S 1494 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIaTY OF CUPERTINO BUILDING-KLEC'1'RICAL PEBIJITNO.
1494
�NGELDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
F BUILDING PROJEL7T IDP.N'TIFicxOON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
i q Moo 8& & C f �u '^ia t-'c.a l'�-�l�
OWNIik:S NAME: 1'HONE: CO N CIY)R'S NAME: LIC NO:
SIC CONTROL
CHI'1'IiCT/L'NG EGR: LIC NO: ADD ESS: ❑
f S1`
CONTAC'k n PHONE: BUILDING PERMIT INFO
OleC�STd / im RE- , Zn ❑ Cnnsultnnt F¢¢S Paid by Applicant(Ini11Rb DG ELECT PLUMB MLCII
ED
LICENSED CONTRACTOR'SIF.'IARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Oo'Z with Section](X10),fDivision 3 ofthe Business and Professions Cod,and my license is RESIDENTIAL
W OO PERMIT ISSUANCE
Fly
in
fall nd effect,
❑SPUWI- ❑KITCIEN REMODEL
CUF LicenseClassLic.a6V
APPLIANCES-RFSIDF.NTIAI. []ADDITION El PLUMBING RE-PIPE
.Q a Dam Commcmr
ARCHITECT-S DECLARATION ❑MULTI-0NIT ❑STRUCTURAL
Fpm PANELS MODIFICATION
Z O'-Z 1 unJc.mnd my plans shall be usedas Public rccnNs
CZ—O I1P'IY)2WAMPS [I INTERIOR El CHIMNEY REPAIR
,m, ty lAuswd Phersinnal 201-TINEAMPS IMPROVEMENT ❑SWIMMING POOLS
'�`CyC aJ OWNER-BUILDUR DECLARAT ION UVIil11WnAMP3 ❑DATII RIiMODE1JREPAIR DEMOLITION
W g .
1 hereby affirm that l am exnnpl Rom Thu Cnnmmnsr'e License Law for the .., -
i6y�5(,O U following reason (Section]0315,Business and Professions Codes Any city or county SIGNS ELECTRICAL OTHIik `C/`V/.
a++'31L F' which requires a Permit to construct,alter,Improve,demolish,or repair any structure
poor to its iwonce,also requires the applicant for such punnitto file a signed statement SPECIAL Cl RCUIT/M ISC.
that he is licensed pursuant to the prusWomof the Commetn/s License law(Chapter)
W GAO (commencingwith Section(NIO)ofDivision3offhe Husitesand ProfessionsCWc)or 'I'IiMP.METER OR POLL INS r. COMMERCIAL:
E L e C thin he is eaempl therefrom and the basis fm the alleged esemptiun.Any soldier of ❑NEW BLDG/ADDITION ❑DEMOLITION
1i• Scenes 7031.3 by any applicant for a pemlil subjects the applicant In a civil penally of POWER DEVICES
�.rZ.N not..mann five hundred dollars($500). C1 TENANT ❑FOOD SIiRVICE
=6 ❑1,es owner of Ne property,or my employees with wa6es os their sole compensafinn, SWIMMING POOL ELECTRIC IMPROVEMENT
wb.0 will dofhewods.and the sfrucwm isnot imendedor offered forsale(See.704,1,Business ❑OTHER
a3mand PhvfessioksCtdeThe C'nom"'',Lici,meLow due,not apply toanowner of OUTLETS-SWITCHES-TEXTURES
ph"my who builds or improves thereon,and who does such work himself or Ih rept
his own cnfployces,provided that such improvements arc nil intended or nffcrcd for NEW RESIDENTIAL FLECTR SQ IT.
sale.IL however,the building or improvement is sold within one year of completion,the SQ.I .PI. RARER g/SQ.ITI'.
ownerbuilder will have the burden of proving[hut no did nor build or Improve for par- •aafka®
posof sura,. ,APR 1`� IHRNRPL4VIWS\a
L as t weer of the property.,Hexclusively Protracting with licensed ut—...rs m T(YfAI.'
conxwn the pmjem(Sec.]044,Business and Pmlexsinns C<de:)'fhe Crm.cusrs hi- 1 1
cense Law does not apply to an owner of property who builds or improves thrown,and QTY. PLUMBING PERMIT Ur vurrTiHNV
whocommc¢forsuch pmjccls witharmonwotr(s)licensed promamm the Contractors CSN V
Liesme Ines. PHRMIT ISSUANCE
❑ I um cxemla under Sec. ,B&P C for this rczann
ACIF.R-DRAIN&VEM-WATIiR(EA) VALUATION
weer Dee
WORKER'S COMPENSATION DECLARATION following
BACK PLOW PROTECT.DEVICE
1 herebyalMnunder Penalty Certificate
one of theefnme for declaraWorker,,Co:
It..ono will forbi Se Cion 3700 of the 1-at3n Craft.
