22315 APPLICANT FILL IN INFORMATION WITHIN RED LINES='USE.BALL POINT PEN ONLY
BuildingPro ed Identification - ' ' - PERMITNO. -
BulldingAddress: - r
1z2S23 XW3VOWN RnAD CUP5"NO ssoJ42 Z 315 .
vner e��++ame: /�np one: M - A
YiJAND UCA II0N SUBMITTAL DATE,
MW MW4 40 g -• 5Ly CITYOF CUPERTINO-BUILDING DIVISION
���U ,,L1 APPLICATION /PERMITcoN
" ��"' �� � BUILDING-ELECTRICAI..PLUMBING-MECHANICAL CATEGORY CONTROL -
Architect/Engineer. - Lia No: - -
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address '
PFRMITISSUANCE ,
• LICENSED CONTRACTOR'S DECLARATION El E.
Ahereby'afOrmthat l am Ecehsed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL '
Ingwlth Sec n7000)of DiWsion3ofthe Buelnemand ProfeeslonsCan
ode, dmJOB DESCRIPTION
y
license is In full force and effect. •PANELS: - C Lv 1 wm/ fn-s•r pec`
- Licence Class Lkec Y s`r FT II x�"
Data - ConhactorUPT02DOA 5ARCHITECTS DECLARATION 201-1000AMP5 - '
q�q�uv90 Z IundentandmyplanshalbeumdespublicneoMs DVER1fp0 AMPS '- SQ.FT.FLOORAREA $/SQ FT
tGyy Llcencetl Profeceional - SIGNS ELECTRICAL
Z OWNEA•HOLDER DECLARATION - ' - 'T
o I herebyaffirm that I amexempt from the Contractor's License Lawfhrthe SPECIAL CIRCUIT/M]SC
OZF. following reason.(Section 7031.5,Buslnece and Profession.Code:Any city or TgMp.METER OR POLE NSI. M-
r� county which requires a permit to contract,aller,Improve,demolish,or repair UQ p
Q anyatmmmpr rtolrelaeuance,alsorequimstheappBcantforsuchpermltto POWER DEVICES
[J file a signed statement that he Is hoansed pursuant to the provisions of the Y
3w II.. Contractor's License law(Chapter 9(commencing with Section 7000)of Divi. _
i O tlon3ofthe8usineuand Profeml wCode)orthathebemmpttherefmmand SWIMMING POOL ELECTRIC
a....7777. the basis for the alleged exemption. Any Wolatbn o(SeR1on 7Q1L5 by any morethan VALUATION
OUILETSSWI'[CIiFSFIXTUItES - 2 V(no
applicant fora permit aubjeda the appilcant to a civil penalty of na _
five hundreddollarshepr. NEW RESIDENTIAL ELECTR. - a
�n ora t,as owner of the property,or he employees with wages r their sole SQFT. STORIES 'TYPE CONSTRUCTION
OROcompensation,,Businethework,andthe structure tacointended o iofferedfor _
sale Sec.apply
to Business Profession Code:The Contractors improve,Ucene law
$ wwho hoanot oessuch torn owner of trough hisonempor improovided that
ryuch _OCC.GROUP
lmpand
des aft ornahimself dedoroffemdfwne.li,ho e;prwhebuilatsuch RE9.[)NTTS"
improvement arenot hindne3varfeampl iokthhowevegthebulilI have 'TOTAL:
Improvement told withtoneyearo(campldihMthemvner-bu8derw111 have ' ' -
anofprovingthathedidnmbuildorimproveforPurposeo(sale.). QTy, PLUMBING PERMIT FEEFED_ DZONR APN
es owner of the property,am exclusively contracting with limned - '
minutes me to contmlt the project(Sea 7044,Business and Professions Code: PERMIT ISSUANCE -
The Contractor's Licence Law does nor apply to an owner of property who -
Wild.or Improve.therehn,'and.who contact; far'such Pealecle with a ALTER-DRAIN&VENT'WATER(EN
c'gAtladhr(s)licensed exemptprular antSeE to the Conmador'sLlcence Law. BACK HAW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec' B&P C for this reaoan -
Owner - nate - DRAINS.FLOOR ROOF,AREA,COND, BANTTARY Y• N_ '
