22305APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pra ee identification -
Build Ing Address;
PEIN9T NO,
21-303 De AhyaC/rile N•
22305
w.k: 974-fi107
gCITYOFCUPERTN4
BUILDING DIVISION
APPLICATION / PERMIT
e
kContractor'.Name:
LIc.Na
✓zBUILDING-ELFCTRICAI.I'LIIMBING-mrcHANICAL
CATEGORY
CONTROL
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: N
El ❑ ❑
PERhITISSUANGE
LICENSED CONTR
I hereby under provisionsof ChON
ueBusi asalonsof ChionsCo
APPWANCFSRESIDENfGL
JOB DESCRIPTION
PANP3S
otlnnlhatlunlcenmd
e,and m•
lhe8udneseandl'rofesslonsCode,and my
In ease I Section force of DlW effect.
licenssieinFull lora antl R.
LictData Cho LLe.N
c.
Date Contactor
UP TO 200 AX�S
201-IMOAMPS
ARCHITECTSDECLARATION
I understand my plant shall be used as public records,
Licensed Professional
OVER 1000AMPS
SQ.FT.FLOORAREA
ED IN
T/SQ. FT.
I SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
Ihereby af0rmthat l am exempt from the Contractor's License law for the
�.1 T.E R
SPECIAL CIRCUIT/MISC
following reason. (Section 7011.5, Business and Professions Code: Any city or
countywhlrh requlxsa permit to construct, alter, Improve, demollah,oreepalr
TIEWFR.
MECORPOLEINST
anystmMmprlortoitsbwanm,aLerequlreslheappOcentfas chperMtm
Ola a signed statement that he b licensed pursuant to the provisions, the
^w
POWER DEVICESnA
O
SWIMMING POOL ELECTRIC
OUTLE'TSSINITCHESFLXT'URES
Contractors License Law (Chapter 9(commencing with Section 7000) of Dlvl- u
dun 3ofthe Business end PecdesslaCade) or that he 1. exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit sub(eco theapplitanl to a civil penalty of nR more than
r
VALUATION
6 �I i70
five hundred
owner of he pr .
❑I,asownerof theproperly,orhe employees with wages atheir sole
NEW RESIDENTIAL FI FETE SQ Ff
STORIES
TYPE CONSTRUCTION
compensation, Is
work end NotruRurc hrContIntended or offered
Bwill usiness w
sale (Sec. 7094 Buslass end Profmloro Cade: The Contractors Wcerue Law
does not apply to an owner of property who builds or Improves themes, and
whodaessurhworkhimaelf orlhrough hisownemployees, provided thatsuch
OCC. GROUP
RES UMTS
Improvements are not Intended oroftered forsale. If, however, the buildingor
TOTAL:
'
Improvemant hsold wlthleaneyearofcbmplRbn,the owner-builderwlil have
tl(R,kurden of proving that he did not build or Improve for purpose of sale.).
L j L as owner of the property, am exclusively contracting with licensed
=in&= to construct the project (Sm 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contescures Llmme Law does na apply to an owner of property who
Wilds or Improves thereon, end who contracts fee such pkejecb with a
cga,T.muta licensed pursuant to the Cantradotd License Law.
LJ I am exempt under Sec 0 k P C for this mason
ALTER -DRAIN VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N_
BBC=N
Owner Date
WORIONAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have a ceMficam of consent to self-insurc, or aFIXTURES'
mnificateofWorken Coreperuetion Insurance craarufled copythereof(See.
3800, lab Q
PER TRAP
SCHOOL TAX V N
RECEIPT N
GAS EA.SYSTEM-1 INCA OUTLETS
PARK FEE Y N
RECEIPTN
Policy N
C a������m���000000anCc y
GAS- F.A. M
A. SYST-OVER 4 (EA)
BUILDING DIVISION FEES
Ified copy Lai hereby furnished.
Certified copy Is filed with the city Impaction divhlon.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbsealun need cut be complded If the permit h foronn hundred dollars
PAID
Date (/N'� RI t11
I S
SEWER -SANITARY -STORM FA 7DOFT
WATER HEATER W/VENT/ELECTR
ENERGY Y�
PAID
($100)orleo.)
I cettifythat In the performance of the work for which this permit Is issued,
1 shall not employ any person In any reserve so u to become abject to the
Workan' Compensation Laws of CalOomb. Date
WATER SYSTEM/TREATING
NEWRESIDENTIAL ['LMB. SOFT.
Applicant
NOTICE TO APPLICANT. If, eller makingthh Certifteteof Exemption, you
should became subjectto the Workers'Comperwtion provisions of the Labor
t txl til
T TAL:
BUILDING
s
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
L
1 hereby affirenthat then Is a construction Lending agency for the perform
ance of the work for which thio permit is issued (Sec. 3097, CIv.CO
lender's Name
Landers Address
1.Aifythatl have read thbipph.ti.nand Ranthat theabove Information
Scorned. I agreeto comply with all cityand county ordinances and Rate laws
TOTAL.
ELECTRIC FEE
PLUMBING FEE.
QTY. MECHANICAL PERMIT FEE
CHANICAL FBG
PFIRMITISSUANCE
PAID:relating
to building construction, and hereby authoAzgreprnentalives of this
city to enter upon the above-menllorad property for Inspection purposes.
agree to save, Indemnify an d keep harmless the City of Cu pert Ino
agaWt liabilities, judgmenh, mks and expense which nay In any way awes
ALTERORADDTOMECH.
Date(We)
AIR HANDLING UNIT(TO 10,000 CFM)
[FEES
SUBT AL:
against said City in mot granting ormh permit.
AIR HANDLING UNIT(OVER IO,000CFM)Slgmm
NSTRUCTION TA
of Applicant/Contractr to
h7(mubrHOOD(W/DUCT)
NSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 107,030 BTU)
Date Rece fa
Will the applicant or future building oemparumme or handle hezaMou.
material as defined by the Cupertino MuMclpal Code, Chapter 9.12, and the
Health and Safety CodeSection25532(a)T
ri Yrs - `J No
Illthe applicant mreminats building o. use devices
HEATING UNIT (OVER 100,000 BTU)
VENTILATION FAN (SINGLE RESID)
-
ISSI�ANCE ATE
.d.uor
dcfln y theequipmentBay Are.
which eManagements algrict? contaminants ae defined by the Bay Area At,
silty Management Di❑❑strkt7
haves read the baraMo 9onaterials requirements under Chapter 6.95 of
rad
BOILER-COMPpHPDR1ID,IHq BTU[
BOILER -COMP (OVER 100,000 BTU)
the California Health A Safety Cade, Sections 75505, 25533 and 25534. 1.
understand that if the building due. not currently have a tenant, that it b my
—Possibility to not fly the necoparat of the requirements which at be met
prior to Issuance of a Certificate of Occupancy.
CU
NEW RESIDFNTIAL MECH. SQ.FT
—
ISSUEDBI'�E��C^��
Owner or authorized agent - Data
TOTAL:
OFFICE COPY