22311 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identlrkrtlov
BuIlding Address: s -s-- 6 ' PERMIT NO.
1a �� 4' T-Ltrral(r^ Q Dr. ' L" 1 J3_ ` 22311
. aphone.
JHnU � I H-5\j CITY OF CUPERTINO-BUILDING DIVISION A A
. Contnaor'.Name: h 1�y(�q Lie.Na APPLICATION I PERMIT —L l
b wh_e�� "- 1_02cq BUILDINGELECMCA PLUMBINGMECHAMCAL CATEGORY CONTROL
Archheet/Engineer. Glc No:
I Cb}-� Id"SU ELECTRIC PERMIT FEE BUILDING PERMIT INFO
QTYAdd. 13Z1A 1 TRO 'SD ( O PERMITISSUANCE pI ❑ 9 1:1 F-1LICENSED CONACTOR'S DECLARATION
I Mrebyaf(Irm tout lei lW.3Mh,B" vW.sot Chapler9(®an m APPLIANCISRESDENIIAL J ANION
Ingwll I Sexiloll form of DIvts1.3o/the ButlrcraandPro(mlovCode,+nd
licensebin fuB fora and e.1 PANELS
License CLns ong - ��a
Due Cormaacor '
ARCHITECTS DECLARATION AI- AMPS
O CZO I undeoAxnd eny plam shall be used m
ed u public reda OO
OVER IODD AMPS SQ.FT.FLOOR AREA f/SQ.Fr.
L)
LI.-td Prdesebvl SIGNS ELECTRICAL
tLA° OWNER-BUILDER DECLARATION I
,F. 7 Ihercbyafflre, h tI...mptf.ths C°Mr ,'.Lia Lawforlhe SI'FGIAL CIRCUIT/M15C
pp 'q� following rtaaon.(Semon 7Q115,Bualnes and Pmfeabm Code:M tl
rot Y ty°r TEMP.METER OAI'OI.E INST.
F� :y onygm=hpe to a permft a am r qu altthea p Uv tfe such,or to
X77 anypruRurtpA«to Fbhe he
alnrnd pumattothntf«vision of to �yypA DEVit"E5
file a signed atstemeM that he h Iloensed pursuant to the proal loss of the
On,I� Contractors Lleeme Law(Chapter9(mmnentlng with Sesbn 7000)of Di+ SW114ANG IDOL ELECTRIC
F,E, sion3 otthe Businusand Profmwv C°de)orthrthebessmpttherefromard VALUATION
•77 the basis for the alleged exemption Any violation of Se Icut 70715 by any
appliantfor a permit subjectathe applicant to a civil penalty of no mom than c""NT[Ch TFl%TURES
p flue and red d olfts(Lri001.
t)III, owner of the Property,or my employees with wages aa their sole NEW R2%DENTIAL ELECTR SQXT. STORIES TYPECONSIAUCTION
persatlen,willdolhe w«iS and the atrume,b not Intended or offered for
0 ask(See.706E Businm and Professors Code:The Conlnaor.Lame Lw
S$ don not apply to an owner of property who bul7ds or Improves t hereon,and OCC.GROUP RFS.UNITS
KKKKKK whodonsuchworkhlmse8«through Msownemployen,prwded that such
Lnprovememaare Mw tendMorotreredf«sole.l(M1owever,IhebuiWing or TOTAL.
Improvememissoldwlthinomyearofcan IelbMtheowner-bullderwlll have
Ll�t�urdenofpmvinglhehedW,mbu0orlmpmverorpurpoaeMuk.). QTY, PLUMBINGPERMIT FEE
LJ L as owner or the property,am excbsively mntncting with Ikenaed FLOOD ZONE AFN
conlratlon W mmtaQ the projeet(See.7066,Bualnm and Professors Code.. PERMIT NUANCE
The Contractor's Llame IAw aces not apply to an owner d property who ALTER DRAIN 4 VENT-WATER(FA)
Wild. or Impm xx thneon,and who mMntla fee uneh p1jeca with a
o+pLl'anorte)litemed pursuant to the Contrader's Liceme Law. FEE SUMMARY
LJ I am exempt under Sec B 4 P C for Nb nason BACK FLOW PROTECT,DEVICE
DRAINS FLUOR ROOF,AREA,GOND. SANITARY Y_ N
• Owner Dale.
