Loading...
23612 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prom Identification PFRb11T NO. Building Address: O S 2 3 612 Wner9 d1M� .p Okn,e,: ' a,71�ap�QL� CITY OF CUPERTINO-BUILDING DIVISION Gantracit 'BN me: Lic.No: APPLICATION /PERMIT BUILDING-ELECTRICA4PLUMBING-MECHANICAL CATEGORY CONTROL p Architect/Engineer. Lk.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PERNETTSSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ihereby actil rm0) lIvIdvlicensed under provisions;P (Chapter da,.nenc- APPLIANCES-RESIDENTIAL _7p DB F. SCRR•I'10 IngwithSMfan7000)o(DlWslon3.fthe Buslnesand ProleslonaCode,and 1 � license b in full force and effect. PANELS License Ctan Lic.Is Date Contractor UP TO 2QQAMpS ARCHITECTS DECLARATION 201-I000AMPS �X I understand my plans shall W used s co public records. OVER VXG AMPS SQ.FT.FLOOR AREA 4/SQ.FT. CLicensed Professional O SIGNS ELECTRICAL Q w OWNER."WILDER DECLARATION �na Et SPECIAL CIRCUIT/M6C F'y/,6 I herebyalBrmtMt l am exempt from the Comract.rs Licens Law for the o9F following reason.(Secllon 7mlS,Business and Profession.Code:Any city or TEMP,METER OR POLE INST. P49.� county which rcqutmsa permit toconslmct,alter,improve,demolish,orrepair 4 �,t3Q nystructure pdorto its Issuance,also requires the applicant forsuch permit to POWER DEVICES 6 r�E V file a signed statement that he Is licensed Pursuant to the preventive of the Contractors License CLaw(Chdssr9(commencin ith SeRion 7000)of Divi. VALUA Os sion 3ofthe Business and Profesns sl. Cod6 m e)orthat heexempt therefroand SWIMMING IDOL ELECTRIC n u� the basis for the alleged exemption. Any violation of Section 7031.5 by any OU.O ETS­SWI.CHE$NXTURES <� applicant for a Ferried s.b)ectsthe applicant to a civil penalty of out rrore than w l dml dollars MIKE. NEW RESIDENTIAL ELECTR SQFL STORIES TYPE CONSTRUCTION 7< s owner of ted property,or my employees with wages as their sole pensztlon,willdotheworkandthestm=m6w intendedor offered for $ O le(Sec.704q Business and Profesimns Cade:TheComract.r.Lt..Law does notapply to an owner aproperty who builds orimproves thereon,and OCC.GROUP RFS.UNITS ca who does such work himself orthrough his own employees,providecithatsuch Improvements are not Intended oroffered for sale.If,however,lhebuilding or TOTAL: Improvement Issold within oneyearofcompletton,the owner-builderwlll have to117unden of proving that he did not wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE L_J L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN • I'FRNfIT ISSUANCE cemmetors to ca,retamt the project(Sec.70K Business a red Professions Code: The Contractor's License law does act apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA) Wilds or improve thereon, and who contracts for such ptnjeca with a FEE SUMMARY o�.t at rea k(s)hcensed pursuant to the Contractor:License Law. BACK FLOW PROTECT.DEVTCE 1ff,I am exempt under SB P C for this reason DRAINS.FLOOR ROOF,AREA,CONT. SANITARY Y N_ . Owner Date RECEII'I p WORKMAN COMPENSATION DECLARATION ❑1 hereby'afflrm that I have a certificate of consent to self-insure, PER TRAP SCHOOL TAX Y N l(-Inre,ora RECEIPT 0 certificate of Worken'Comperaatfon Insurance ora certified copy lhersaffSec. GAS b CJ EA.SYSTEM-11NCA OUTLETS PARK FEF. Y N 3800,laRECEIPT p On tl GAS EA.SY5TEM-OVER4 MA) C om raBUILDING DI VISION FG[S []CenyiRed copy a;hereby famished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE MCertifled copy 6 filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Thissectionneed not ed completed if the permit Is forom hundred dollars SEWER-SANITARY-STORM EA.200FT. Dale Recei 1# (9100)orlessJ I�V / ENERCYFEE Y_ N_ I certifythat lathe performanceof the work forwhich this permit Is issued, I atoll not employ any person bra any manner so as to become subject to the Workers Compensation laws of California. Date SYSPEM/TREATINK; e .r IT PAID OZ Applicant E9 DENT AUI ' Date Recei t# Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you sheuld become subject to the Workers'Compensation provisions of the Labor _ TOTAL: CCN Code,you mus:forthwith comply with such provlsions.rth6 permit shall be - BUILDIN G FEE W > deemed revoked. a O CONSTRUCTION LENDING AGENCY SEISMIC FEE ( ^ Ihercbya(Rron that there b a construction lending agency for the perform TOTAL: ELECTRIC FEE 7 Z anof the work for which this permit 6 bsued(Sec.3097,CIV.G.) O O Lander.Name PLUMBING FEE LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE OW Icentifythat l havereadthisapplicitionand siatethatthe above Information 1 Iscorrect]agree to comply with all city and countyordinanms and state laws PFRVIITISSUANCE FEES PAID: >_ W relating to wilding construction,and hembyauthotlureprexntatbvesofthIs Fcitytoenteruponthcwve.mentlomd propertyfor Wpection purposes. ALTERORADDTOMECH. Z (We)agree to s ,indemnify and keep harmless the City of Cupertino Date Receipt# V againstbabiltie gment.,cnw.ande.pen.e.whkhma in anywayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL' ago red'.1d C c . ce the granting of lhi t. 0. AIRHANOUNG UNIT(OVER 10,a)QCM) CONSTRUCTION TAX Si mmn Applcant/ n actor - D.Itp/ �. / IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE 6/1/ A/ Will the applicant or luture building om pant store.,handle Mous HEATING UNIT(TO 100,OD0 RM Date Recef t# material as defined by the Cupertino Municipal Code,Chapter 9.12, rad the — Hx.I Yard Safely Code,Sectioon25532W? HEATING UNIT(OVER(00,000 BTU) TOTA Wit)the applicant or❑future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as dented by the Bay Area Air lity Marugement District? BOILER-COMP OLIPOR 100,0(0 BTU) Ys ❑No a have reaPP p d the hazardous matefla6 requirements under Chapter 8.95 of BDILER-COMP I OO,OW BN) �1 B the California I lealth A Safety Code,Sections 255D5,25533 and 25534. 1 understand that if the building does not currently have a tenant,that itis my NEWRESIDENTIALMECII. SQ.FT responsibility to notify the occupant of the requirements which must be mat II 11/!A� ' 1 199 prior to issuance of a Certificate of O pa ncy. o /v7 as�2 Ownaroraitlavimdagent Date ISSUED BY. TOTAL: OFFICE COPY