WORKMANCOMPENSATIONDECLARATION RECEIPT# '
QI hereby affirm that I have a certificate of consent to self-Insure,or a FI(T1IRESS PER TRAPSCIIDOL TAX Y N
cor locate of WorkeW Compensation insurance hra certified copy thereof(Sec. RECEIPT#
3800,Lab CJ .4 PARK FEE Y .N °
Com '," RECEIPTX
Com any GAS EA.RYSTIcbt )' BUILDING DIVISION FEES
[PCenified copy is hereby furnished: - IFPS - PLANCHECK FEE
Certified copy Is filed with the city inspection division. BJ �
CERTIFICATE OF EXEMPTION FROM WORKERS' O 1 PAID r
COMPENSATION,INSURANCE ,..,SHWF.ILSANTT Date Remi t#
(Thiscectlonneednmbecompletedlfthepem ttforonhundreddollan
(f1I mdifyth - ,. WATER HEATER W/VENT/ELECTR ENERGY FEE Y-'
''N
(certify thatlnthe person in any
so as to become
permit le booed, —
I shall not empty any person Ira any manner so u to become eubkt to the
Worken'ComPencetton Gwe o(Califhrriia:Date WATER SYSTEM/TREATING PAID '
Z- Applicant
Z O NOTICE TOAII.-AICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFI', Dete � Recei t#
F'
should become subject to the Workers''Chmpereatlon provtion olthe Labor TOTAL:
N Chde,youmustforthwithcomply with such Provisions orchis perMbhall be '
W � deemed rerSked;' BUILDING A
CL F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE• t
I hereby affirm that there b a contmdlon lending agency for the perform-
Z ance of the work for which this permit is tuedCJ
factual 3097,Civ. TOTAL ELECTRIC FEE
V O Lender'.Name - - - - PLUMBING FEE
IL I– Lauder'.Address - " QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have readtht appBcetbnaM damthatthe abovelaformation
IL iscorred.I agreeto comply with all dtyand county ordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to building construction,and herebyauthhdae repreau,ative. fthis
I— Z city to enter upon the above.mentioned property for Inspection purposes. ALTERORADDTOMECH. ' -
(We)agree to save,Indemnify an d keep harmless the City of Cupertino - Date Recel t#
against liabilities,judgment,eos4aand expenses which may In anywayaccnae AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL: -
.8.1n id City^Neon ✓e coo t grants thi/s�m.t�It' �-
� ��� GVJfI��(b AIR HANDLING T)NI'i'(OVER 10,0)]CFM)' CONSTRUCTION TAX
wgnx mofappliram/Contractor - Dam 11JJCt77 EXHAUST HOOD(W/DUCT) - - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occvpantatore or handle hazardous HEATING UNIT(TO 100,000 BTU) - Date ReCei t#
material as defined bythe Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000877!) _ • '
❑Ye.- . [�No TOTAL•
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) NCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air - -
alityManagementDisMct7 BOMER-COMP QHPOR 100,000 BTU)
. Yes No
-
'. II have read the laza ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) "rlr.k 'y � -
the California Health&Safety Code,Sections 75505,75533 and 25534.I' `7y'�
understand that lithe building does not currently have d tenant,that it is my , NEW RESIDENTIAL MECH. • 9Q.
mFf
responsibility to notify the occupant of the requireent which must be met
prihrto Issuance ofa Certificate of Occupancy., -
Owneror authorized agent Date -- ISSUED BY: Ut��a"''Vs't'^a'��
'TOTAL:.
OFFICE COPY