No preview available
21422 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification PFRMITNO. Building Address: / 21422 � ^ "JT rt w re C [' one: A aQ CITY OF CUPERTINO-BUILDING DIVISION Contractors Na : LIc.N.: APPLICATION /PERMIT �'� Gf-g1.Q rj A h act Lk.No BUILDING-TIECTMCALPLUMBING.MrCI NICAL CATEGORY CONTROL M , Bt QTY' ELECTRICPERMIT FEE BUILDING PERMIT INFO Add.. PhRh9TISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I herby Sactio 70Mut lam Bcnsedunder usloa oral PrfCha)nsCodeamen AI'PIlANCFS.RESIDENML JOB DESCRIPTION Ingwlth Sec9on7000)ot DIVINon3 office Buslnessand I'rofeaeloonCode,and my license Is In full jgtcraaad effect PANELS y p-'w� ,��" C�` License Claes/��C'-//'_Llc p V IT P� 1T /1 Date Contncto ARCHITECT', DEC" ATION 201-IOOOAMPS he (understand my plans.haB W used as public record.. OVERI00 FS SQ.IT.FLOOR AREA $/�.FT. COC U Licensed Professloral SIGNSEL CAL < - OWNER-BUILDER DECLARATION SPFf_1ALC /M 1 herebyaffnnthat l am exempt from the Contractor'sLimme law for the 70 ... following reason.(Section 7035,Business and Pmfesabre Code:Any city or Fzl"' countywhlchrequimapert ttomnshut,alter,Impmve,demollsh,orrepair TEMP. L anystmture prlorto Its leeuame,alaorequirmthe applicantfonuch permit to ('OWER O fik a signed etatemen[that M b Ikensed pursunt to the provlskw of the 3 k Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- L C f, O etoo 3oflhe Bunlnessand Professions Ceds)mthat he is exempttherefr,mand VALUATION yd S the basis for the alleged exemption. Any violation of Section 7MI.5 by any O_,ash appBcent fora pamdt eubjecb the applicant too civil penalty efnetmomthan E XN �Rl..�L.J co 11 five hundred dollars($500). AL EL SQ.Ff. STORIES TYPE CONSTRUCTION n ❑1,as owner of the property,or my employees with wages as their sale compensation,will do the work,and the structure is not Intended or offered for Msale(Sec 7041,Business and Professions Code:The Contractors License Taw ^j$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS who does such work himeelforthouugh his own employees,Founded that such Improvement are not Intended oroffered forsale.If,however,the W ilding,r TOTAL: improvement issold wlthinoneyearofcompltion,lhe owner-bullderwlllicave tie rden of proving that he did not build or improve for purpose of sale.). , QTY, PLUMBING PER FT FEE FLOOD ZONE APN L1 L as owner of the property,am exclusively contracting with licensed contractors to com uct the project(Sec.7044,Business and professions Code: PQtMIT ISSUANCE The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(") Wilds or Improvesreo then,and who contracts far such p - - lojm,with a - ctor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec B A,P C for thin reason Owner Date DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N RECEIPT p WORKMAN COMPENSATION DECLARATION FLYNRES PER TRAP SCI100L TA% Y N '01 �QI hereby affirm that I have certificate of consent m tneure,ora RECEIFT M Poli,Lab CJ ') retifirab c.) S EA rker�Comperuatlonlnsurance ora certlfkd mpypythereof(Sec. GAS-FA, INCA OUTLETS PARKFEE Y N PoliConary n GAS F.A.SYSTEM-OVER 4(EA) DING DIM Y BUILDING DIVISION FEES Cen�ed copy b herebyfurnished.the cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE CertUied copy u filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GRE-ASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2OWT Date Revel t# ([hieneed not Wcompleted Bothe permit b(Dronehundred dollars ($1(I()olast.) ifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N Icertifythat torics performance of thework forwNch this permit Is issued, I shall not employ any person In any manner s t v t bjrt to the WATEEt SYSTEM/TREATING Work Appilers'Co/npeneatlon ao(l forplaA_ate_+l� PAID O Z NOT( an aia.. NEW RESIDENTIAL PLMB. SQIrL Date Recei t# Z 0 NOTICEcomesufdC/AM:IL orkfter ma Co this Ceionpravisfttftcatr of Exemption,you should becomesubject to the Warkan'Compensation pmWbau of the Labor TOTAL: N Code,you moat forthwith comply with such provisions orthb permit shall be BUIL12ING FE > deemed revoked. W G CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirtnthat there is a construction lending agency for the perform ELECTRIC FEE M Z ance of the work for which thin permit is Issued(See.3097,Civ.C.) TOTAL: L) O Lender's Name PLUMBING FEE LL h Leader'.Address QTY. MECHANICAL PERMIT FEE ECHANICAL FEE OW Icenifythat l have read thbappllotionand tatethattheabove information M a Is corms.l agreeto comply with all cityand county ordinances and slate laws PERMITISSUANCE FEES PAID: >. W relating to building construction,and hereby authorize representatives ofthis I'_ 00 city to enter upon the above-mentioned property for lmpetion purposes. ALTER OR ADD TO MFiCH. DatC ReCCI t# _ (Vie)agree to save,Indemnify an d keep harmless the City of Cupertino P against Babllltles,Wgmmb,cotsand xper..which may In anyway acme AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL: Igai toad nstsi eme.ft Britoil of thln IL PIR HANDLING UNIT(OVERIO,MDC[M) CONSTRUCTION TAX �i/Ll�fwA 2 Sigrutureof Appmant/Ctractor t AII E)D5THOOD(WIC /DT) CONSTRUCTION TAX PAID: HAZAR OUS MATERIALS DISCLOSURE Will theapplicant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date ReeCl t# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Health and Softy Cadr Section 25532(a)? HEATING(IMT(OVER 100,000 BTU) TOTAL: FIYes Na0111 Will the eppllcant or tore building occupant use equipment ordevlms VEN'IT"TION FAN(SINGLP.REBID) I CE DATE which emit hazardous air contami®nb as defined by the Bay Area Air (� IBy Maaugcmcnt Dbtrft7 BOILFR-COMP©IN OR 100,IX0 BTU) I No .I Yev ve read the haze sus matctals requirements under Cha peer 6,95 of BOILER-COMP(OVQt100,000BN) SIL. the Glifomia liealth A SafetyCode,,actions 25505,75533 and 25534. I _y�y understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQkT. 1 � WeWR respo nobllily to notify the occupant of the requirements which at be met prior m issuance,(.Certificate of Occupancy. Do,mr or authorized agent Date TOTAL: ISSUED BY: OFFICE COPY