the Workersce of Corner. DRAINS-FLOOk,ROOF,ARTA,GOND,
STORIES TYPE CONSTRUCTION
smirk,as provided for by Section 3]1N)of the Lrhnr Cnoc,far the perfommnce of dm
work fm'which Ihirmunteis issued. IsIXTURES-PER TRAP
have Imo will maintain Worker's Cone orthenn hamrwhi h myuirco t i Section
3]INlnik LuI Code,fonhe performance,l'thework liaribe,whis permit is isuweJ, GAS-EA.SVS'TEM-I INC.40l1T1.1?'I'S OCC GROUP AI'N
Work����LLy,��y��p��b,p'In�sumnc me and l'nlley mamher me
Carrier:�eaa-iJ��c Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRPASERNDUSTRL WAS'T'E INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(lTissufion need not be completed if the Permit is liar one hundred dollars g1an) GRFASIi TRAP
nr less.3 PLANCIIIiCK FEE
Icenify NulmNeperformanccofthework forwhich Phispermitisissued.[shall SEWER-SANITARY-STORM EA.2110 IIT
not employ any person in any manner m as to become subject to the Workers'Compen- ENERGY I1E
O Z mono Isws of California.Date WATER HEATER W/VENT/F.LECfR GRADING IgiE
Q Applicant
fq NIE'ICE7 TO APPLICANT:If,after making This Cenific.e of Escmption,you should WATIiR SYSTEMII'REATING $DTI 4 FE Is a `ate' becomes.hjccl to the Workers Cnmpensallon pookionsof the Lido,Code.you most
W �y fonhwilh comply with such previsions or[his permit shall he tfeemed revoked WR'I'ER SERVICE ��-
Q
CONSTRUCI'IDN IJINUINO ACIiNCY NIiW RESIDENTIAL PLMfi. SQ.PI'. PAID
L) Q Iherehyaffirm[hmthe ,kriconsfraction l ciningogency far he perfairmocco Dee R ipla
the work for which this pvical Ls Issued(Sec.31197,Civ.CJ
!^ Isnder's Name TOTAL:
Uj Lender's Address TOTAL:
0. BUILDING
F.'
I w gree o c I have reed this application and dams Ih.the above information i ion is
h corrcngcom to comply with allciryhal amnsentatnanms and sem lawsiiupongm QTY. MECHANICALPERMIT FEE
VZ rthmengcisimed proand hromshtica emp¢smmives of this city[center upon lM SEISMIC FI?F.
above-(We) green,
property for inspection keeple. PERMIT ISSUANCE
(We)agree m save,indemnify anJ keep humtless fhe City of Cupertino against F.LIfLTRIC PC 1:
liabilities.judgments,costs and expenses which ney in any way aceta¢against said City ACI'HER OR ADD TO MECH.
in consequence of the grommg of this
Permit PLUMBING IW.
APPLE CAct'U STANDS PLY WITH ALL NON-POINT' AIR HANDLING UNIT PTO I0,fNX)CI'M7
SOURCE RF S. MIiCIIANICAI, iE
/0— AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION
.01 lure d Apph.IaIricer, 9", Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION E
11 S MATERIALS eapa DISCLOSURE
Will the appli uwre twilling r¢cupvm store or handle hazardous material II881'ING UNIT(TO IOO,fX10 BTU)
as defined by the C penin,Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(0? HEATING UNIT(OVER factKKI BTU)
C]Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Dee Receiptp
Will the applicant or future building oecupanl use equipment or devices which BOILER-COMPpHP OR IOf1.IXX1 H3V1
Oral hamtdous air contaminants as definod by the Hay Area Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,(X)0 BTU)
�Vc El No
I N1
Ihuve real the huwNnus mwerials rcyuirnnentc under Chapter 6.95 of the Coli AIR CONDITIONER ISSUANCE DATE
l iunia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NI7W RESIDENTIAL MECH, SQ.Fir.
handing does not currently have uncut,Ilial it Is nay re,ordlaility m notify the occupant
of the resluiremcnis which must he mel poor to Issuance of n Ctnlficute of Occupancy.
Ownerormffimized age. Date TOTALI ISSUED BY:
OFFICE
MARIA ALICIEICUSTODIO 0858
P. O. BOX156238 90-7811211Ili
SAN JOSE+,-CA 95156 Aoo
PAYTR LM.r.
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4AIQ MoKee.\VLlle 011l.e 1
n-� JOII AIaKEE ROAD
�RYi SAN p1SF.C1LRORNIA 03127
RANK11611NF.ST (4031347.3030
it
i FOR
1: L2LLOO 7821: 0858 0LC306L89Sill
n
CITY OF CUPERTINO
RECEIPT
No. 04047
/
DATE
Lk �( S�
�l 1
FROM ED W%Z` \,
ADDRESS P,c-j- %Y`r, Vp S' �
CASH CHECK MONEY
OR
�3 DOLLARS CENTS
M—
1�OV mg, WNI;s
13'1,OV �i0
Sn
RECEIVED
BY
75501 CROWN BUSINESS SYSIMES,INC 10001 R 3,n,
To whom it may concern
O
Kai-Niers Tu& Le Yen Wang, deed of trust to
property at 21869 Monte Ct., Cupertino, CA 95014, agree
to let CHARLES XELLY, INC. to move the residence
away from the address above.
Kai-Hien Tu
Le-Y Wang
Date: 41PAQ y, i 9 '8
State of California
County of Santa Clara
Kai-Nien Tu and Le-Yen Wang, after first being by me duly sworn, declare that the
above statement is true.
S ub scri ed and.. sworn (affirmed) before me this 9`h day of April, 1998.
o0000000000N0000a000
otarytary Public N WOLFS
RM CALIFORNIA !ACOUNTY AROBERTAANN WOLFSn ExpiresComm.No. 1147789 D001
U p NOTARY PUBLIC•CALIFORNIA 0
r. :e SANTACLARACOUNTY Q
My Commission Expires 4
July 21, 2001 000 {
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