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HomeMy WebLinkAbout20782 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Nuildina Proiect Identification PERIMITNO. Building Address: ' f)0 ('1 tolov'AvzI4A6o GV5 �pnere Name: _ AYPLACA110N�i 11-IAL DAIL CITY OF CUPERTINO-BUILDING DIVISION 7 raName: ue.No: APPLICATION / PERMIT. 1h 1 Ke S P I e CO AJ ST• CATEGORY Co ' ,Architect/Engineer. LIC No: BUfLDINC-¢ECTRICALPLUMBINGMECHAMCAL 1•]H�•'J �1 I- �S/-wke'.Ma T PAI,�Cpp'�� C�/9 7S�I'Q,fv'' ('1 ,ELECTRIC PERMIT ,`' ,+ PEE 1•+i' :BUILDING PERMIT INFO,,-: , Address: �Q e,GL. C.:ANI9Ina0 S\I%pf.(/ I PERMITISUANCE lea C27 �, rases f.�.u, LICENSED CONTRACTOR'S DECLARATION I 9 Iherebyaffimnthat lamlicenaed under pronationsof Chapler9(comareno-1 APPWANCFSRES(DENFIAL JOB D7A&zz.Ingwith5 ion7000)oflNWsion3ofthe Buslrussandl mf sionsCcee;andmy license le in foil and effect PANELS Dat nyge Class Lie.p 5 Z � a 4\ �/ I- 5!�- 2 Confractor 3?p TO I'M hB'S ARCHITECpSDECLARATIO I MI-1000AMPS I q�q�uu ce Zp ".I understand my plarushall be used as public records. : OVER 1000 AMPS B �' -SQ.FT.FLOOR AREA S/SQ.FT. k (0 Llansed Pro(esslonal SIGNS ELECTRICAL U J 7 <<�<(g OWNER-RUILDER DECLARATION SPECIALCIRCUIT/MISC Ihembyaffirmthailamexempt fromthe Cmamdm'°Llanselawforthe FLpr Z Q following reason.(ima p rQ to Bmmaand Pm pmons emle h,y city 1. STw � p / .xi fountyng reason. Prefpsions Code:Any eftyi.! TEMP. OR TOLE - q� any structure prior to its Issuance,alsorequlres theappllant forsuch permit to E5 fl`h a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES ' Q60m Contranofs Liecrue Law(Chapler9(mmmenMg whh Section 7000)of DM- SWIMMING POOL¢ECM yA1.DA'IIDN COQ slon3o(the Businem andPMewiomCode)orthathehemmptthemfromand Q , N �pl5j' the basis for the alleged exemption. Any violation of Section 7031.5 by any �'jT��,,��'' F�U�/Il J•( �J O D ' applicant fora permit sub)ects the applicant to a civil penalty of not more than e ` OUnETSSWITCFIFSFIXTUR )d_Xs -pi 1 a I_ five hundred dollars(55001. NEW RESIDENTIAL ELFGTR SI'pRiES / TYPE CONSTRUCTION �n ❑I,as owner of the property,or my employees with wages as their dole 'L C compensation,will dothe work,and the structure is not Intended or offend for Y 0 sat is(Sec.7014,Busies and Prefeaskna Code:The Coniracors License law IpO [? $ does not apply to an owner ofproperty who buildsortmpmees therron,and OCC.GROUT' RES.UNITS C: whodoessuch work himself orthrough his own employees,provided that such Improvementaamnmt tendedoroffered fordak.![howeveylhebuildingor TOTAL: O impmvementis oldwit hinoneyearof completlogtheowner-bullderwill:,. _ theburden of proving that he did nee build or Improve for purpose ofsds.). IQTy, PLUMBING PERMIT.,' `I FEE, FLOOD ZONE APN L�I,as owner of the property,am exclusively,contracting with licensed PERMIT ISSUANCE •••s contractors to construct the project(See.7044,Business and Professlom Code: I The Contractor's License Law does not apply to an m owner a pperty I ALTER- - builds or Improves thereon,and who contracts for such ptolect DRAIN k VENT with a WATER S ' Co 1 co' t,Iactor(e)Ilansed pursuant to the Contraaor'e Llanae Law. I I I�• "' i 'FEESUMMARY' LJ BACK FLOW PROTECT.DEVICE qr ITRIJ2v PI-ES I am exempt under Sec B k P C for this reason I I .I Owner Dana I DRAINS FLOOR,ROOF,AREA,COND. 1 ]SANITARY Y_ N_ WOR KMAN COMPENSATION DECLARATION / RECEIPT •~ pl hereby M.that I have a artiRate of consent to self-ineu re,'or a�3 FIXTIFRRS PER TRAP I tpc� SCHOOL