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HomeMy WebLinkAbout21432 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: - 21432 l"llf 2�a�a ) .`�J`7"b5166. CITY OF CUPERTINO-BUILDING DIVISION Lie'No: APPLICATION /PERMIT Til • ' �. © 5.57. ___ i.UILDINC...?LECTRICAL-MU.iBI[:G'.,4WHAMCAL CATEGORY - CONTROL M Architect er LIc.Qu QTYI ELECTRICPERMTT FEE BUILDING PERMIT INFO Address:IDMS OCgn(�7'- PFRMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ihercectionrm )of Division ofthe usineslsions and Pr(Cselons9de,and my APPLIANCES-RESIDENTIAL _ `)pB pFSC ION Ing with Section 70that Drethrnsed un erprossand Professions code,and my � license Is In full farce a d effect. PANELS LimnsDate_ Clan_ Coftftacwl Ste_ Date 1a-S Lie.0 - Yom" ARCHITECT'S DECLARATION 201-1000AMPS si"J. I understand my plain shall be used n public records. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT, O �j Licensed Professimc l SIGNS ELECTRICAL 6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MI:SC Iherebyoffirm that lam exempt from the Contractor's License law for the 70 'a following reason.(Soctlon 7MI5,Boslnceeand Professions Ctyor ode:Anyci O Z t TEMP.METEOR POLE MIST. FAQ rountywhich rcquireaa permittoromwct,alter,bnprove,demolbh,Orrepalr rN1 anystructurepriortoitsI ame,aL rquireslheappliantfor such permit to 6 POWER Di.'l10ES�O Ole a signed gatement that he is licensed pursuant to the provisions of the F�O� Contractors License Law(Chapter 9(mmmencingwith Sen1on7000)ofDlvi- sion3ofthe Business and Profsedoru Code)orthat he ie exempt them(romand SWIMMING I'0(,]L ELECI7RIC VALUATION 6 5 the basis for the alleged exemption. Any violation of Section 7W I.5 by any OUTLP7SSWITCIiESEXTUIRFS applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500). I,as owner of the property, NEW RESIDENTIAL ELEGTRSQFP, RIPS TYPE CONSTRICTION p poky,ar my employees with wages r there sole �Ja compensation,Busio the ness and rk,and Pred.ione,Cocturebno.intended oronse Lar 5 p vie(not7064,Busmen andf property Code:The Contactorshme law $ does not apply to an owner of property who builds or I.E.theme,that and s^ who docssuch work himself orthreu hhisownem l OCC.CROUP RES.UNITS g If,how ver theed that h Improvements arcnot Intended o rotco pl&ioe.t(h ner. alder ilI have Tpq'p Improvement Issold within oneycarolcompletion,tMowner-bulidcrwlll have the rden of proving that hedid net bund or Improve for purpose ofsale.). QTY, PLUMBING PERMIT F III-S qPN u L as owner of the property,am exclusively rontracYing with ncensed PERMIT ISSUANCE Q contractors to construct the project(Sec.7044,Busmen and Profession Code: The Contractor's License Law does n°t apply to an owner of property who ALTER-DRAIN&VENT-WATER[FA) Wild.or Improves thereon, and who contracts for such p,jeeta with a onp1I ctor(s)ncesed pursuant to the Contractor's Llcense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY L�I am exempt unser see. B& P c for this rescan ® DRAINS FLOOR,ROOF,AREA GOND. SANITARY Y_ N_OUTSi FIE FI Owner Date I WORK MAN COMPENSATION DECLARATION RECEIPT 0 FIXTURES PER TRAP 10OLTAX Y_ N_ i hereby affirm that I have o lreurate of consent to opythwre,Ora RECEIPT If rtt late of Workers Compenationlnsurance or a certified ropythereof(Sec. 3800,Lab CJ /� /� GAS EA.SYSTEM-1 WC.40f17LET5 PARK FET: Y_ N_ Policy t JS SJ�r��� GAS P.x.SYSTEM-0VER4(FA) RECEIPT N Com any BUI LDING DI VI SION FEES �Cenified copy Is hembytured Ortified copy V filed with the city Impmion division. GREASE/INDUML WASTE INTERCEPTOR PLANCHECKFEE ity yyaa�Y CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID URA I COMPENSATIONNINSURANCE SEWER-SANITARY-SIORMEA.200FT. Date Recei t# Cfhlssekion need netcompletedSURA is(�rone hundred dollars ($100)or len.) WATER HEATER W/VENT/ELFL7R .� ENERGY FEE Y N I me lythat in the performance Of the work for which this permit is baued, 1 shall not employ any person In any manner so as to become subject to the WAT[R SYSTEM/TREA7INC Workers Compenvuon laws of Cau(omb.Date PAID O Z Applicant NEW RESTDEN77AL P1MB. SQsr. Date ReceI [# Z O NOTICETO APPLICANT:It,after making this Certificate of Exemption,you should become subject to the Workers'Compmuation provisions of the Labor TOTAL: N Code,you must forthwith comply with such provisions orthis permit shall be LU > deemed revoked. BUILDING FEB ILp CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirmthat there is a construction lending agency for the pekorm ELECTRIC FEE 7 Z once of the work for which this permit is isaued(Sec 3097,Civ.C.) TOTAL: 1 '� (,) O Lvndera Name PLUMBING FEE LL lendeesgddreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Icertify that l have read thisappliation and staethattheabove Information a Ismrma.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID: relating to building construction,and hereby authokre representatives°!this In H Z city to enter upon the above-mmentioned property for inpection purposes. ALTERORADDTOMFLH. Date ReCCj [# — (We)agree to save,indentfy an d keep harmlese the City of Cu panlno P against liabnlOes,judgments,cogs and expenses which may In any way accrue AIR HANDLING UNIT go 10'"CFM) SUBTOTAL: agaimtvYiid City Incoe tienreof the granting ofthis permit. u . m �a s -qo AIR HANDLING UNIT(OVER IDIM CFM) CONSTRUCTION TAX Sig®tureof Applicant/Contractor Date D(1-IAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAlARDOUS MA RIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI f# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - Ilealthand SafetyCade,S#&ion 25532(a)7 HEATING UNIT(OVER 100,00ft BTU) TOTAL: FLi.0b YatNo Will the applies re building Occupant use equipment or devices VENTILATION PAN(SINGLE RESID) DATE za which emit hardIffs(�ous air contaminants as defined by the Bay Area Air TINcE Quality Management D'uI"ct2maBOILER-COMP OFB'OR 100,0(10 BTU) J z.//-•�'h Yea N° 29199, 4havereadthehaza usteka mc requiren underChapter6.95of BOILER-COMP(OVE100,000 BTU) the California Health&SafetyCod,Seal.ns 25505,25533 and 25534.I understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr responsibility to notify the occupant of the requirements which must be met rip'. nF Ar,^nY'., prior to Lssuaere W Certificate of Occupancy. 1 O.vnerorauthorizedagent Date TOTAL: ISSUED BY:Jc OFFICE COPY