22424APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProteaIdentification
Build i"gAdd ress: t�OM. 5 /Vn 0ETQ WWD�Q CU 1- 0100 CA
PERMIT NO.
22424
on
37LIETT� $DfJ f-�`t�-(RS.�
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-E3,ECTRICALML GING-MECHANICAL
APPLICATION SUBMITTAL
/'
U /
Co ctoraName: Lie. No:
CATEGORY
CONTROL N
Architect/Engineer: Llc. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addrtss:
PERIATISSUANCE
❑ ❑ ❑
LICENSED CONTR under provisions
I herebyion7nthatl c
erpes,and sof ChaonsCo
APPLIANCCSRESIDENTIAL
JOB DFSCRETION
PANELS
Ingwhh Section force afd effect. the Businesaand Prates+lonsCode,and my
Divisionofthe e,and
licenseLlcxmclxe fuBforceusdlc.#
License Cba
J
Date CCmAr ontractor
DECLARATION
AR silwa be
I understand my plareslwube used sspubecn rorda
e(•Lr
'OVER 1000
OVFR IOOO AMPB A 1 11�.
Ku
AREA
5/FQ.FT.
Licensed Profcaiuvl
OWNER -BUILDER DECLARATION
I hercbyaffimnthat I am exempt from the Comractor'a License Taw for the
following reason.(Section 7W IS, Buslnea and Profeabm Code: Anycity or
county which requites a permit to mrutmct, alter, improve, demolish, orrepair
SIGNSELECTRICAL IF 4 -
T E R
///��a
SPECIALCIRCUIT/MISC
TEMP. MEIFROR POLE INST.
anysuucmre Erfurt. it. issuance, also requlresthe applicant forsuch permit to
file a signed statement that he Is heresed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURES
Contractor's License Law (Chapter 9(mnurenWg with Section 7000) of Ethel-
slon 3 ofthe alowe Bustaresand ProfeCode).rthat he is exempt therefromand
the basis for the alleged exemption. Any violation of Section 71115 by any
applicant fora permit subjects the appllcamto a civil penalty of not more than
—
VALUATION
7� v
RESIDENTIAL ELECTR Fr.
five hundred dolbrs(S50W.NEW
n1, as owner of the property, or my employees with wages as their sole
STORIES
7YI'ECOh'STRUCTION
compensation, will do the work, and the structure Is not Intended or offered for
sale (Sec. 7044 Business and Professions Code: The Contractors License law
does not apply to an owner of property who Wilds or improves thereon, and
whodoessuch workhmselforthrgh hbown employees, provided that such
w
OCC. GROUT'
RFS. UNITS
TOTAL:
Improvements are not Intended oroffered forsale. If, however, thebuildingor
Improvement baoldwithln oneyearofcompletion,theowner-buBderwilp have
th rden of proving that he did not build or Improve for purpose ofsale.).
i= as owner of the property, am exclusively contracting with licensed
contractors to mrotruct the project (Sec 7044, Business and Profeabru Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property whoALTER-DRAIN
Wilds or Improves thereon, and who contracts for inch ptojecb with a
cNact.r(s) licensed pursuant to the Contractors License Law.
LII am exempt uncle Sec _� B & P C for this reason
&VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOORROOF, AREA, GOND.
SANITARY RECEIPT N
Owner to
ORKMAN COM SATI DECLARATION
F11 hereby affirm that 1 have • rnrtifica a of consent to selMnsure, or a
certificate o(Workma Comperaallon Insurance or a certified copy themof(Sce.
3800, Lab C.)
FIXTURES PER TRAP
SCHOOL TAX Y_ N_
RECEIPT M
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
Policy p
C. y
c
GAS EA. SYSIFM-OVER 4 (EA)
BUILDING DIVISION FEES
ffCcanrtlfied copy Is hereby famished.
❑ Certl(led copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF O(EM PTION FROM WOR K ERS'
PAID
SEWER -SANITARY -STORM EA 200FT
COMPENSATION INSURANCE
(Thbscctfon need not M comple ed If the permit b f.rone hundred dollars
($10(fiorlca.)WATER
I certify that in the performanceof the work for which this permit is bused,
Date ReceI I#
HEATER W/VENT/ELFI'.TR
ENERGY FEE Y_ N_
WATIR SYSTEM/TREATING
I shall not employ any person In any manner m as to became subject to the
WorkersCompensation Laws of California. Date
PAID
NEWRESIDENTIALPIMB. SQ.F T.
Applicant
NOTICE TO APPLICANT: If, after making this CertBicate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
Date Recel t#
TOTAL:
BUILDING FEE
•L!
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
a _
I hcmbyaffirmthanhem is. construction lemingagency forthe perform,
rn of the work for which this permit is blued (Sec. 3097, Clv. C.)
1<ndera Name
Landers Aadrea
Icertifythatl have read this appBcatlonand statelhat theabove Information
b correct. I agree to comply with all city and county ordinances and state paws
f;
!elating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agree to save, Indemnify an d keep harndea the City of Cu proton
against liabilities, pdgreants, meta and expenses which may in any way accrue
t sold Cloy in mrsecat }<e ooffDDgq grantin M this pennlq
n I\ �7J /
iMM�'-- T��o 41
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID -
U
ALTERORADDTOMECH.
aIC RCCCII)t#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIRHANDLINGUNR(OVER10,WOCFM)
CONSTRUCTION TAX
d L—_t/C
Sigm o(AppBcant/Contractor a�
IXHAl15'T HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle hazardous
HEATING UNIT (TO 100,000 BTIJ)
Date ReceI I#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
I Icehh and Safety Code Section 2S532(a)?
YesNo
Wili the applicant .r inure building occupant use equipment or devices
HEATING UNIT (OVER 1 W,000 BTU)
TOTAL:
VENTILATION FAN RESID)
ISSUANCE DATE.
which emit hamrdous air contaMm pts as defined by the Bay Area Apr
Qct lily Ma nagemout Dist rict?
Yes ❑ No
Ihave mad the h.90cesmaterials requirements underChapler6.95of
Pw
AD
BORER-COMP(31Rs OR 100,001 BTU)
BOILER-COMP(OVER M000BTU)
Califomla H & ealth Safety Code, Sections 25505,25S33 and 25534. I
understand that if the building does not currently have a tenant, that it is my
'JULthe
NEW RESIDENTIAL MECIL SQ.FT.
responsibility, to notify the occupant of the requirements which must be met
prior m issuance of a Certificate of Occupancy.
t
ISSUED BY:
Owner or aulh.rized agent Date
TOTAL
OFFICE COPY