22717 APPLIt;AN I IU FILL IN INfUFiMAI IVN W11 F11N FitU LINt� — U,t tiALL F'VIN I F'tN VNLT
Buildin Pro'ect Identification PFRMITNO.
Building Address: n 17�� n
� � ,��.a�e GG �
wners ame: hone: q p
.f �r' CITY OF CUPERTTNaBUILDING DIVISION ���
con orSNa�: � L��.Ho: APPLICATION / PERMIT
� BUILDI[VG-II,ECTRICALrPLUMBING-MECHANICAL CATEGORY CONIROL N
A itect/Engineer. Lic.No:
t3T�t ELECTRIG P�ItMIT FEE BUILDING PERMIT 1NF0
Addresx PFRMIT ISSLIANCE �
LICENSED CONTRACTOR'S DECLARATION � � �
I hereby affirm that I am licensed under provisions of Chapter 9(mmmenc �'�ANCESRESIDENTIAL JOB DFSCRIP'ITON
ingwith Section 7000)ot Division 3 of the Business and ProfessionsCode,and my
license is in fu and effeet. Q PANIIS
Licen Clasa Lic i/ J ��''�r�,�r
DaM �i Contrador � 4
ARCHITECTS DECLARA ON 201-1000 AMPS
�O I understand my plans ahall be used as pub' records. OVER 1000 AMPS FL $/SQ.FI.
`�"�J V Licensed Professional SIGNS ELECIRICAL � �
t-:Q eW. OWNER-BUILDER DECLARATION L� � � I I T�
cn�� SPECIAL CIRCUIT/MISC 1 V 1
�., I hereby affirm that I am exempt from the Contractor e L�cense Law for the V {
O.,� following reason.(Section 70315,Business and Professions Code:My dty or �METER OR POLE INST.
Z F" countywhich requires a permit to construct,alter,improve,demollsh,or repair C � �
��a any structure prior to its issuance,also mquires the applicant for such permit to �
file a signed statement that he is licensed pursuant to the provisions of the ��R DEVICES
3 w� Contractora License Iaw(Chapter 9(commencing with Section 7000)of Divi- gyy��qNG I'OOL II.ECTRIC VALUAT�Qt�j,_
��� sion 3 of the Busineas and Professions Code)or that he is exempt therefrom and /� �
�¢� the basis for the alleged exemption. Any violation of Section 7031.5 by any OLTTT.ETSSWITCHESFIXT'[JRFS �(J���`-�
�,Q� applicant for a permit subjectn the applicant to a avil penalty of nat morn than ��
�o five hundmd dollars($50�. SQ,FI', STORIFS TYPE CONSTRUCTION
o,�' NEW RFSIDENTIAL ELECTR
z¢ �I,as owner of the properiy,or my employees with wages as thek sole
compensaHon,willdo the work,and the structure is not intended or ofteted for
�q sale(Sec 7044,Business and Professions Code:The Contradots License Law
r3� dces not app ly to an owner o f property w ho b ui l ds or improves t hereon,an d OCC.GROUP RFS.UNITS
� whodcessuchworkhimselforthroughhisownemployees,providedthatsuch
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one year of completion,the owner-build erwill have
the rden of proving that he did not build or improve for purpose of saleJ. (,3'j'y, pLUMBTNG PERMIT �E N7,ppD 7ANE APN
�I as owner of the property,am exclusively wntracting with licensed �TT ISSLTANCE
contractors to construd the projed(Sec.7044,Busineas and Professions Code:
The Contractoi s License Law dces not apply to an owner of properiy who �.�_DRAIN dc VFNT-WATFR(EA)
builds or lmproves thereon,and who mntracb for auch pcojecte with a F��$���X
mntractor(s)licensed pursuant to the Contractor'a Ltcense Law. BACK FLAW PROTF�CT.DEVICE
�]I am exempt under Sec B k P C for thls reason
Owner Date DRAINS FCAOI;,ROOF,AREA,COND. SAIVITARY Y N_
RECIIPT N
WORIaNANCOMPENSATIONDECLARATION �(.I.URES-PER.IRAP SCI30pLTAX Y_ N
❑I hereby afflrm that I have a certificate of consent to aelf-insure,or a RECEII''r M
certifiwte of Workers'Compensation Insurance or a certified mpy thereof(Sec. GAS EA.SYSI'Qvt-1 INC.40UT'LETS PARK FF� Y [Y
3800,Lab CJ p �14--�
Policy M /V l�`1 GAS-EA.SYSTEM-OVER 4(EA) RECIIPT p
� BUILDING DI VISION FEES
Certified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCII''I'OR PLANCHECK FEE
�Ceriified copy is filed with the city inspection division.
