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HomeMy WebLinkAbout21020 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification - PERMITNO. Building Address: 21020 2 L -z.. '� l�l L �K'C y j nn ane hone. A ADAIL CITY OFCUPERTINO-BUILDING DIVISION �/ 2—�{,a co^tratloaName: Lie.No: APPLICATION I PERMIT +l BUILDING-ELECTWCAL PLUMBINGMEC}IAMCAL CATEGORY CONTROL If Architect/Engineer. Lk.No: . QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO ; naarea> 1:1 1:1El FLOG U�f PLUMB PERMITISSUANCE LICENSED CONTRACTOR'S DECLARATION Ihereby rctionaffirm that lamecen3 ofthe under ustnesprovisions of Chapte Codeanenc- MPLIANCESRESIDENTIAL JOB DFSCRQ'fION gwith I.FOn7000)Of d effect' o(the 8uslnessandPrd(essloneCode,andmy license lain Full and dfeR.3(2� 47 PANELS License Class Lica ] PKI.JI lin.-.fl.0 Data Contractor T up IQ 200 AMS ARCHITECT'S DECLARATION 701-1000 AMPS gomz I understand my plans shall be used as public records. OVERIODOAMPS SQ.FI.FLOOR AREA E/SQ.Fr. jou Q U Licensed Professional SIGNSELECTRICAL SII HQN OWNER-BUILDER DECLARATION C SPECIALCIRCUIT/MLSC Z owleg reason. 9actio m exempFIL5,B from the d Professions C use Law for the oo � following reason.(Section 7m15,Business and lsro(esslona Code:Any city or OZ1' county which requiresa permit to construct,alter,improve,dennluh,orrcpair ORPOLEINST, hn anystructure prior tolls issuance,alsorequfrestheapplicant for such permit top0 �• DEVICES,'^ p� e. file a signed statement that he is licensed pursuant to the provisions of the � Conlmctor's License Law(Chapter9(commencing with Section 7000)o(Divi- NC IY)OL VALUATION O %on3ofthe Business and ProfessionsCods)orthat he b exempt therelmmand ,,ryry 5' the basis for the alleged exemption. Any violation of Section 7(31.5 by any OUTLETSSWITCHES ld©OlJ applicentfar.permitsubjmUtheappbcanttoadvilpemltyofnm=mthan VV five hundred dollars(8500). Ll NEW JAMAu ❑I,a......f the property,or my employees with wages as their sole STORIES TYPE CONS'IRUC'rION fr ¢ compensation,willdo the work and the structure is not intended or offered for _j O sale(See7644,Businessand Profession Code:The Contractors Lim.law - F'd$� docs not apply to an owner a property who builds or improves thereon,and OCC.GROUIs RFS.UNITS 0.0. who does such work himself or through his own employees,provided that such Improvements am not intended oroffered for sale.If,however,thebuilding or TOTAL: , Improvement issoldwithin oneyearofcompletion,the owner-wilderwill have ("iden of proving that he did net wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE Lj L as owner of the property,am exclusively contracting with licensed HOOD ZONE APN contractors to mntmct the project(Sm.7044,Business and Professions Code: PERMIT ISSUANCE The Crntnctore License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA)wilds or Improves thereon,and who contracts for such piects ojwith a FEE SUMMARY ❑tra&or(s)Formed pursuant to the Contractors License Law. gpQC FLAW PROTECT.DEVICE OUTSI DE FEES 1 am exempt under Sec. B &P O,for this mason DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ Owner Date RECEIPT p WORKMAN COMPENSATION DECLARATION FDC[URFS PER TRAP SCHOOLTAX Y_ N_ ❑t hereby affirm that I have a certificate of consent to self-insure,ora RECENT p certificate ofWorkera Compensatim Insurance ora certified copy thersuf(See. GAS EA.SYSTEM-1 INCAOU1LEIS PARK FEE Y N polisM00,Lab C.) RECEIPT p Policy N GAS EA.SYSTEM-OVER 4(PA) BUILDING DIVISION FEES Co any ECertifiedeopyisherebyththecid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE ❑Ccrtlfiedropy is filed win the cityinpeciion division. CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date .Receipt# Qhissection need not Se completed if the permit isforom hundred dollars (S100)orlem.) WATER BEATER W/VENT/ELECTR ENERGY FEE Y N I rertlfythn in the performame of tWwmk focwhich W s permit Is Beed, I shall not employ any person in any manner so as to become subject so the WATER SYSTW/TREATING Workers'Compensation Laws of California. Date PAID 0 Z Applicant NEW RE4DPNTIAL PLMB. SQFT. Date Rrcei t# Z ONOTICETOMPLICANT:ILaRermakingthis Certlftoteot Eaemption,you should become subject to the WorkesCompensation provisions of the Labor TOTAL: Code,you must forthwith compp comply with such provisions or this permit shall w F rn BUILDING FEE Ch 05 j deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE S I hereby affirm that them is a corutmction lending agency for the perform TOTAL: ELECTRIC FEE M Z arca of the work for which this permit is LvuN(Sec.3097,Civ.Q 02 tender,Name PLUMBING FEE 1= Leraersnddren QTY, MECHANICAL PERMIT - FEE li MECHANICALFEE 0 W I<ertlfythatl have read thisapplicatbnand statethat theabove Information 0. Iscorrect.I+gree to complywith all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID: relating mbuilding conanuctiov,and hereby authorize representatives of this F N city to enter upon the above-memioned property for inspection purposes. ALTER OR ADD TO MECH. Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V agafratllabilities,pdgerentsrortsand seAI expenswhichmayinanywayaccrue R HANDII LING NP CFO Ill."CFM) SUBTOTAL: against said City in consequence of thetin furls its I . 6 w 5 -4 Zjj AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX gnatum of Appbcant/Contra r Date IXHAus'r HooD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUSMA IALS DISCLOSURE Will the applicant orfuture building occupant store or ha ad Is hazerdous HEATING UNIT(TO 100,000 BTU) Date RC i t# material as defined by the Cupertino Municipal Cods,Chapter 9.17,and the IleaBnand Safety C�wn 7SS37(a)7 HEATING UMT(OVER 100,000 BTU) TOTAL: s ❑Yes Will the applican orfuture building occupant use equipment or devices VENHLATION FAN(SINGLE RFSID) I �DATE which emit havanT safrcontaminants as defined by the Bay Area Air Oualily Mamgement trid7" BOILER-COMP OR 10Q000 BTU) 4 Yes SEP 12 1990 haveread theh s To requirements under Chapter 6.95 of HOMER-COMP(OVER100,000 BTU) the California limlth safety Cod e,Section 25505,25533 and 2S534. I understand that lithe wilding docs not mrrentlyhave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. /� ,s{(s aha respomibilitytonaifytheo pantoftherMuine otswhichmustbemet Cdy.0(,feUUPIfifq priorto cola Certificateof Oearp 7a® mm WfJ 9-iz- v ^,•��rry�11���� /l/rpY��J 07he,or authorized agent Data TOTAL: ISSUED BY:��/�I OFFICE COPY