ORI0a1AN CO. PFNSATION DELLA N pT(.NffFS PER.CRAP SQiODL TAX- Y N
❑I hereby orrlrm that I love a l m0 of.° Mif to.Pyffisnn,ora RECEIPT g
mW,Lab of Worker'CampemaH.lrmurana«aartlfled ropy Nneof 6ec. GAS F.A.SYSIENI-1 INIZ.4OULEIS PARK FEE Y N
Ivir 0 CJ
Policyg GASFASYSTEMZVFRA(EA) DING Ta—
C^n^ nY BUILDING DIVISION FF.E_5
�]CMBied ropy b hereby WmLcityeity
�eertuka ropybmea with the Wpemon alum.. CREASE/BNmusrRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPFNSATIONINBURANC6 SEWER.SANfTARYSURMEA]POET Date RLarol t#
MOD)or I..)
(Thla need outuecomplMcd lithe peat leu« rc
ohundred dollen P
I certify that rothe penorm.na°rthework for which tM,permit I.Naeed, wwTEA MATER w/vFxr/FI.rtlx ENERGY FTE Y_ N_
I shall not emploY any Perane In any manner a ss to become subject to the WATQi SYSTEM/TREATING
Workers Compenaatbn I.wsor CUlltomia.Dee PAID
C' Z ApplicantNEW RE5IDENTIAL PIAIB. FT. DatC Recti t#
r O N'OTICETO AMICA IT:If,after making Urs CenF-_,; fEaemptbn,you e'Q
should Meme sub)eet to the Worlon'Com,evaUon pmovbbv of the Labor TOTAL:
~ N Code,you most forthwith comply hal
with such provlems orthks permll+ l be
Q > deemed revoked.
W p CONSTRUCTION LENDING AGENCY SEI MIC FEE
CL IherebyafBrmld b
hethenbamrslrom.kndingagencyrortheperrom, ELECTRIC FEE ( _p
Z ane of the workfor which this permit is issueee 3097,C1v.C.) TOTAL:
(,) O Lender's Na'^e PLUMBING FEE
LL h- Lend.e.Addoaa QTY. MECHANICAL PERMIT FEE - MECHANICAL FEE
O W IcertlfythatIfuvennxilhL applla ic, and..Ihrtlhe abovelnM.11.
bmrnect.Iagree to comply with all city ami county,ordwnmand.slate law. PFAhfIT L%UANCE FEES PAID.
IL releing to building mrstrom.,and hereby authorise representatives ofthh
?N city to enter upon theabove-mentbrad property for Wpeatbn purpoao, ALTER OR ADD TO MFGH.
(We)agree t°rove,indemnify an d keep harm].the City of Cupertino Date Receipt#
V agaWt habWtlea,judgments,mats and expemes which my In anyw.y..e NR HANDLING UNTr(rOI0,0DDCFM) - SUBTOTAL: .d
ag.lvt acid CNyp comequenoe of the gnnxing of this pe
�,�yn`�'`'/Z�/ I AIR I-uNDUNC UNIT rovEx 1D,DDocF�n CONSTRUCTION TAX
Signature ]l puont/contn « r D,t —M
Hoop(w/oucD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the app] uto,hutumbullciing oomp m donor lendle havrdous BEATING UMT(TO 100,000 BTU) Date Retei t#
material as defined by the CupertinuMuNtlpal Code,Chapter 9.17,and the
H.Ith.M SafetyCode Sem.75537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 0
❑Yea, N No
Will the applicant«fuWn Wilding°ccupant sae equipment or dev cs VENTILATION FAN(SINGLE RESID) I$SUANCE DATE
whkh cret hantdon ab contambsntsas defincd bythe Ray Area Air Q/ Yl
Qualfty Mamgemeol DWrIet7 BOILER-COMP OM'OR 100,0(D BTI)
I Yn gal
half nad the ta:+ requirments 2554. 1 of BOILER-COMP(OVERtW,0008T1) JUNj
the unUandl t Health 45af°Iy Cods Sectom75505,5a teran75536. I M!\ M^a.
understandlhat notifyf the the ingdon ofnot emquir M1aaa h1uh rust it bury NEW RESTDFTRIAL MEIN. SQ.FT
repovWirea re natty the occupant ee the requirements which must be mel Mgt prior to L�uanm ofaCertllkatc of Oaaupanry, /
Ownerorauthoe&n1.gent Dale 7biA1, ISSUED BfO A� V
OFFICE COPY