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HomeMy WebLinkAbout21276 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —*USE BALLPOINT PEN ONLY Building Project Identification - PLRMIT NO. Building Address: / /��I f") 2 © 5TT_v Y GIG 6 waters ante: one: - �./ CITY OF CUPERTINO-BUILDINGDIVISION ` con a�oesName: " Lie.No: APPLICATION / PERMIT �F K E _C A ;:1 F� C—I��I/I BUILDING-ELECTRICALPLUMBING MECHAMCAL CATGGORY CONTROL p Architect/Engineer, .. LIB No: ... Cry l ELECTRICPERMIT tj, :,.�IF�EE ° !BUILDING'PERMIT INFO" •-�1 Address: PFRMITISSUANCE LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions of Chapter 9(..c APPLIANCES-RESIDENTIAL - JOB DFSCRI'TION ingwith Section 70000of DlvesicM3 ofthe Business and Professlon.Code,mcl my - Iimnaelelnfullf9 deffect. -5&200 i/ PANELS /�� CvLr[�/,r•�a� Date se Cla�,L%f/. LichY' / 1-114V ,`1 U`LWe'Vf Contractor ITT0200ANTS Aleshall be CLARcre OVER00DOAM 020 Iundernland my pbnsshallb used as public reroNw OVERIWOAMPS 5Q.Ff.FLOOR AREA S/SQ.FT, Cl� Licensed Professional SIGNSELECTRICAL - uuuu . NER-BUILDER DECLARATION OW SPECIAL gIRCUIT/MISC ZL., Iherebyaffirmlhatlamexempt from the Contractor's License law for the ' oo following ereace.(Section 70315,Businessand Professions Code:Any city or J O 2 F. TIME.M OR POLE IN VP cnystmhimpdorrequires apermit nceaL truuimtheaimprove, ntfmolbh,orrepair tto - f�- 1 any at ruamrepdormltnhatho 6:Laoredpursueat to the provision of tm WER DEVI -A C file a signed statement that M b licensed pursuant to the provisions of the 3q(. Contmdor's License Law(Chapler9(mmmendngwlth Se on7OW)of Divi- MING I'ODL ELEC VALUATION O sion3ofthe Bualnessand ProfesslonsCodeltellut hebexenetlhere(romand , F the basis for the alleged exemption. Any violation of Section 7031.5 by any O E;5-&TCHESFlXTURES - I {! �� applicant forapermiteubjMatheapplicanlloa civil penalty of not=.than e five hundred doll5500). a 4 .FT. STORIES TYPECONSIRUCTION Fi R G° ars NE RE4IDENTIAL ELTR/ GGGG1711 �n Q I,as owner of the property,or my employees with wage as their sole zR compeneatlon,wllldo the work and Meetrodure isnot intended or offered for \ r F� asle(Ser.7B44,Business and Professions,Code:The Contractor` License Law ilii [ $ does not apply to an owner of property who builds°r improve:thereon,and r p V OCC.GROUT' RFS.UMTS whodoeeauchw°rkhim Uorthroughhis wnemployees,providedthatauch _ Improvements are not Intended orofreredforests.If,however,the building or ➢ TOTAL: 2 LtLTS Improvementfaeoldwithinoneyearofcompleiorythc°wner-bullderwill i tf kurdennrpmat vingthhe did notbuildorlmprove forpurpeacofsale.). QTY, ,PLUMBING PERMIT I �p 'FEE,,i FLOOD ZONE APN , Lf I,as owner of the property,am eulusively contracting with licensed PERMIT ISSUANCE rontrectom to construct the project(Sec.7044,Business and Professions Code: The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilda or Improves thereon, and who contracts for such projects with a 'FEE`SUMMARY . ' m�(factor(s)Ilceneed pursuant to the Contractor's License Law. BACK FLOW PROTECT,DEVICE a LJ I am exempt under See B&P C for fhb rcawn DRAINS FLOOR ROOF,ARFA,CONTE SANITARY Y N Owner Date RECEIPT p WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N ❑6,hereby affirm that I have a certificate of