Loading...
21351• OZ ZO H y lY j WE3 CL 'o U _ LL ~ Ow r 0. H U) _ Z U— APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Project Identification Building Address: PERMITNO. 21351 CITY OF CUPERTINO-BUILDING DIVISION APPLICATION / PERMIT BUH.DINGELFCTRICALPLUMBING-MFCH LAICAL APPLICArUNTUMMITAM A y G°^t a �Q+9 CATEGORY CONTROL # Architect/Ggineer. Lk. No: QTY ELECTRICPERMIT FEE BUILDING PERMITINFO Address: PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACEOR'S DECLARATION Iherebyaffirm that l am licensed under provisions of Chapter9(commenc 'ngw+th Sect(on700Bof Divbion3 ofthe Businessand PrefesslonsCode,and my license is Infull o deffect o e^ as" CoLicn mrto ° 9 a� �y ARCHITECTS DECLARATION I understand my plans shall be used as public records. Licensed Professional OWNER -BUILDER DECLARATION I hereby of — that Ison exempt from the Contractor's License lawforthe following .... (Section 7031.5, Business and Professions Code: Any city or c ntywhichmquiresapermittommtmct,altegimpmve,de=lB h,orrepair anysrructure pdorm+ts issuance, elan requiresthe applicant forsuch permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9(mmmencing wish Section 7000) of Divi- slon3ofthe Bualnessavd Professions Code) Code) orthat he is, exempt therefrom and the basis for the alleged exemption. Any violation of Sed+or 70315 by any nor applicant fora permit subjects the applicant to a civil penalty of nmare than five hundred dollars (5500). F-1NEW I, as owner of the property, or my employees with wages as their note compensation, will do the work and the structure Is not intended or offered for sale (Sec 7044., Buebuss and Professions Code: The Contrmi license taw does not apply to an owner of property who Wilds or improves therm, and who does sachw work himself or through hison employees, provided that such improvements arc not intended or offered for sale. If, however, the building or Improvement lssold within one yearofcomptdbn, the ownerWilderevi+l have t"ed of proving that he did not bund or improve for purpose of sale.). L as owner of the properly, am exclusively contracting with tlansed contractors to construct the pmjed (Sec. 70K Business and Professions Code: The Contractor's Llanse Law does nor apply to an owner of properly who b IIA or imroves pthereon, and who contracts for such ptojects with a }}LLt{Tadoi I+ansed pursuant to the Contractors License Law. LI I am exempt under Sec. B & P C for this reason APPLIANCES -RESIDENTIAL PANELS j08 DESCRB'DON 701-1000 AMPS OVER ]BOB AMPS SQ. FT. FLOOR AREA S/SQ.FE. SIGNS ELECTRICAL $PECIALCIRCUIT/MLSC TFMC METER OR POLE [NST. POWER DEVICES SWIMMING POOL ELECTRIC - VALUATION /7� - / J OUTLETSSWITCHESFIXfURFS RFSIDENUAL ELFCTR SQ.PL STORIES TYPE CONSTRUCTION TOTAL: QTY PLUMBING PERMIT FEE PERMIT ISSUANCE ALTER -DRAIN & VENT WATER (EA) OCC. GROUT' UNRS RIS. FMCYD APN BACK FLOW PROTECT. DEVICE FEE SUMMARY QUIal E FITS Owner Date WORKMAN COMPENSATION DECLARATION emby affirm that I have a certificate of consent to self -insure, or a mFtiliutecfWorkeri Compel -VaH Insuranaorarerlifledropythemof(sec. MOD, Lab C) .C�IO,�D3 Policy # L</ DRAINS FLOOR ROOF, AREA, COND. SANITARY Y_ N RECEPT # FIXTURES PER TRAP SCI )L TAX Y: -W:::— RECEIPT'# GAS EA. SYSEEM-I INCA 01 GAS EA. SYSTEM 4(EA) PARK FEE Y_ N_ RpCEEET#C'ECert_flcd -OVER BUILDINGDIVISION FEES copy is Hereby fumished. Fzjccrlified copy is filed with the city inspection division. �0— CERTIDUTE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Th+ssedimmei not becompleted lithe permit Laforonehundred dollars ($100) Blyth Isnot emanon the person Permit is ho the I shall not employ any person In any manner n az to becorre subject to the numork so as to become Workets'Compensation laws of California.ATER ornia.Date - Applicant NOTICETOAPPLICANT:If, aker making chis Certlfkate of Exemption, you should become subject to the Workcn' Compensation provisions of the Labor Code, you most forthwith comply with each provinces orthis permit shall be da"'edmOOked. CONSTRUCTION LENDING AGENCY 1 hereby a farm that there is a construction lending agency for the perform ance of the work for which this permitE Issued (Sec. 3097, Civ. C.) Lenders Name Lender's Address I ceNfythat I havemadth3sapplicatlonand statethat theabove Information u correct.1 agree to comply with all erti county ordinances and state laws relating to building consrmctmin, and hereby authomm representatives c f this dry to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify an d keep harmi the City of Cupertino ago labllities,pdgments,00rtsand expect w hmayinanywayaccrue ag ns old Cil Incense eine gram chis permlt. q" G si store of Applicant/ cants or Date ! HAZARDOUS MATERIALS DISCLOSURE Will the applics"i future building occupant store or handle harardous mzterialasde0ned by the Cupertino Municipal Code, Chapter 9.12, andthe 1 r-1 Ye9d Sally Cadet fFdloon 75532(a)1 Will theapplicim, (u re building occupant use equipment or devices which emit harardoma ntamfiemi defined by the Bay Area Air Quality ManagementD co o have read them a oes materials mqulrements under Chapter 6.95 ofER the California Health & Safety Code, Sections 25505, 75533 and 25534. 1 u nderstacad that if the building does not currently has a tena nh that it is myMECIf tbllityrondBytheoecvp tof the 1 is which rwst bemetlssuan o(a Ceflea pa // r//' <-4"r GREASE/INDUSRL WASTE INTERCEPTOR PLANCHECK FEE PAID Date Recei t# GREASE TRAP SEWER-SANTTARY-STORM EA. I(i WATER HEATER W/VENT/ELECTR ENERGYFEE Y N PAID Date Recei t# SYSTEM/TREATING NEW'READENTIAL PLMB.SQ,FE. TOTAL: BUILDING FEE 0 TOTAL: SEISMIC FEE ELECTRIC FEE QTY. MECHANICAL PERMIT FEE PERMIT ISSUANCE ALTER OR ADD TO MECH. AIRHANDLING UNrrr ETOI0,WOCFxU PLUMBING FEE MECHANICAL FEE FEES PAID: Date Receipt# SUBTOTAL: AIRHANDLINGUNTr(OVER10,000CFM) FXHAUSTHOOD(W/DUCT) ' CONSTRUCTION TAX CONSTRUCTION TAX PAID: HEATING UNIT (TO 100,000 BTU) Date Reaei t# 000 B'C(p HEATING UNIT (OVER 100MRESIDENTIAL 3 r FAN (SINGLE RFSID) �s�TOTAL: ISSN ATE C C p A �as�* (617 1l V4 i ✓Cu�( ISSUED BY: P�- BOILER -COMP DEEP 100,0(10 BTU) 100,000 BTU) SQ.I7. lY)TA L: aulhonred agent Date1 OFFICE COPY