23079r -
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln Pm'ect Identification FE1tM1TN0.
Build' Adams: Gl�e.�
�2e�� � Uax+�� P 23079
¢r CITY OF CUPERTINO-BUILDING DIVISION �^ ��7 f (
Contractor's Name: LIB Na APPLICATION / PERMIT �• J
� 54' BUIL.DINGELECTWCAGPLUMBINGMBCHANICAL CATEGORY CO
Arch ect/Ps neem IX No:
QTY ELECTRIC PERMIT. FEE BUILDING PERMIT INFO
h I PLUMS M[f]ll
Aaarea: PFRhI'r lsaT3ANCR
LICENSED CONTRACTORS DECLARATION
lhmbyaffnmthanlam BremaduMd pro Wb ofChapter9(� APPI]ANCES.F= L ipg DFSCRIPHON
IngwithSM n7000)of Dlviion3oftheB"lrc dlhofeWmaCode and
license is In full force and effect.
Lkxve Clas LUX
Date Comractor L 50
ARCHITECTS DECLARATION
�'Z r'iudemand my plan shall be used n public record& OVERT AMPS kuEo 9/SQ.ET.
[O
u Licensed Prof®Loral SIGNS EI.ECIRI P U T R
OWNERpt ER DDECLARATIONSPECIAL /MISC 7�
ZI.., a Thereby afBrmtlul lam exempt(romthe Contractor's License Law(o the
(Section reason.(Seon 70115,Business and Pmfmbn Code:Any city or
Faantywhkh rcqunnapematromrmWn,alter,lmpmrc.dennlbh,orreryir ETF�R ORI'OIE AIT. ATE F
Me.nructvrcpriemeMthat he is pursuant
ro sochpermte IOV.'FR DEVICES
O��� file a stgned tenement that he b Licensed punvant to the provisions d the
a Contractors license Law(Chapmr9(comarencing with Section 7000)d DiA
�30 don3o(the Bustnessand Profembm Code)orthathe6vemptthere(mmand '` 'SNC FOO.ELECTRIC VALUATION
y.' the basis for the alleged exemption. Md y violation Section 7m IS by any SW I.rcHt5FLY7T1RE5 �� �� O
�j «Q applicant fora permit subjMa theapplieenn to a Wil penalty of not more than JC
6 five hundred dolbn($50O). NEW RESIDENTIAL ELECTA SQYT. STORIES 7Y1'ECONSiRl1CIlON'
�n I,as owner of the property,or my employees with wages as then sole
mmpersatlogwBldothe work,and the structure 6 not lmmded or offered for
O .sale bee 7044,Business and Prdealons Code:Ilse Contractor.U.law
sc� domnatapplyto.no aipmpertywhobulldeorlmpmvmthereon.and OCC.CROUP RES UNITS
doessuch work himsel(¢thrwgh hisown employees,provided that such
improvements are not Intended ordfered for aale.If,howevu,the building or ToIn
improvement 6 sold within ora yeargfa¢mplelion,the owner-0u Eder will have
tkLburaen of proving that he did not bund or Improve foe purpose of sale.). QTY. PLUMBING PERMIT FEE
"L as ower of the pmperty,am e.I.Mvely contracting with B¢nrd FLOOD ZONE APN
cootracmn to construct the pmjed(See.7044,Buatrm and l'mfesebm Cede: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner d property who ALTER-ORA W kVENT-WATER TA)builds or Imprgvm thereon, and sob comraab for.e L pto)eaa with a- FEE SUMMARY
nTT1 r(s)11mpt under
to theContnctors Lir&PLw. BACK FLOW PROTECT.DEVICE
U I am eumpl under Sec B k P C for thio reason
DRAIJS FIOOf{ROOF,AREA,COND. SANITARY Y N
Owner Dale RECFII'f X
WORKMAN COMP a ceATIDN DECLARATION FD(TURES PER TRW' �' SCHOOL TAX Y N
❑I hrrcq affirm that I have.certificate d eonsem to sell-insure,¢a
ccFs
38001 Labmte of Wgrken'Compewtlgnlmunn¢ors¢rtlfkd appy thersoflsec. OAS EA.SYSLF3af-1 INC4011TLEI5 PARK PF]i Y N
