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HomeMy WebLinkAbout21088 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY Building Pr eat Identification - - PERMIT NO. 1 Building Address: 210.88'1 0.V}^{Vy^{ , CITYOFCUPERTINO-BUILDING DIVISION I O"a"-I'�6 a o/{.Name: r ' ' (� Lie.No: APPLICATION /PERMIT r—L-� '^-'�` 661 (6 BUILDING-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL Archl(ed/Engineer. Lie. o • .O T. 'it,. .,u �' l y ' ' i • :.'„','0 BUILDING PERMIT INFO,,:' a Qn'L +i. ELECTRIC PERMIT "PEE ....- .. . .. . Address: - - PERMIT ISSUANCE ❑ , ❑ ❑ ' LICENSEOCONTBACPOR'S DECLARATION - IherebyaBirmthatlamBcensetunder,provisions of Chapter 9(commene- APPLIANCESRESIDENTIAL - JOB DPSCRIPTION. ingwithSMian7000)af DM,ion3ofthe Bus apal'f>!(ydovaCode,and my license isinfµi{fojce_andef(ect LcePANELS Linse lass �!7 Lic.M Date [)n__ContraRarUP TO 200 A rq , W ARCHITECPS DECLARATION �� P( 0AMPS ttOp Iundemtand my plans;shall be used as public records. a OVERVER I 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT. E t9 Licensed Professional SIGNS ELECTRICAL a GG vu OWNER-BUILDER DECLARATION �+a M SP"LCIRCUIT/MLSC - ?F, owing reason. lhat ection iexemptfroessadPrecta/saCedseiawforthe pp following mason.(Settaprmitus Business and Professions Code:Anytltyor —TEMP.METER ORIOLE INS/ K� countractum requil ionto Is insuarromvtvitinesaltth, aproveit f6rsuch(sh,ormit to g any structuretatemeltshat he abomgPfuirmnit to the provisions of the POWER DEVICES file a signed statement that he b Ilcemed`pursuant to the proWlov of the _ 3wI-. Cont.clur'a License Law(Chapter9(commencingwith Section 7000)of Div(- SWIMMING OJ, slon3ofthe Businessand Pmfeniov Cole)orthathehexempttherefromand VALUATION F3 6 S the drab for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWI FI ES OQ $ five hundred dollars (S50b0j)e.na the appllcanttadvll penalty of not morcthan NEW REST A FG SQ,FT. STORIES - TYPECONSIRUCTION �n 1,as owner of the property,d my employees with wages offered soh 7 Dm(Sm.744,willdothe.....d Pnodeatheetmde:Th Contactorot Intended or License eLaw O sale(Sm. ppy to goal neeaandf property Code:The or leop ews Llceve Law �$ whododoes tapply torn imaerafproughhison ilds emorlmprovn/hereon,and OCC.GROUP '~ RFS.UNITS whoovementswork tIntelfor ndedoroughed ors employees,provided that such Improvementsarcnotintendedreoffered Tarsale.If,h ew bthebuilaingorrDRAINS. TOTAL: improJementbwld wllhln oneyearofcomple(lon,theowner-bullderwlll have - ' - ihinardenof proving that he did not build or Improve for purpose ofbale.). BING PE MIT,sI"•,it;'), {�FE$;l` FTpppgp(,� Apdr u I,as owner of the property,am exclusively mntracting with license contractors to mvtruct the project(Sec.7044,Business and Professions Code: TEN ANCE The Contractor's License Law does not apply to an owner of property whoAIN& -WA Wild a or Improv.thereon, and who contracts far.0 In ptoless wit a • 'FEE$UMMARY - ) .� . cop(Iactor(sexem t underpursuant to the ContraRor's Llcenu Law.. I LJ W PROT .D 1.� �, ! .. I am ertmpt under Sec B&P C(or fhb mason _ LOOR QD A D. SANITARY Y ' N_ Owner Date ' ` RECFErf p �� WOR KM AN COMPENSATION DECLARATION PERSCHOOLTA% Y[f'I hereby.aBlrm that I have a mrtiflrste of consent to self-insure,or aR���,p � SYSITM-t C.4 UILEIS PARK FFE Y_ N3500,Lab CJ © �CI' Z�a.3(L . - — RECIt# Porryp fr SYSTEM-OVER4 )Compppppaer jy ha LCuil'a� BUILDING DIVISION FEES ertlEedcopy is M1erebyfamished. INDUSTRLWASf'I EPTOR PLANCHECK FEE " Certified mpy is filed with the city Impaction division. CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID . COMPENSATION INSURANCE SEWER-SA STO EA ZOOFT r(This seition need not be completed lithe permit b forov hundred dolladollarsDBIC Recti t# ($100)or less.) WATER BEATER W /ELECTR ENERGYFEE -Y .N• I ttrtify that In the performance of the work forwhich this permit Is lmued, .. I shall not employ any person In any manner an o to become subject to the WATER SY TREATING f Workers'Compensation Laws of California: Date PAID O Z Applicant NEW REST AL PLMe. SQFf. Date Remi t# Z T7 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you - shouldbemme.ubjedtotheWorkem'Compensation provisl of the Labor TOTAL: CCN Code,you most forthwith comply with such provhlons orthb permit shall be U E W > dromed revoked. �� a CONSTRUCTION LENDING AGENCY SEISMIC FEE - IhembyafOrmthattherelsaconstrudlon lending agency f....a peeform- TOTAL; ELECTRIC FEE Z ante ufthe workfor whichthb permit h bsued(Sce.3097,CIv.CJ U O Lender.Name PLUMBING FEE IL 1— Iandera Addmes MECHANICAL'PERMIT PEE I MECHANICALFEE O W MTI 1cedtfythatl have read thbapplirationand state thattheabuve Information - ,`n a. S Blamed.Iagreeto complywith alltltyrnd rountyoNinan...ad Adr:awe PERISSUANCE ,4o FEES PAID: } W relating to building construction,a nd Mreby authorize representatives of this t#i R I9 CCe - F city to enter upon the above-mentlDrud property for inspection purpoeca.' ALTERORADDTOMECH. Z Z (We)agree to save,ins emrdfy an d keep harndess the City of Cupertino DBP against llabiB ,jadgnents,cortsand expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,090 CFM) SUBTOTAL: against eai n uenmof the granting of this�erml�/ FI'I`„ AIR HANDUNc UNIT(OVER tB,BBBCFM) CONSTRUCTION TAX Signatumof Applicant/Contractor ,� Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU)' " � ' Date RCWIpt# material as defined by the Cupertino Municipal Code,Chapter 9.IZ,and the - Health aensd Safety Code,_SeNoon 25532(a)? HEATING UNIT(OVER 100,000 BTU)' TOTAL: Willthe applicant or❑future building occupant useequlpment ordevices VPNTILATION FAN(SINGLE RESID) ISSUANCE DATE , which coot hazardous air centaminantsas defined by the Bay Area Air - - Quality Management District? BOILER-COMP QHP OR 100,009 BTU) 4 Yea g No .'. havereadthehnzar ous ma -' "� terials req. under Chapter 6.95 of BOILER-COMP Jill BTU) _ the CalifmW?Iealth&Safety Code,Sections 25505,75533 and 25534.I and eratand that if the build Ing does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.F7 �Ll )990 responsibility to notify the occupant of the requirements which most be met `-" priorm ante aCertiOcateo(O.panry. �''- C , rte— —..� , 1 .• /CRY Of iw Owner drldthoriud agent _ Data -- - / a.el ISSUEDBY OTA L: a OFFICE COPY