consent to serf-hears or RECEIPTN certificate o(Workeri Compensation Insurance or a certified ropy thereof(5ec. 38W,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK IFR Y N PoliryN - GAS EA.SYSTEM-OVER RECEIPTN Com any - BUILDING DIVISION FEES rcertlfied copy furnished. GRFASE/iNDUSTRL WASTE INTERCEPTOR PLANCHECKPEE '1-1 GlffUed copy is filed with the city Inspection division. .. CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200f+1'. Datil Remi t# Ohlseectlon need not PENS ctI if the INSUR it is,for one hundred dollars / ($I BE)or less') NATER BEATER W/VENT/ELECTR ' ENERGY FEE Y N I rectify that Be the performance of the work for which this permit Is Issued, I shall not employ any person in any manner so as to become subject t°the WATER SY5.lEM/TREAT'ING Workeri Compensation Laws of Califomla.Date PAID O Z 'Applicant- NEW READ[NTIAL PLh18. SOFT. Date Recel t# Z O NOTICE TO APPLICANT:If,after making thea Certificate of Exemption,you Fshould became subject to the Workes'Compensation provisions ofthe Labor - TOTAL: W Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING W > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC II 70 TE Z I hereby affirm that there lea consuuctiet lending agency for the perform TOTAL: ELECTRIC FEE O sure ofthe work for which thin permit is issued(Sec.3097,C1v.C.) U Lender':Name PLUMBING FEE ly F LendereAddress . QY. MECHANICAL'PERMIT FEE MECHANICAL FEE O W I certllythatl have read lhisapplicationand statethat the above information iscomect.I'll.to comply with all rhyand county ordinances and state laws PERMTTISSUANCE PEE$PAID: CL } relmingto Wlldleg construction,and hereby authorao represenladves°Rhe, ' H Z city to enter upon the above-mentloned property for inspection purposes. ALTERORADDTOMECH. Date Reeel t# (We)agree to save,indemnify an d keep harmless the City of Cupertino P _ V against liabilities,judgmeets,cost:and expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,0DOUND SUBTOTAL: againata dClty in consryun r the StanY'n8 of tt is permit. ' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX �(,riAp cm ' ect u A-16 0 CONSTRUCTION TAX PAID: Si naNrc°(Applicant Contractor t IXFTAUST HOOD(W/DIK'D HAZARDOUS MATERIALS DISCLOSURE _ Willtheapplicant or futurebuildingMunicipal ode, hhand le hazardom HEATING UMT(TO IW,000 BTU)I Date Reeel t# H, lthmaterial as defined by the Cupertino 3Munldpal Code,Chapter 9.1 7,and the - HealthandSafety Cod e+—S�ection 25532(a)i HEATING UNIT(OVER IW,OW BTU) TOTAL: 1 ❑ Yo LJ No Will the applicant or future building occupant use equipment or device: VENTILATION PAN(SINGLE RESID) I$� DATE which emit hazardous air contaMeacab as de0ned by the Bay Area Air ality Manageent District] BOrLER-COMP OFR'OR 1 W,0(e BTU) Yea No OCT 111990 1 1 1990 heve mread the haze�ous materials requirements u oder Cha pier 6.95 of! BOILER-COMP tom 1com BTU) U I the California Health k Safety Code,Sections 75505,25533 and 75534. I undontindthatlfthebuildingdoesnaarrentlyhaveatewnt,that ltbmy NEW RESIDENTIAL MECIL 5Q.I7. ' /a�.� as�p responslbillty to notify the occupant of the requirements whichmust bemet CRY V4 Cup"no prior to Issuance of a Certlrlate of Oceupanry. - Owner or authorized agent _ Date ISSUED BY: """`� v`a" — _x•• TOTAL: OFFICE COPY