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HomeMy WebLinkAbout20801 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification ..� PFKWTNO. Building Address: 20801 O/1O1 eters a one' APPI1CKTI6V9UffPnTA7T5A= CITY OF CUPERTINO-BUILDING DIVISION et9ra ams: Lie.No: APPLICATION /PERMIT 7- Z��O BUILDING-FlF MCAT PLUMBINC-MFJC:F LAICAL CATEGORY CONTBOLIMI h ect/ ,Rl r. Lie. o: U' CLl S u QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address _ PERMITISSUANCE Z.tDO IF ❑ LICENSED CONTRALTO s D(CLARATION U f9 I hereby affirm that l am licensed under provisions of Chapter9(mmmene. APPLIANCES-RESTDEM7AL jUb UISCKII']ION ingwith Semon 7000).(DiW.ion3ofthe Businessand PmfesstonnCode,and my license Is In tollfo and effect PANELS l �p"t Lice ic La A• "T�� l~/IB s Date G.rdrsROr WE 2011000A.MIsS ARCHITECTSN OVER1000AMPS SQ.FT.FLOOR AREA 5/SQ.FI, OO2 I understand my planssMRbe useds. O Licensed Professional SIGNS ELECTRICAL 6 OWNER-BUILDER DECLARATION SPECIAL IRCUI 1 hereby am.that I.exempt from the Contractor's License Law for the Zp. following reamer.(Section 7m15,Business and Profenions Code:Any tlty,or FF' countywhichrrgpapermktomrutruMAter,impmve,demoltah,orrepalr TVAP.METER A NSI. anystructure priortolts latuance,also requiresthe eppbcent(orsuch perMtto In 06 'i p file a signed statement that he is licensed pursuant to the provisions of the 3 cv$ Contractor:License Law(Chapter 9(commencing with Section 7000)of Divi- G ECTRIC � t + VALUATION O slon3ofthe Busln...nd Professloos Code)or that he b exem therefrom and , V p <s the basis for the alleged exemption. Any violation of Section 70211.5 by any O ETS FIXfURFS a O /\ ©5 apphunt for a permit subject the applicant to a civil penalty of notmorethan (.l F. Rve hundred dolUn(S500). I,as owner of the property,or my employees with wages as thec.m. AL SQFr. STORIES TYPE CONSTRUCTION k]6 mmpensaticewilldothe work andthestructure Lt not intended or offs r O sale(Sec.7094,Business and Professions Code:The Contractors License $ does not apply to an owner of property who builds or Improves thereon,a d cs^ who doessuch work himself orthrough his own employees,provided that M�11 OCC.GROUP RES.UNITS Improvements arc not Intended sroffered for sale.If,hmvevegthebulld TOTAL: W Improvement bsold within.neyearefcomplellon,the owner-builderwill have s t men.fpmvinglnat he aid not Wild.rlmprove for purp.seefsale.). QTY. ry BING PERMIT FEE 1-1.001)ZONE APN �L as owner of the property,am exclusively contracting with licensed ppm U CE contractors to comtruct the project(Sec 70K Business and Pro(esslous Code: 'Me e Co tumor's License Law does one apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM or Improves thereon, and who contract for such plojects with a FEE SUMMARY cgIlVactor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE IJ 1 am exempt under See. B&P C for this reason OUTSIDE FEES DRMNSFTAOKROOF,AREA,COND. SANITARY Y_ N_ • Owner Date RECER'f M WORKMAN COMPENSATION DECLARATION FIXTURES PER TRA' SCHOOL TAX Y_ N— RECEIPT hereby affirm that I have a certi0ute of consent to calf-Imre,ora RECEIPT I certlfiateo(Workers Compensation losunnmora certified copy thercof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y N 38001ab C.) RFLEB NN (Policy p GAS FA.SYSTEM-OVER 4(EM Com any BUILDING DIVISION FEES Certified copy is hereby furnished. GR[ASG/INDUSfIiL WAS17iINTE[tCF]'IOR PLANCI-IECK FEE F_1 Certified copy is filed with the city inspection division. '73t a ) CERTIFICATE OF EXEMPTIONCREASE TRAP EXEMPTION FROM WORKERS' PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(pF f. Date RCCeI til (Thisseeti.n need one he completed If the permit Is Wrone hundred dollars ($10().r less.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y_ N ce _ I rtify N that the performance of the work for which this permit is Issued, I shall not employ any person in any manner so as w become subjectto the WATER SYSI.EM/.[TREATING Workers'Compensation Laws of California.Date PAID icant Z Z NOTICETOAPPLICANT:If,after making thisCertifcateof Fxemptlon,you NTWRESIDFNIAL PCMB. SQ.FT. Date Recti t# F0 sh. 1dbemme.bjeettothe Work m'Comp mationpro biomofthe Labor TOTAL: CCN Code,you most forthwith comply with such provisions or this permit shall be BUILDING Er + .QQ LU > decemd revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE D Il Ihereby affirm that there isamn+tmctlon lendingagency forth perform- TOTAL: ELECTRIC FEE M Z ante ofthework forwhlch this permit In lssued(Sec.3097,CIv.C.) O O ]ender:Name PLUMBING FEE LL Lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U Icertlfythatl have read thisapplicationand statethattheaboveinformation O W bcorrect.Iagrectocomply,eth allchyand county ordlnancosand state laws PERMIT ISSUANCE FEES PAID: } M relating to building commuction,and hereby authorGe repres.ntativesofthk I— N city to enter upon the above-mentiorcd property for inspection purposes. ALTER ORADD'TD MECH. ? (We)agree to save,Indemnify an d keep harmless the City of Cupertlno Date Recei tic V against liabilities,pdgmems,cossi.ed expenses which may many way acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: aga lost said City In consequence of the granting of this permit. AI 4C. R HANDLING UNIT(OVER l0,000CIM) CONSTRUCTION TAX gmtu m of Applicant/Contractor Date EXHMJSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will thea applicant or luture building ant store or handle haeardous BEATING UNIT CFO 100,000 BM FP B octv P Data RCCCi tN _ material as Safety by the Cupertino Municipal Code Chapter 9.12,and the / Health and saretyc . .on 7553xa)r HEATING UNIT(OVER IW,000 BTU) TOTAL: k'ft1 ❑Yes ° Willthe applicant or,future building occupant by the Bay re.devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE which emit harardous a r mntaminanta as defined by the Bay Area Air . Quality Management Dlet 7 NOILGR-COMP OHI'OR 100,009 BTU) '!•y 6Lfl , 4Y s o have resdthe haaa nus materlab rcqulrcments under Chapter 6.95 of BOILER-COMP(OV[R 100,000 BTU) the California i lealth& lety Code,Sections 255115,25533 and 25539.1 understand that i(thebulldingd.es notmrrently haveatenant,that it bmy NEWAESIDENIIALMECH. SQ.IT. omporsibility to notify the occupant of the requirements which must M met prior to issuance of a Certificate of Occupancy. I �{C7it�y�o'fµC�u�ne(r�t+n�n� (7caner or authoomd agent Dale ISSUED BY:,1J(Jk�r) �Y-)`a'V t) TOTAL: OFFICE COPY