Loading...
HomeMy WebLinkAbout21362 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Protect Identification PfILMITNO. Building Addmm: 21 362 ame: - - one: - A rs_ .)cW�_A�M _ ('-�t•�,�j—©'jos CITY OF CUPERTINO-BUILDINGDIVISION �• Cent ctnrsNanm: LIc.N.: APPLICATION /PERMIT . o _ BUILDINGE.ECTRICALPLUMBINGMECHAMCAL - CATEGORY CONTROL M Architect/Engineer: Lic.No: - ' r BUILDING PERMIT INFO-, " QTY ",p ELECTRICPERMIT FEE Address: IQ PERMITISSUANCT ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirmthat l airs licensed under providonsof Chapter 9(mmmesc APPWANCFSRESTDENI7AL JOB DESCRIPTION Ingwith 7")of Dlv [_he BusinemandlrofnsloaCodc,and my I license Isinfull and affect. PANELS License Clam -(��a_Contractor VIA ` Date�� - ARCHITECTS DECLARATION AMPS' O xxx---'l1" ---tLK]]]---•••\\\..Jll q�q�vv 0 7o I understand my phm shall be used m public mmmds OVER OVER1 1000 AMT'S SQ.Ff.FLOOR AREA f/SQ.FT. Li. Pro(emlonal - - SIGNS ELECTRICAL fn a OWNER-BUILDER DECLARATION SI'FGIAL CIRC / TSC - zF. � Ihereby of imthat l am exemptfiamthe Cantradors License Law for the - following reason.(Section 7011.5,Business and Pmfesslons Code:An d r FE,'"' county which requeasa permit to construct,alter,improve,demollsh,or repair TEMP su aeystruchire prior Wits Issuance,also requires the applicant for pedNtlo O file a signed statement that M Is limn ed pursuant to the pirwis of the ppyygRD µ Contractor's License Law(Chapter 9(mmmene ng with Section 7000)of Divl- �0 onofthe Budruisa and PmfessloaCode)arthathe Isexemplthere(rmmand BWPShRNG ECTRIC d3 - VALUATION " y.' the basis for the alleged exemption. Any violation of Section 7071.5 by any 65 appbmntforapermitmbjedetheappkcanitoadvllpenaltyofnalnmmtMn OVILETSSWITC1iFSHXiVRFS five 1,aro dollars thepru NEW RESIDENTIAL ELECIR SQyr. STORIES IYPECONMUCT10N compensation owner of the property,or my empbyen with wages thele dole �7n askC ,willdothework,and thesCdureh noNntendedractne or License eLaw q des not apply to so o.owner df pmEr lm�s Cade The Contractors License Law $$ and whodoessuchtorkhmedrorthmug y ivhobuilds orees,prvided that mnuch OCC.GROUP RFS.UNITS whodoementsworkMmself edoroughed owns.If,ho employees, ,the building or improvement a,re said Wendnsycar foomorak.If,however,thender buildingorTOTAL: improvement bmldwithin oreysarofcomplellon the awner-bu0derwill have IlAIZurden of proving that he did not build or improve for purpose of mk.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN u I,as owner of the property,am exclusively contracting with licensed I PERMIT ISSUANCE contractors to mmtma the projed(Sec.7014,Business and Professions Code: ` -Co Tim Contractors License law does not apply to an owner of property who - ALTER-DRAIN k VENT-WATER(RA) - builds or Improves thereon,and who contracts for such Expleds with a c. II(ador0)licensed punuanl to the Contncta's Li...I.. RACY FLOW PROTECT.DEVICE - FEE SUMMARY LII am exempt under Sec B 4 P C for this reasonni ITSI DE FEES Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_ . Date RFGEIrT p ,�( WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N if hereby affirm that 1 have's Insurance of consent to op thereof ora RFL=p If Late of Workere'Compewtlonlnsuranm ore artlflM ropyoemof(Sec. 3800.Lab C.) GAS FA.SYSTIM-1 INC.6 OUTLETS PARK FEE Y N Polirya - GAS E.A. YSI}2d-0VER6(FA) RECFII'I'f Com any_ BUILDING D I VIS ION FE ES CertlBed ropyIs here ylumIshed. CRPASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE ' Certified copy Is(]led with the sty lrapcction divblon. - , CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TIRAP PAID COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 20011. Date Reeei t# (I'hlsacdion need red be complcted Bthe permit Is(Drone hundred dollars (f10()orlem.) WATER HEATER W/VFM/ELEC'['R ENERGY FEE Y N I omily that ti the performance of the work forwhlch this permit is Issued,10.11 not employ any person In any manner so m to become subject to the WATER SYS[IM/TAFAUNG PAID Workers'Compenation Laws of California.Data ' O Z Applicant Date Recei t# Z O NOT/CETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Fshould become subject to the Workers''Compeuation pmvblom of the Labor TOTAL: jr N Code,you=at forthwith comply with such provIslora rthis permit shall be , 7 deemed revoked. BUNG TL• LU p CONSTRUCTION LENDING AGENCY SEISMIC FEE I hercbyaffl rmthat there is a construction lending agency for the perform, 1 ELECTRIC FEE Z ance ofthe work for which this permit Is issued(Sce.3097,Civ,C.) TOTAL: ,Il Oo () o Landers Name PLUMBING FEE xQO LL I— Landersaddrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Iredlfy that lhaveread thIsapplkatlonand data thattheabove Nformation C Is correct.l agree to comply with all city and rountyordinareas and state lawsPERMRISSUANCE FEES PAID: relating to building romtmctlon,'end hereby authorize representatives of this F Z city to enter upon the abovementioned property for inspection purposes. ALTERORADDTOMECH. — (We)agree to save,indemnify an d keep harmless the City of Cu ped Ino Data ,Reeei t# against habilltickIdgmams,.9.and expenses which may In any wayamue AIR HANDLING UNIT(To to,00 CrM) SUBTOTAL: agabat aid City In mosaquenn of the granting of this pemslt. NNR HANDLING UNIT(OVER 1g000CiM) CONSTRUCTION TAX Signaftim ofX ppliant/Cnntrator Data EXHAUST IIOOD(W/DUCD CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the a ppllant orfutu re building occupant sore or ha nd le hazardous I(EATING UNIT(Tb 100,000 BTU) Data ' RCCCI t# material as defined by the Cupertino MuNdpal Code,Chapter 9.1 2,and the Health a nd Safety C Section 25532(a)7 BEATING UNIT(OVER 100,000 BTU) - TOTAL: 1 ❑Yes o Will the applicant orfu m building ecu pant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSL ITE which emit hazardous air contaminants as deflned by the Bay Area Air �'/ra.�R�riv3 •. Quality Management_Dl�st�,1�7 BOILER-CO MPOIPOR100,000BTU) 4 Yes M Na q have readI he I.It s m ode,Se requirements;2SS nb 5S33under anChapter 25,534. 1 of - BOILER-COMP(OVER 100,000 BTU) the California health Ee Safety do Sections 25533 and 2557d. I u responsibility red aut it notify the occupant not erequir have which most b mat NEW RESIDENTIAL MECH. SQFT. peortoiimuaoofaCtheo to oftoftherequlrcment.which must be net wi A.aspdn prior to Lssuana o(a Cedlfkate d(Ompancy. - �kS Y�LR9.RlL1AT x-40. (s. 11�2u Owner or mthorized agent Data ISSUED BY: TOTAL: OFFICE COPY