Loading...
21426 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PFR.MITNO. Building Address: 21 4 2 6 s(o fubr '' ernns __ant�e^^:,^, ..--,^,'' on A A �P—Z aM LI I af53 s3 CITY OF CUPERTINO-BUILDING DIVISION � ,Z—�^� ntr d rat Name: �7 uc. a:/ APPLICATION /PERMIT (o BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N rchitect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PEPMITISSUANCE ❑ ❑ 11LICENSED CONTRACTOR'S DECLARATION I Ferebyaffirms that lamsionsd under eBusinwland Pro ofChapter c APPHANCESRESIDENTIAL JOB DESCRIPTION ingwlih Section7000)ol Di effect. the Buslnessand ProlesslanaCode,odd my licensebin rat end effect. PANELS License Lir.M---� �R'F'QO-IC Date, -Contractor ARCHITECTS DECLARATION 401-1000 AMP"' p�p�uu 90 77,, I understand my plans shall be used as public records. OVER 10110 AMI'S SQ. FLOOR AREA $/SQ.FT. Licensed Professional SIGNS ELECTRICAL OWNER-BUILDER DECLARATION S('F-CIALCIRCUfT/MISC fp, 7 I herebyaffirm that l amexemptfmmihe Contndor'sLlrenx Lawfmthe 70ZH� following reason.(Senlon 7m1.5,Businessand Prof.i r,Code:Anycityor TLMP.MLTPR OR POL NST. cmntywhich requlrna permit tocomtroct,alter,impmve,deonlish,or repair anystructure priorto its issuance,also requinothe applicant fee such permit to POWER DEVICES file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter9(commencing with Section 700])of Divi- SWIMMINGLELECTRIC VALUATION O slon3ofthe Businesaand Profs®lore Code)orthathel.om therefromand the basis for the alleged exemption. Any violation of Sedloe 7031.5 by any OUTLETS TCHES-FIXTURES applicant for a permit subjectsthe applicant toll civil penalty of out more than five hundred delta.%S0( . NEW DENTAL ELECTR 7�n I,as owner of the Property,or my employees with wages as their sole SQFT. STORIES TYPE CONSTRUCTION compensation,will clothe work and thestructure b nm Intended or offered for p -In(kc.7614 Business and Pmfceska Code:The Contractor.License law s$ does nm.pply torn owner,of property who Wilds or improves thereon,and OCC.GROUT' RIS UNITS E who doessucliworkhimxUorthrough hhownemployme,providdthgsuch Improvements arc net intended oralferd for sale.If,however,the W ilding or TOTAL: improvement b sold within one ycamlcompletlon,the owner-bullderwili have t4L4urden of proving that he did not build or Improve for purpose of sale.). QTY. PLUM G E p1.00D ZINE APN u L as owner of the property,am exclusively contracting win Ilmnxd ppRMiTLSSUANC rontnecton to construct the project(Sec 7014,Business and Professions Code: The Contractor'.License law does not apply to an owner of property who Wilds or Improves thereon,and who contracts for such projects with a AL -DRAIN6 gWfaetor(s)licensed pursuant to the Contractor'.License Law. BA FLOW IC FEE SUMMARY c 1I I am exempt under Sm. B k P C for thin reasonOUTSIDE I LES DRATR AREA,COND. SANITARY Y N_ • Owner Dace RECEIPT WOR KMAN COMPFT'SATION DECLARATION PERSCHOOLTAX Y N rcure by affirm that I have a oldifirate of consent to self-Ins ,ora mn�JWRFCEPf M mer icateofWorked'Compensationlmurancemacedifk mpythereof(Sec. GAB ,SYSTEM-1 INCA OUTLETS PARK II Y N P800,olicy# C.) O-� y��b'�(� � RECEIPT# Policy# O CffGAS FA.SYSTEM-OVFR4( ) Cam any FABUILDING DIVISION FEES Certified copy hereby furnished. GREASE/INDUSTRL WASTE RCFPTOR PLANCHECIC FEE �ertified copy 6 filed with the elty inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-!!Oe EA 200FT Date Recei t# (ThlssecHon need not be completed lithe permit Is for one hundred dollars (51W)orles.) WATER HEATER W/ /ELECTR ENERGYFEE Y_ N_ 1 comlythat 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 WATERSYSTEM/ EATING Workns'Campensationlawsof Cabfornb. Date PAID O Z Appllcmt NEW RESIDP AL PLMB. SQFr. Date Recei t# ZO NOTICE TO APPLICANT.If,after making this Certificate of F sropeon,you Pe should becomsubject to the Workers'Compensation provisions of the Labor TOTAL: CC0Code,you resat forthwith munplywltlesuch provisions orthls permit shall be BUI • INC • W _ deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE Q. Iherebyaffirm that there is a construction lendingageneym,,he perform TOTAL: ELECTRIC FEE DZ sore of the work for which this Permit is Issued(Sec.3097,Civ.C.) PLUMBING FEE V O Lender's Name LL F boider.Addrees QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW I mNfythat l have readthb appliceticnand statethat the above Information IL boomed.I agree to comply with all city and county ordinances and state laws PFRMITISSUANCE 12 OD FEES PAID: r relating to building construction,and hereby authorize representatives or this I.- U) cityto enterupon the above-mentioned property fee inspection purposes. ALTFRORADDTOMECH. _ Date Receipt# (We)a t save,Indemnify an d keep harmless the City of Cupertino AIR IiANDLINC UNIT(x010,000 CFM) V .93 til tie dgmenb,mets and expnnxa which may sr�anywayaceme SUBTOTAL: agsinst e i nuquence of the granting of thin gerinf. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Sigrumme of Applicant/Contractor i Date IXFiAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) rQ�� Date RCCCI t# material as defined by the Cupertino Municipal Code,Chapter 9.1 4,and the IBaln and Safety Code Section 45534(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: Z CJ3 Yes n No Wllltheapplicantorfuturebulldingoccupantuseequipment ordevims VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE which emit haaniom air contaminants as defined by the Bay Area Air *-Win Quality Management Distrid7 BOILER-COMP QHP OR 100,000 BTU) ��aG� YesII'�No have read the fuer. ous materials requirements under Chapter 6.95 of BOILER-COMP(OVERi c(L"BTU) DEC A 1 ' the California Health k Safeycde,Sections 75505,25533 and 2553/. 1 S 990 understand that if the building doe.not currently have a tenant,that It is my NEW RESIDENTIAL MECFi. SQ.FT. responsibility to net iy the oro pant of the requirements which most be met V prior to Issuance of a Certifiate of Occupa ney. �uv OF Alft4olp Owner or authorized agent Date O ISSUED BY:_ TOTAL: OFFICE COPY