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HomeMy WebLinkAbout19680 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pro'ect Identification - PERMIT NO. Building Ad Zd� T, 19680 s aces: Phone: AA A CITY OF CUPERTINO-BUILDINGDIVISION ��—q Lie No: APPLICATION / PERMIT 3 - O 7 D BUILDING ELECTRICALPLUMBINC MECHAMCAL CATEGORY CONTROL N Architect/Engineer. Lie.No: QTY ELECTRIC PERMIT 'FEE BUILDING PERMITINFO`- - Address: PERMITISSUANCE 1:1 ❑ El CONTRACTOR'S DECLARATION [hereby af(trri that l am licensed under provisions of Chapter 9(communc MPLIANCEZRESIDENTIAL JOB DESCRBTION ingwith Section 7000).!DiA ion3ofthe Businessand PrefesoonsCode,andm Itmnse b m l d effect. PANELS - - Llmnsoclies Llc.R � Da Contractor ARCHITECPS DECLARATION 2014000AMPS aO Zp I understan my plans shag be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA s/SQ.FT. ZLicensed Professional SIGNS ELECTRICAL ¢ OWNER-BUILDER DECLARATION fr• eFn SPECLI- I2CUI r �.., owing rafRrmthction7 xemptfrom ossa Contractors License Law(orthe following reason.(Section 7031.5,Business and Professions Code:Any city or r TIMP.ME � OR NST. in countywhich requbvs a perrNttocotutruct,alter,Improve,demogsh,orrep'. ' a anystructure priort.its issuance,also requiresthe applicant forsuch pemdt to POWER A.O file a signed statement that he Is licensed pursuant to the provisE of the 3 Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- E-�O� slon3 ofthegusiness and ProfessioreCode)orthat he is exempttherefromand SWIMMING LEL VALUATION gt�" the basis for the alleged exemption. Any violation of Section 70315 by any E O applicant fora permit subjects the applicant to a civil penalty of.et more than OUTLETSSWI7'C flue hundredowner ars he pr. NEW RESIDENTIAL ELFCTR SQFT. STORIES ECONSTRUCTION' ❑Las owner of theproperty,or my employees is not Ihwagesr offered ersole compensation,Bels Bothe work and ionthe s Code:Th not intended or offend for O sale(Sec.apply to Business and Professions Code:The Contractors Llmnse Law $ does not apply roan owner ofproperty ughhiswho Wildnem orlmprovated that and �^ who does such svorkhimself orlhrough hlsownemployees,provided that such OCC.GROIJI' RFS.UNITS Improvements are not intended oroffered forsale.If,however,thebullding or TOTAL: Improvement insold within oneyearofcompletion,the mvnent uiderwill have the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE F- DZONE APNr ❑L as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7014 Business and Professions Code: PERMIT ISSUANCE The Contractors License Law does net apply to an owner of property who ALTER DRAIN&VEM=WATER(EA) Wilds or Improves thereon,and who contracts for such pipjects with a - . FEE SUMMARY ' c tractor(s)licensed pursuant to the Contractor'.License Law. BACK FLOW pROTECT.DEVICE '❑i am exempt under Sec B &P C for this reason OUTSIDE FEES DRNS R FLOOROOF,AREA,COND. SANITARY Y_ N_ Owner t Date AIRECEIPT It WORKMAN COMPENSATION DECLARATION FIX'TURFS PER TRAM' SCHOOLTAX Y_ N ❑I hereby affirm that I have a certNace te of consent to self-Insure,ora RECEIPT N certificate of Workeri Compensation Ins ancertified a or a copy thereoS f(Sce. GAEA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N 3800.Lab C.) n �f �s /s — 1'olicyp C©' /ll / 7�1i RECEIPT GAS EA.SYSTEM-OVER 4(EA) 'Cram art BUILDING DI VISION FIiES FCertified copy,b hereby th the cid. PLANCHECK FEE F1 Certified copy E(Jed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR CERTIFICATE OF EXL'MPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER SANTIARY STORM EA 200F7 Date RCcei t# (Thissectlon need not W completed lithe permit is for one hundred dollars (sIOD)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N m I rtifythat in 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 to the WATER SYSTEM/TREATING Worker Compensation laws of caut.rnia. Date PAID z Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQFT. Date Recei l# Z O NOTICE be a APPLICANT:If,.her rx'Commaking a sation Certificate, tthe L-bo should bacon¢subjecttothe Worker'Compemaisinpmvhis permit shall Labor TOTAL: Code,you must forthwith comply with such provisions or this permit shall W Q W > aeemea revoked. ' BUILDING FEE CONSTRUCTION LENDING AGENCY SEISMIC FEE a d I hereby affirm that there is a construction lending agency forthe perform ELECTRIC FEE Z ance of the work for which this permit Is Issued(Sce.3097,Civ.CJ TOTAL: 02 lender's Name - PLUMBING FEE ' IL 1— lenses Address QTY. MECHANICAL PERMIT- FEE MECHANICAL FEE OW Icertifythatl have read thisapplication and watethat theaboveinformation - 1 c.rmm lzgreet.emrplywfth allcityand muntyordm..cm..dstate laws PERMIT ISSUANCE FEES PAID: } 0. relating to building construction,and hereby authorize representatives of this city to entero n the above,mentioned property forW ion ALTER OR ADD TO MECH. H Z ty p° p party Zero purposes. Date Receipt# (We)agree to save,Indemnity and keep harrees which the City y a acerao ' V against Liabilities,pdgments,mats and expenses wMchn yin any way sews AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: agaimtsaid City in consequenceoft a mg hi erenit. CPA' A R ANDL NC UN T(ovER los OCFM) CONSTRUCTION TAX 2 Sig of Appll /contract Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: MAZARDOU ATERIALS DISCLOSURE rill the applicant or future budding occupant store or handle hazardous HEATING UNIT(TO BTU) DateRecel t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade gjarZ5-532(.)? HEATING UNIT(OVER 100,000 BTU) s TOTAL: ❑Yes �1Co Will the applicant or future building or,upant use equipment or devices VENTILATION FAN(SINGLE RESID) ISIVA6DATE which emit hazardous air mntamiwnts as defined by the Bay Area Air �PeIAA Qua 4lily Ma ragem ent Dlslrin BOILER-COMP(3HP OR 100,0W BTU)Yes 13-< - /� TT�� (�(1 have read the havmT materials requlmments under Chapter 6.95 of BOILER-COMP(OVCR 1011,000 BTU) -MAR V 81990 the California Health&Safety Code,Sections 75505,25533 and 25534.1 - understandthattfthe building does not currently have a tenant,that it is my NEW RESIDFNIIAL MECH. SQ.FT. responsibility to notify the occupant of the requirements which at be met Ci { rflr�'10IRo pri. issuance of a Certific O ancy. `VII a7r �" 00'r or authorized agent Date TOTAL: ISSUEDBY:`1` ~� OFFICE COPY