22323 APPLICANT TO FILL N INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY /\
Building Projt4I PERWTNO.
Building Address: 22323 ,
11hi
T' Gone: p
2S5 731 CITY OF CUPERTINO-BUILDING DIVISION
Corrado •Name: 4,t(� LIc.No: APPLICATION / PERMIT
imb .-1Z BUILDING-E,ECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL R
A ItM/ Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMETISSUANCE ❑ ❑ ❑
' LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l sat L'censed under provide..of Cha pier 9(commenc APPUANCESRESIDENTIAL JOB DESCRITMON
Ingwlth5ect1on7W0)of Division 3efthe Businessand ProfessionaCode,dad my
license is in full force rad d(ed.'� � ''�� PANELS
License Cl. Ic.M �7.5 /V •i . � �l
Date Contnctor�t�(O(L(LiLA �ikJ.l LtQ+ �(/L
ARCHITECPS DECLARATION T*- 201"IOOOAMI'S
7 I understand my plana shall be used as public record. 4at4 J OVER I ODD AMPS SQ.FT.FLOOR AREA N 5/SQ.FI'.
O
zLicensed Professional SPMIA LECTRICAL I
�¢N OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLC 11\V� b{'- LED
14
H 7 1herebyaf@mmm
thatlae.eprom
t fthe Comncde.LkrrdeL wfmthe
7. following reaeon.(5ced.70)1.5,BuMneaand Promsunas Codc Anycityor TEMP.ME=OR POLE INST. :jai
countywhich requires a permit to construct,alter,Improve,demolish,orrepalr i P T
El
a�[ Q.Y anystmcture ptiortotolswance,aborequimstheappBantfersuchpermitin q
m�U file a signed statement that he is licensed pursuant to the POWER DEVICES provisions of the V , '
Contractor'.License Law(Cha a 9(commencin withSection7000)ofDlvi-
HOO<r^ slon3ofthe Bualneeand Profevlons Cade)ortha8hebexempttherefromand SWIMMING POOL ELECTRIC
p E yP^I the basis far the alleged exemption. Any violation of Section 7{)1.5 by any
0 5 OUTLETS-SWITCHES-FIXTURES
-
EE Q five hundred dollars
the applicant to civil penalty of not more than
A five hundred dolhrs(5500). NEW RESIDENTIAL ELECTR
.. Ej 1,as owner of the property,or my employee with wages as their sole `'�'�' STORIES TYPE CONSTRUCTION
.7. compensation,will d o the work and the stmeure is not intended or offered for
Wsale(Sec.7094,Business sad Professkns Code:The Contractors License Law
$ does not apply to an owner of property who bulids or improves thereon,and
5^ who docssuch work himself or through his own employees,provided that such OCC.GROUP RIS.UNITS
Improvements arc not Intended oroffered forsale.If,however,the building or TOTAL:
Improvement issoid wlthnormyearofcompletb th.owner-bu0derw111 have
thrrdcnof pving that N<did not oae
builder Improve for purpofsale.). QTY. PLUMBING PERMIT FEE E DTDNE APN
ro
1,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: _0
The Contractor's License law does not apply to an owner of property who
ALTER-DRAIN&VENT-WATER(EA)
Wild.or improve thmeoa,and who contracts(o such p(ojem with a
aq➢f[attor exempt
So,
the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this mown
OUTSIDE FELS
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner - Date - RECEIPT p
WORKMAN COMPENSATION DECLARATION .NRESPER a SCHOOL TAX Y— N_
� affirm that affirthat I have a comficam of consent to self-Insure,or a RECEIPT s
certificate of Workers'Compensation Insurance ora rectified copy thereof(Sec. GAS EA.SYSTEM.1'INC.40UILM PARK FEE Y N
3800,lab C.) -Co
p CAS.EA.SYSTEM.OVER 4(EA) DING DIV
Cray BUILDING DIVISION 10N FEES
0Cenified copy is hereby furnished. PLANCHECK FEE
K/-�enUied copy b tiled with ted city inspection division. GREASE/INDUSfRL WASTE INTERCEPTOR
CREASE TRAP
' CGRTIHGE O
TF EXEMPTION PROM WORKERS' PAID '
COMPENSATION INSURANCE SEWER-SANRARY-STORM E.A."FT Date Recel t# .
(Thissectlon need not be completed lithe permit Isfor oae hundred dollars
($100)erles..) WATER HEATER w/VENT/ELECIR ENERGY FEE Y_ N—
I cortlfythat In the performanceof thework forwhlch thi.permit Is lssued, o
I shall not employ any person In any manner co as to become subject to the . WATER SYSTEM/TREATING
Workers'Compensation law.of California.Date PAID - -
O Z Applicant NEW RESIDENTIAL PLMB.—SQ-FT. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
should become subject to the WorkerComperoat ion provbiom of the Labor . TOTAL:
� H) Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L I hereby affirm that there is a construction lending agency for the perforrr TOTAL: I/v ELECTRIC FEE
W
D Z an re ofthe work for which this permit es Issued(Sec.3097,Civ.C.)
U O lender,Name PLUMBING FEE
U. I- Lendcr'.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE '-l
OO Icerti(ythat l have read this application and Matethatthe above Information
C iscorrect.I agree to comply with all city and county ordinancesand state laws PERMIT ISSUANCE FEES PAID:
} relating tobuilding construction,and hereby authottm representative ofthts
F.. N city to enter upon the above-mentioned property for Impression purposes.
(We)agree m ave,Indemnify an d keep harmiev the City of Cupertino ALTER OR ADD TO MECH.
_ Z Date Recei t#-
V against habilltle g coed end cgp rues which mayln anywaynorue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: - Q
agabstaaid Citylnconseque o(the gran ting of this permit.
7 2,3 9 AIR HANDWNG I2hT1'(OVER t(I000CFN) CONSTRUCTION TAX
nature of Appfica-MC50atractoF Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAM R DOLS MATERIALS DISCLOSURE
Will the appllant or future bu llding occupant store or he ndle havardom HEATING UNIT CFO 100,000 BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.72,and the
Ha Rhand Safny Codpr�S ion25532(a)2 HEATING UNIT(OVER 100,000 BTU)' TOTAL:
❑ Yes I74LNo
Will the applicant oYfo,c building occupant use equipment ordevices ' VENTILATION PAN(SINGLE RESID) IV&6 DATE
which emit havardous air contaminants as defined by the Bay Area Air
Quality Management n7 BOILER-COMPOM'OR 1W.IXq BTU) -
4Ye No
have read the Faxon case rmatcriais requlremmnts under Chapter 6.95 of ' BOILER-COMP(OVFR tIp,(XIO BTU) {�1 y ��111
the California liealth&Safety Code,Sections 25505,25533and 25534.1 k) b 19W
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECFI. SQ.FT.
resporuWllity to notify the occupant of the require mawhichmustbeort
prior m Lauancc of t n Occvpanry. �' � Z�� Mile.�/}1 �Qp ' I
tierorauthorlxe agent Date TOTAL: ���""""^tISSUED BY:-*NLA- .4 1(��y
' I
OFFICE COPY '