22476APPLICANT TO FILL IN INFORMATION L b — Ubr LL -U1 1 -= 114 'J.'IL t
Building Project Identification
Building Address: y�
t L�j L A ht7DL�. v' CLI P ,-�4Z> j rR'7
PELMIT NO.
22476
wners.Name: one:
1'
ptA`c�tvl� VISvYA,NP NII- CrjL;-2:6
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BLTLOINGELECnUCALPLUMBINGMMIMNTCAL
A SS A At
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Contracmrs Name:'`
V
CATEGORY
CltiiJ]RO
(=% p
gie Llc. oC7
rchiln
. � ,ELECTRIC PERMIT... 'FEE -
79TY 7
BUILDING PERMIT INFO
Address:
U CLQ, UNiK " ll
\� I�(I I� �I
Lx JOB a `1
PERNITISSUANCE �.L Q7
LICENSED CONTRAROR'S DECLARATION
Thereby affirm that !ant Bcensed under provisions ofChapeer9 (mrrvnmc
APPEANGE&RESIDE\TIAL
JOB DESCRB'CION
PANELS
2ingwith Section 700o)o(Divlsion3 ofthe Businessand Professions Code, and my
license is in foil force and effect.
--T-
+� . l
� V �
License Class Lic. 0
Data Contractor
ARCHITEC75 DECLARATION
Iunderstand my plaroshallbeused ns public records.
Licensed Professional
UP TO 100 A,\
l 1 PJ
201-IMOAMP9
OVER TWO ANA'S
SQ. FT. nOOOOR AREA
I O
$//SQ. FT.
SIGNS ELECTRICAL
SPECIALCIRCLTT/MLSC
OWNER -BUILDER DECLARATION
I hanclay off rm that I am exempt from the Contractor's License Law for the
MNIR IETLR ORPOLEINSr.
following reason. (Section 70715, Business and Professions Code: Any city or
countywhich require a pemut tommtm&, alter, lmpmve, demolbh,.rrepair
anystructure prior to its issuance, also requiresthe applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWLNMdNG POOL nECTRIC
/ d OUILETSSSViTCHESm=URFS S, (�
Contractor's License Law (Chapter 9(commencing with Section 7000) of Divi-
sion 3 of the Business and Professions Code).,that he is exempt therefromand
the baso for the alleged exemption. Any violation of Section 7001.5 by any
VALUATION
' 2'�CX
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars (5500).j
F-11, as owner of the property, or my employees with wages as their sole
ItEW RESIDENTIAL ELECTR SQ.17.1
STORIES
Cu ONSTRCCTIO],
compensation, wfildotne work, and thestructure is not intended or offered for
Sale (Sec. 7044, Business and Professions Code: The Contractor, License I,aw
docs not apply to an owner of property who builds.r improve thereon and!A
who doessuchwork himself orthrough hisownemployees, provided thatsuch
improvements are not intended orcfferd forsale. Khowevegthebuildingor
9pu
— T
C.GROLP
D
RES. WITS
TOTAL' r1
improvement osold within oneyearofcompletion,theowner-builderwill have
,he burden ofpmvingthathedid.ot build or improve for purpose of:ale.).
1, as owner of the property, am exclusively contracting with Ilcensed
ront,wim; to construct the project (Sec. 7034, Business and I'm wi ons Code:
- -
PLUMBING PERMI
- APN
PELNiT ISSUANCE
the Contnttor's License Law does not apply to an owner of property who
Wild, or Improve thereon, and who contracts for such pS.jem with a
cc
,ll!JS,actor(s) burned pursuant to the Contractor's License Law.
LJ I am exempt under Sec B h P C for this reason
E'SUMMARY
ALTER DRALN &VENT -WATER (FA)
-
BACK Flew PROTECT. DEVICE
OUTSlfVFFFS
DRAINS- FLOOR ROOF, AREA, CONT).
SANITARY RECEIPT
Owner Date
WORIG\IAN COMPENSATION DECLARATION
F-11 hereby affirm that I have a certificate of consent to ,elf -insure, or
certificate cdWorkers'Compemation Insurance ora certified copy lhercof(Sce.