CERTIFICATE OF EXEMP'I'ION FROM WORKERS' G�E T� PAID
COMPENSATION INSURANCE �R s,yM.I..�zY_srox�t�,y 2oo�t. Date Recei t#
(This sedion need not be completed if the permit is(or one hundred dollars
csioo>or��.> �nin�rm t-�nx�►,viv�•n.iEt,Ec.rx ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued, — —
I shall not employ an�person in any manner ao as to bemme subject to the �qrA1'ER SYS7FM/TREATII�IG
Workers'Compensation Iaws of California.Date PAID
; Z APPlicant NF.'W RESIDENTIAL PLMB. SQ.Ff, Dete Recei t#
� O N01ICE TO API'LICANT:If,aker maMng this Certificate of F�cemption,you
should become subject to the Workers'Compensarion provisions of the Labor TOTAL:
Cy Code,you must forthwith mmply with such provisions orthis perndt shall be BUILDING FEE
u j deemed revoked.
L 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE •
I hereby affirm that there is a mnstrudion lending agency for the perform- TOTAL: ELECTRIC FEE
� Z ance of the work for which this permit is issued(Sec.3097,Civ.C.) PLUMBING FEE
) � Lender's Name
F- Lender's Address C2TY. MECHANICAL PERMIT FEE
j `U IcertifythatIhavereadthisapplicationandstatethattheaboveinformation MECHAI�IICAL FEE
is cormct.I agree to comply with all city and county ordinances and state laws PFIi1vITT ISSUANCE FEES PAID:
r y relating to building construction,and hereby authorize representatives of this
city to enter upon the above-mentioned property for fnspedion purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
� against liabilities,judgments,rnsts and pensea whl h may in any way accrue ��NDLING LJNIT(TO 10,000 CFM) SUBTOTAL:
a' ' Ci in cons nce of granting o is permit. CONSTRUCTION TAX
�J � AIRHAPfDLINGLTNIT(OVER]O,OOOCFM)
� CONSTRUCTION TAX PAID:
Signature of Applican tractor Da FXHAUST HOOD(lN/DLJC'n
HA DOUS MATERIALS DISCLOSURE
Will the applica or future buflding occvpant store or handle hazardous �-ATTNG UTIIT(TO 100,000 BT[J) Date Recei t#
material as define by the Cu rtino Municipal Code,Chapter 9.12,and the
Health and Safety Code �on 25532(a)? HFATING iJNIT(OVER 100,000 BTLJ) TOTAL: l
�Yes No
Will the applicant or future building occupant use equipment or devices VEN"IILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haTardous air rnnt nants as defined by the Bay Area Air �
Quality Management Dist' BOILER-COMP(3HP OR 100,000 BTLO ��
�Yes No
I have read the hazar ous materials requirements under Chapter 6.95 of �n�-CO:viP(OVIIt 100,000 BN) (1�
the California Health&Safety Code,Sections 25505,25533 and 25534.I ti7 �� � ���e
understand that if the building does not cvrrently have a tenant,that it is my N@W RFSIDFNTIAL MECIi. SQ.Ff. j �
responsibility to natify the occupant of the requirements which must be met �
rior ' uance of a Ce 'icate cupancy.
/z c�' . �Gdt �ti
ner or authorize Dat ISSLJED gy.
TOTAL:
OFFICE COPY