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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Builein Pmjert WeodHrghan
Bal ng3dregg: ` so L� dd _as -3- 6iLo
PERMIT NO.
22316
ams:11hone.
Ors E%Li oG7jftZL/L`YL
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-p,FGTRICALI'jUMECHA
M81NG-MCAL
AA A
\,
Contractors Name:VUe.N.
OwU�"
CATEGORY
CONTROLN
iArchltect/Engineer: Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PERMETIS5UANCE
h/j ❑ ❑ El
CONTRACEOR'S DECLARATION
I hereby affirm that l am becrsed under provisions of Chapmr9(mmmenc
I ceng,1 Section to. an d effeon3ofthe Buslnesaand ProfessionsCade, and my
license is to full force and effect.
License Clam LLCM
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shalt be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyaffirmthat I am exempt from the Contractors License Law for the
following reason. (Section 7031.5. Bushings and Professions Code: Any city or
county which requires a permit to construct, atter, Improve, demolish, or repair
any structure 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
Contractor§Lienee law(Cha pier 9(rommencing with Section 7000)of Diel-
.ion 3ofthe Boninessand PmfimAv aCcde).,thA heis exemptthercfromand�es
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant (ara permit subjects the applicant to a civil penalty a( not more than
ollsom (S500).
live 1, ago drofthepro
❑ t, as owner of the property, or ho employees with wage as their sale
compensation, 7o., Buldolhe work end thestmcture is, not intended or offered for
sale (Sec. 7p9y to Business owner f property wCode:buldsTh. Contractors License law
ry and
does not spply to work
owner of property who builds or improvesthereon,that
who does such workhimself or through hbown employelis, provided ihatech
improvements are not intended oroffered forsale. K however,thebuild[ng or
Improvementbsold within oneyearofcompletiogtheowner-buRderwill have
le ,den of promngthat he dm not bulla or improve for purposeofask.).
[ as owner of the property, Se .70KexclugvelyBusi rontradmg with licensed
construct the project (Sec. appy Business and Professions Code:
Codd
Tho Contractor's
The Contractoro License law does not apply to an owner of property who
Wilds or Improves epQeua and who contracts ice ouch ptojecn with a
the Contractor. License Law.
cgnt�aator exempt under Sec.
Lf I am exempt under Sec. B & P C for this reason
APPOANCESRESIDENTIALwith
JOB DFSCR[I'1'ION
^ ��
sir fes' }`�-`
PANELS
— UP TO 2DO AMPS
201-1000 AMPS
OVER 1000 AMPS
SQ. F7. FLOOR AREA .
$/SQ. FT.
SIGNS ELECTRICAL
SI'ECIALCERCUIT/M7SC
TEMP. METOL OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLElS5WI1CIiFSEXIVRES
VALUATION
V O 0.,
NEW RESIDENITALELECTR SQ.P17.
STORIES
TYPE CONSTRUCTION'
TOTAL:
QTY, PLUMBING PERMIT FEE
OCC GROUP
RFS. UNITS
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EN
FLOOD ZONE
nrN
FEE SUMMARY
BAIX IIAWI fCIF
i n
DRMNSFLOOR ROOF, AREA, CONE. t-'
FIX.IURES nuy (:J J
-''iT-
A RY Y N
RECOI'T R
Owner Date
l here WORKMAN COMPENSATION DECLARATION
a c or consent rnifi to op(-tnere, ora
❑ R5' affirm that I have o Insurance
certificate of Worken'Compensatlonlnsurance ora certified copy thereof(Sec.
38W, lab C.)
- LTAX Y_ N_ -
I RECETT p
CAS EA SY -t IN ,EIS S/
RK FEE Y N_
RFLEB'TM
BUILDING DIV] 51 ON FEES
GAS EA. SY � -0VERd(FA) _
Colman y
❑p Certified copy Is heed with
❑eertmea copy b rase wpm the dry Inspection division.
cit.
CERTIFICATE OF EYEMPEIO.Y FROM WORKERS'
COMPENSATION INSURANCE
(Thtssexa.) need na be 2ompined If the permit is(Drone hundred dollars
(St I mnifess.)
I cont that emin ploy anyhe ersen In an tmannerhe work fo am to b this eesubjecrmit Is beN,
I shall not employ any person In any mannerso as to become subject to the
Wmkess'Compensab.(rGwa of Cali(ornla. Date
Applicant
NOTICE TO APPLICANT: if, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Code, you most forthwith mmply with such prov vbmor this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that thereb a mnsmsctlen lending agency for the perform
ance of the work for which this permit is beed(Sec. 309 a, CN. C.)
Lander'. Name
Lender§Address
1certifythatI hivereadthisapplicstionanl gate thattheabove Information
Iscoreact.I greatc, comply withal[ city and county ordinances and gate taws
relating to bullding ronstmctum, end hereby authorize representatives of this
city to enter upon the above-rventioned properyforhap,ethmpurposes.
(We) agranto sve, Indemnify and keep harMess the Ct tyof Copcrtio
againstllabillties, ryd menti, mesa xpengesw ch ma anywayaccme
a at tyi nseque granit, th a.
!
GREASEANDUSTEL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei O
GREASE TRAP
SEWER -SANITARY -STORM EA 2(017.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
-
I
PAID
Date Recd tit
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQ.FI.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL:ELECTRIC
E L F
ELECTRIC E
EEE
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMETISSUANCE
FEES PAID:
ALTERORADDTOMECH.
Date Recei tit
AIR HANDLING ]MIT (TO 10,000 CFM)
SUBTOTAL:
AIRHANDONG UNIT (OVER 10,WOCFM)
CONSTRUCTIONTAX
51 ae rcof Applimnt/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
Wiilthe applicant or future building ottvpant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Code Section 25532(1)7
E-1 Yrs No
Will the applicant orfuture building occupant use equipment or devices
which emit hazardous air is mtream, as defined by the Bay Area Air
Quality Management District?
4Yes ❑❑ No
havere.dthehazardousmaterialsrequirementsunderChapter6.95of
h,Californui Health&Safety Code, Sections 25505,25533and 25534. 1
understand that if the building does not currently have a tenant, that it b my
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
Date RL'<ef til
HEATING UNIT (OVER I W,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Illu
4/U'9
`fcq
a3.v M�
�\1���/. ,W��ass� f t�A,}�.s,s l Ye-,
ISSUEDBY: s->��tRA��'
BOrLFR-COMP DEEP OR 100,000 BTU)
BOILER-COM.P(OVER 100,0W BTU)
NEW RESIDENTIAL MECH. SQ.F7.
Owner or authortzed agent Date
TOTAL:
OFFICE COPY