3800, lab C)
FIX.1.��.�P
SCi00L TAX Y_ N_
RECEPI' N
GAS -FA. SYSTEM -1 INCAOUTLETS
PARR FEE Y_ N
RECFE'r N
Polity M
Com an��l Fes—
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DIVISION FEES
R.RCertlfed copy is hereby ta.
he dtylnspectiondivision.
Certified copy ci!Bed withh the
CERTIFICATE OF EXID,4MON FROM WORKERS'
CREASE/INDCSIRL WASIEIMERCFETOft
PLANCHECK FEE' P31�
PAID`71-1-L017 a�S
'T I�
GREASE I]W'
SEWER -SANITARY -SCORN EA MET
COMPENSATION INSURANCE
(Thissection need not be completed if the permit is for one hundred dollars
(S100)mless.)
1 certify that in the performance of the work for which this permit is issued,
DatC RC 1 til
WATER HEATER W/vFM/ELECTR
ENERGY FEE Y
WATER SYSTEM/TREATING
I shall not employ any proton In any manner so as to beton¢ subject to the
Workers' Compensation laws o(Glilomia. Date
Applicant
PAID
Date ecei tN
NEW RESIDENTIAL PI -MB. SQA .
NOTICE TO APPLICANT-. If, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
T TAL:
BUILDINGFEE
Cede, you must forthwith comply with such provisions .,this permit shall be
SEISMIC FEE
deemed revoked. TI
CONSTRUCTION LENDING AGENCY
there bamnstmcti.nlendlna gena forthe perform
Ihercby arkfo wu is
an<e.(the work for which this permit sued (Sec.. 3097, C1v. C3
I. rider'a Name
Lenders address
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY: MECHANICAL PERMIT "FEE
MECHANICAL FEE L�
I cenifythat l have read thisapplicittion and state thatthe above information
earn.I:.meto comply with all city and county ordinance and state laws
u re
relatin cibw ng tris tory dherebyauthome representatives. this
city ent cup' rh pbe Ft acted property for inspection purposes.
c) a e o sa n d keep harmless the CR of Cilpertmo
,a ins, liabi es,y g M, ndepenseewhichm yth ywayyy home
agmtat saw ity in o Ithe gr. (this permed.
` r'T ..1�
PERMIT ISSUANCE yl.`�
FEES PAID:
DafC Re ClPtil
((yy
ALTAR OR ADD TO MECH. 1•
AIRtb\NDLINCLNITCTO10,000CFM)
SUBT TAL:
AIR HANDLING UNIT (OVER t0,000CM1
CONSTRUCTION TA
1 '
ERtLWSr HOOD(W/DUCT)
CONSTRUCTION TAX AID:
Signator of pct nt/Cmnract rj I Date F f
TARDOUS�MATERIALS DISCLOSURE
Will tM1 pplicant or future building occupant store or handle haurdous
material as defined by the Cupenino Municipal Code, Chapter 9.1; and the
Stealth and Safety Cdr Scale. 25532(a)?
❑ Yes �] No
Willtheapplicant or mmrcbcildingoccupant use equipment ordee,trs
HEATING U\TT(TO IMMOBTU)
Date Recei t#
L'1TT (OVER loo ,.(10 BTU7
Fr
TOTA
I VEN"ILLATION FAN (SINGLE RESID) I
IST�WATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Maroagrment District?
' Iha eread the hav'2 sYes o materials monairements under Chapter 6.93 of
fir-
r'�L�1,7 Lo r
BORER COMP OHP OR 100.000 BTLI
BORER COMProeER 100,11001Tu)
the California Health h Safety Code,Setions 25505, 23 Sand 25S3k.1
understand that i(the building does not currently nave a tenant, that it is my
INEIV RESIDENTIAL \fEC i. PQ.17.I
1
responsibility to notify the omtpant of the requimments which must be met
t
priorto issuance ofaCertificateo(Occupancy.
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