T I
38001 Iib C.I
Co X RECEIPTX
OAS EA.SYSTEM-0VFR 4(FA)
- Comm +ray BUILDING DIVISION FEES
Cenlned copy b hereby furnished. CRGSE/WDUSIAL WASTE INTERCEPTOR PLANCHECKFEE -40
-ifiod copy 6 filed with the city Inspection division. t
CERTIFICATE OF EXEMPTION FROM WORKERS GREkSETRAP PAID/.a -4—* 6J-0
COMPENSATION INSURANCE SEWER,SANITARY FA NOF7 Date Recei [41
all,section need net be completed B the pem it 6 forom hund and dollars
�40)¢leM.) wATWCI-IEwTm w/vEhrr/FucrR ENERGY FEE Y N
I certify that in the performance of the work for which this Permit is used,
1 shall no employ any penin in any manner w as to become subject to the WATER SYSTEM/TREATING
worker:Comperuatlon La.W GBfom6. Dae PAID
ZZ Applicant NEW RISDENMLI'IMB. SQFf. Date Ricci IH
O NOTICE TO APPLICANT:11,aher matlng this Certificate ofd o y
_ should become subject to the Woderi Cnmpersatlms provisions laou bory TOTALN Cnde,you meat forthwith comply with such provisions orN6 permit shall be [�
W `> deemed revoked. .
CL c CONSTRICTION LENDING AGENCY SEISMIC FEE
I hereby afFlmn that there Is a construction lerdimg agency for the perform ELECTRIC FEE,
7 Z anon of lheworkfor which thy,pemdt b"uuN L5ec.304J CW.CJ TOTAL:
V O I.erder.Name •LY�T6Z1A - PLUMBING FEE
H. 1<Mere Addrem QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W 1¢rtttythree to mad comply is with
allcitbnandaatethat the yordinancesabovedstateation
ws
1 Is correct.building complywlth all tltyaodmunrytm mp m and state laws I'FRMTI ISSUANCE FEES PAID:
} dlly to enter
ru upon
nigmml`uctlm,aM krtby property
irm;=76tivm o(lhb
F.. = ds(Weagree to she.inde-membrcd lmpertyforinspe tion of Cu pe. ALTER ORADD'N MECH. Date Recei tM
(We)agree t,save,indemnify and keep harmlm the City of Cu accrue
g
V eganut-LdLC ,'rdgments,man and mperLsm which may i^any wryamue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL
ago .&Lac W
gra,dnig this pemd. AIR HANDLING UNIT(OVER 10,1100CEM) CONSTRUCTION TAX
111 41A
sig ppDim EXHAUST HOOD(W/DLrn CONSTRUCTION TAX PAID:
HERIALS DISCLOSURE
Will the&..loag occupant stoat or haMle havrdous BEATING UMT(IO 100,000 RDn- Date RcceiIN
material as defired by the Cupertino Municipal Code,Chapter 9.1j and the
Health and Safety Code Section 75S.'1](a)? HEATING UNIT(OVER 100,000 BTU) TO
Yca + No❑llles Rion,
budding amnpons use equipment or devices VENTILATION FAN(KWGLE RESID) ISSUANCE DATE
which emit hazardous air aonta minnns as defined by the Bay Area Air
Qua my hla nsgement District? BORF.ILCOMP PHP OR 100,0M BTU)
yes ❑No {k y�
I have read the hevrdous muteria1s rNeimments under Chapter 6.95 of BOIIFR-COMP(OVER IO0M,000 BTU) P I ID
the CaErom6Holthk Safety Coda Swi.b 5505,75533and75534.1
understand that lithe building does wt arrrently have a teranL that it 6 my NEW RESIDENTIAL MECH. SQFF
rop.mlbllty to notify the occupant&the nqumments whi�h most be rrrt "'�A L�
P.rortobauan¢da CertlficateofC4vpancy. - � 1 �
Owner or authorind agent -Date Cl
`••••-
TOTA ISSUED BY:
OFFICE COPY