 Ofthe Bushes and Predeslos Code) orthat hels exempt them(mmand
the Web for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjects the applicant to a civil penalty of net room than
VALUAMN_ '
red owner Of thepr.
tlFe 1, as
s owner of the property, or my employes with wags as thele sole
NEW RESIDENTIAL ELECTR_SQ.Fr.
STORIES TYPE CONSTRUCTION
o
mmpe Business workand thestroctureh cotntract
Business and L Ww
r License Law sale (Sec.
c. 7044. Cods; The
f propoios
or improve,
dos not a es,uch torn owner ofthroug hiswho builds orlmprwested that and
pply to ereon
who doessuchwork hisownemployees, that such
OCC.GROUP RES. NITS
ethroegh
improvementsarenmintendedoroffered (wale.If, h nee q deer ilingor
not Intended however,theb
o calor theawner-W ildswell have
Improvement aBold wlthat os,
O
did n
t rdeno(proving that he did not Wlld orimprove for purposeafukJ.
hruild
Lj L as owner of the property, am exclusively contracting with licensed
contractors to tract the proeo project (S 7004 Bushes and Prof.[.. Code:
mru
QTY, PLUMBING PERMIT
PERMIT ISSUANCE
A
The Contvctorb Li... law dm nM apply to an ..or of property who
Wilds or Improves thereon, and who contracts far such pka)ects with a
c'factor(s) licensed pursuant to the Contractors License Law.
L -J I am exempt under Sec. B k P C for this recon
ALTER DMIN k VENT- WATER (EA)
S
Lown
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREGOND. p
A,
MTURES. PER TRAP r�
tITARY
ECERT# '
Owner Date
WORKMAN COMPENSATION DECLARATION
❑i hcrcby af(Irm that I hive • srtifiste of cssent to se141nmre, w a
certificate of Workeri Compesatlon Insurance or a srtified copy thereof (Ser.
3800,1.bC.)
SCHOOL TAX Y N
RECErT Y
S GAFA. SYSTEM -1 INGt OUTLETS
PARK FEE Y N
RECE1'oliryY
GAS EA. SYSTEM-OOVER
Com ray
DING 1N
BUILDING DI VISION FEES
Certified copy Is hercbyth the city
�Certlfed spy Is (fled with the city Inspection division.
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECICFEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectlon need not be completed if the permit is forces hundred dollars
PAID
Date Recel t#
SEWER SAMTARY STORM EA. 200FT.
WATER I-[EA.I.F�t W/VENT,/aec.I.R
ENERGY FEE Y N
PAID
W) or los.)
I srtifythat N the pertormuns of the work forwhich this permit is lamed,
I shall not employ any pe a manner so as to become subject to the
Worksr�yptpyg0tion w I =nor
so n
WATER SYSTEM/TREATING
Applies I Il \(.0 i'l P UAA/T'll—rte—F=
NODCETO APPLICANTN, after making the Ce"M(e of Exemption, y6u
should become subject to the Workers'C.mpesatlon previsions of the Labor
Code, you must forthwith comply with such provisions; or this permit shall or
deemed revoked.
Date Recel t#
ly RESIDENTIAL PLM O. SQ.Ff.
TOTAL:
ILD
^'
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
Ihambyafflrm that there is a construction lending agency for the perform�T
ance of the work for which this permit Is Issued (Sec. 30W, Civ. C.)
��e
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Iendcra Name
Lender's Address
laertifythttlWvereadtheapplisti... mist.tethatlhe above in formation
bcormet.I agree to complywith all cityand county ord[nanttro and stale laws
MECHANICAL FEE
PERMIT ISSUANCE /'
FEES PAID:
misting to building construction, and hereby authorlu representatives of this
city to enter a Pon the above.mentioned preporty for inspection pu rposes.
(We) agree to save, indemnify an d keep harmless the City of Cu Fortino
against ilabilties,judgment.,oun.nd ex permits which may in any way accrue
inert said City softhegrantl gof this permit.
rr-. r7
N 1- r7-
ALTERORADDTOMECH.
Date Reeef [#
p
AIR HANDLI NG UNIT (TO 10,000 CFM)
SUBTOTAL:
'
AIR
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signature of Applian omractor
EKI lAUS'T HOOD (w/DTKT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Date RCCeI
HEATING UNIT (OVER 100,000 BTU)
TO
I lealth and Safety Code Section 25532(x)?
Ys No
Ret
the applicant w core building occepant use equiprront or devicesVENDLATION
which emit bars mous air cents Ms nts as defined by the Bay Area Air
Quality Management District?
4 Yes I-INo
have mad aSossa of
rcons
FAN (SINGLE RESID)
ISSUANCE DATE
R�
IP j� g
BOILER -COMP OTB' OR 100,0(10 BTU)
BOR-FR-COMP(OV17t 100,MD BTU)
Healthe h
Code, Se
lW California Health k s,(ny Code, Sunla. 75505, 25577 and 255M. I
255nb5533 and 25534.
NEW RESIDFNTIAL MECH. SQXT
understand that if the building does not currently have a tenant, that It is my
notiof a ytheocte of dtherequlrcmenlewhich moat be na't
responsibility ranttoIssuance
prior to Isuenco of ti Certificate o(Occohe req
JUL f9 1992
CITY t
�,�,
ISSUEDB
Owner or a
authorized agent - Date
-
ro
OFFICE COPY