Loading...
20902 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY Building Project Identification Pf1LWTN0, tluildi Addresr. 20902 T nera one: -ate i�kCITY OF CUPERTINO-BUILDING DIVISION re 's APPLICATION / PERMIT CC// BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL 8 Architect/ giver. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address; tl PERMITISSUANCE ElO ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirmthat l am Demand under provisions of Chapter 9(rommm APPLIANCE4.RESIDENTIAL JOB DFSCM-1`10N ingwith Sedion7000)of Dlvision3ofthe Buslnessan ProfessloneCodGaodmy BcenselamfoRforceandeUed. — 1 PANELS a Life Cl Lic�N dew Date Lilll111 Q'ARCHITECTS - p11�AM� Com. [i(/ �/ ARCHIbeused ECLARATION 00 ]undersand my plan shaBWused sspublic rerords OVER]0100 AMPS ` SQ.Ff.FLOOR ARG E/SQ.FT. Oµ O E� Licensed professional SIGNS ELECTRICAL a «<<�j OWNER-BUILDER DECLARATION Ci SPECIAL CIRCUIT/MISC L., Ihebya(flmnthatlem exempt(romthc Contractor's License law for the Z re-06 following reason.(Section 70315,Business and Professions Code:Any city or FZI"ui county which requires a permit to mvtroct,alter,Improve,demolish,or repair TQdP.MEIPR OR POLE INST. f7V q`a�1 '7 any strodure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES w file.signed!statement that he ls licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(mmrrencingwith Section 7000)ofDivi- SWIMMING POOL ELECTRIC VALUATION �,�Og sion3af1he0ualnem and profeaslovCode)orthat hebexempttherefromand +�-7 ©Sp 6 the basis for the alleged exemption. Any violation of Section 70315 by any, OUILETS_SWITCHESFI%7URFS - appllcant fora Fermat subjects the applicant to a civil penalty clout more than a five hundred dollars($SM. NEW RESIDENTIAL ELECTRSQ.F7. STORIES TYPE CONSTRUCTION I,as owner of the property,.r my employees with wages as ffeir.ole �7¢ compe .7'l ,Business and rendthestuduretnolntractrintended o License eLfor ,. �q sale(Sec.7064,Business and Professions Code:The Contractors Llceve Law ry does not apply to an owner of property who Wild.or improves there.,and b OCG CROUP RES.UNITS 0.0. whodoeasuchworkhbroeRwthwgh Maownemploym,provided that such Improvement are not Intended oroffered for sale.If,however,thebullding or TOTAL• Improvemcntissoldwithln.neyearofcompldio,theowner-bulWerwill have ttn4.rrden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN as owner of the property,am exclusively woua—S with licensed PERMIT ISSUANCE contractors to construct the project(Sec.7064,Business and Profes.ions Code: The Contractors License Law doe,not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) Wilda or Improves thereon,and who contracts for such p(njeda with a cgDt(ador(s)licensed pursuant to the Contrador's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY LJ I am exempt under Sec. B h P C for this remon DRAINS FLOOR,ROOF,AREA,COND. SAMI'ARY Y N Owner Dare RpCRE,r y WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N 01 hereby affimn that 1 have•cerrificam Insurance of consent to opythmre,ora RECEIPT p certificate of Worken'Compevatl.nlvurance ora certified copythemo((5ec. 3800,Lab C.) GAS G.SYSTEM-t INCA OUTLETS PARK FEE Y N P%, Polity MDING Df x Com any - GAS.EA. 1 ) BUILRECEPTVISION FEES ffCertmed copy is hereby furnished. GRGSC/ s PLANCHECK FEE �Cer ifled copy 6 filed with the city impedion division. CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE PAID COMPENSATION INSURANCE SEWER-SANIT TERM G.200Rf. Date RCccl tri (This sectlon need not W completed lithe permit Isforons hundred dollars (E100)m2nia.) WATERI♦FATERW/VENT/ELECTR E GY FEE Y_ N I certify that t the performance of the work forwhich this permit to Issued, I shall not employ any L w.ws.(inCallfomia.Data any manner m u to Wrome subject to the WATIRSYSIEM/IRFATTNG Wwkcre'Compensadon aPAID — Z I Z � NOTICE TO cant MPLICANT:Il after nuking this CertBla/e of Exemption,you NEW RESIDENTIAL Pf.MB. SQFT. Date Remi tN should berme subject to the Workers'Compensation pmvtl.v of the Labor TOTAL: 0 Code,you must forthwith comply with such proulsov orthis permit shall be mreB IN 717, W > deeed voked. ' a CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there t a mmVudlon lending agency for the perform- ELECTRIC FEE Z ance ofthe work forwhichthis permit is Issued(Sec.3097,Civ.C.) TOTAL; OO Lender's Na PLUMBING FEE LL H Lendcea Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OW I certiythat l have read thtappllciti.nand statethat lheaWve Information CL Isroned.I agresto complywlth all cityand county ordinances and statelaws PERMITISSUANCE FEES PAID: >. N relating to building mvtrudlon,and bamby.uthmri a representativiceofthis F Z cltytoenterup.n the above-mentioned property for Inspection purpose. ALTERORADDTOMECH. _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt# against liabilities,judgments,cost and expenses which nuy In an��y/]syfay aSSScru� AIR HANDLING UNIT(TO 10,0100 CIM) SUBTOTAL: against dCItyI zonseque co th antinglofthl"RErmlt.l/Y17�% AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTIONTAX igvtuo t/Contra` Dale D(HAUSTHOOD(W/DUCn CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOS Will the applicant or future building occupant starer hVjle harard.m HEATING UNIT(TO 100,000 BN) Date Remi til material as defined by the Cupertim Municipal Code,Chapter 9.17,and the - Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Yes N. Wlllthe applicant Sam m building occupant use equipment ordevims VENTILATION FAN(SINGLE RFSID) InAtlCE DATE which emit hazardous air contaminants as defined by the Bay Arca Alr Mality Management District? BOILER-COMP OtIP OR 100,000 BM Yea ❑❑No AUG^ have read the hazardousmaterials rct qulremenunderChapler8.95of BOILER-COMP(OVER t(p,000 BTU) 171990 the California Health k Safety Code,Sections 75504,25533 and 255M. 1 understand that lfthe building does not currently have a tenant,that it t my NEW RESIDENTIAL MECH. SQ.Ff. responsibWty to notify the occupant of the requirements which most be and City Cf CIIPO/If6n prior to Issuance of a Certificate of Occupancy. - x Owner or authorlmd agent Date ISSUED BY:� s TOTAL OFFICE COPY