TAX Y_ N_ 1 e rufiate of Worken'Compsosathe,Int urana ors certified ropy thereof(Sec. RECEIPT N GAS EA.SYSTEM-1 INCAOUTLE1'S Polky eb C.I PARK FEE Y T - CAmry nv GAS FA:SYSTFM-0VER4(EA) RECEIPT If ' I I BUILDING DIVISION FEES Certified copy Is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE CcrtBied copy is filed with the city leapection division. -, CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETAAP PAID 7 //^`/O .Jfe661 f-• COMPENSATION INSURANCE Irhl°setion need not becompleled lithe perood Ls fororm hundred doltan SEWER- SANITARY-STORM EA.200FL I Date Receipt# ($100)m ten) WATER FTFAI'FR W/VENT/¢ECTR �!NERGY FEE Y N I artlfy that In the performance of thework forwhlch this permit 1°Issued, I — I shall not employ any person in any manner so as to become subject to the WATER SYSTI M/TREATRNG PAID - 7/20 Worlicant ompenutlon lawsbtGllfomia.Dow __ + _ 86G ,-�I�jo O Z AppllcaM . -"- Z O IYOTICETOn, bj t.th1,a. making pbCeitiflateo(Fx .flhen,you) NEW RESIDENTIAL PLMB. SQ.FT. I Date Receipt should become subject to the Workers'Compensation provlslona ofthe Labor I TOTAL: a. M Code,you mustlMinvilh comply with such provisions or this permBShail be BUILDING FEE ��Q lL > deemed revoked. 1 I SEISMIC PEE I44'ry d CONSTRUCTION LENDING AGENCY ]herebya(llrno slut there is a construction lending agency forthe perform] aN e, ?LECTRIG FEE '11 rj`x'ZQ D O ance of the work for which this permit is Lnued(Sec.3097,CIv.C.) TOTAL:] s V Lender's Names PLUMBING FEE Z q fp Jy f- Lenders address QrY.1 'MECHANICAL PERMIT FEE ' MECHANICAL FEE U 1retilythat I have read thisappllat(onand statethat theabove Information LA,,CD 0 W is rorrect.I agree to comply with all city and county unbosom and state laws , PERMIT ISSUANCE 111,CID FEES PAID: } relating to building rovtruction,and hereby authorlu representatives of this i 1- 2 city to enter a Pon the abovementioned property for Inspection pe rposes. ALTERORADDTOMECH. - (We)agree to save,Indenal/y an d keep harmless the City of Cupertino - Date Receipt# age inst liabilities,pdgments,costs and expenses which may in any way argue AIR HANDLING UNIT(T010,000 CFM) against said City In consequence of the granting of this permit. I I SUBTOTAL: �? AIRHANDLING UNIT(OVER ifixocITD' 1 CONSTRUCTION TAX Signature m(Appliemt/Cotltractorl Date EXHAUST HOOD(W/DUCT) I CONSTRUCTION TAX PAID: HAZARDOUS'MATERIALS DISCLOSURE Will the appllant or future building occupant store or handle havamous 1 HEATING UNIT(TO 100,000 BTU) , I Date Receipt# 1 material as defined by the Cu pertleo Municipal Cade,Chapter 9.1 2,and the I lealth and Safely Cod" 25532(a)7 HEATING UNIT(OVER 100,000 BTU) Yes No I -2_ I TOTAL:. Will theappllca rat future building occupant use equipment ordevices 1 VENTILATION PAN 6INGLE RESID) I Co ISSUANCE DATE hmh'emit harardoua future as defined by the Bay Area Air , QualBy Management bird? � BOILER.COMP©11FOR100,000BTU) 4 Yes o RO p� .�� have read lhehaza ouamatedals requirements under Chapter 6.95 of I BOILER.COMP(OVER TN,000 BTU) r"-a'�'i�' the California lleal[hk fety Code,Sections 25505,25533 and 25534.1 understand that lfthebulldln does not current) have a tenant,that it tam NEW RESIDENTIAL MECH TI. - B )• y c Q 19 r prior to b0ity in of a Certificate occupant to of reopa requirements which most be rrat i ��Vl bN 6 of he prior to Issuance o(a Certificate ofOmpanry. "q 'Yee.-retRKP �(� / Ownnr or authalzed agent ✓ Date I �y ISSUED BY TOTAL: I 1_\•� I OFFICE COPY /