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HomeMy WebLinkAbout23933 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY bulldin Protect Iaemlllcatlsn PERMIT NO. BuOding Addreas: 23933 am: one: CITY OF CUPERTIN6BUILDING ON ^�-7 1J�7 can anar.N. �/�ry� C b.Na: APPLICATION IPE IT / C �„nLEy �-(/ ,J: + DO� BUILDING-ELECTRICAL PLUMBIN H LAICAL CATEGORY CONTROLX Architect/Fagtnser. Lt.No: II BUILDING PERMIT INFO QTY ELECTRIC PER IT FEE Address: I S . PERMITISSUANCE KENS EDCONTR under Provisions APPLIANCES L / Jun I..hSyion7Othat l.m Bcensed 3ofthe usiro andlsrfCsions9de,and c 7„ 1Vvi�'•/T�/ ingwlthSMlon7000)ofDlvlalon3oflhegurslnnaand/P,ro�lnNonaCode,and P If=rase I.in full and d(ect. �...I"]�O w Cleanse Cla LILY .• ..• .•� . ._ a • >- Date Con[nc[ar ARCHITECTSDECLARATLON 1-1AMPS NS ELEC L QOR_SQ.I�FL © FT. PS 0 O I understand my place shall..used as public records \V� E I� Licensed Professional {. d�Q OWNER-BUILDER DECLARATION SPECIAL CIR LSC ® PLJ N, I hereby affirm that I am exempt from the Contractte.License Law for the foliowingrnaon.(Serion70115,Bu.InenandProfenbnsCode:Anycityor TEMP,METER PO INST. og B St F� cauntywhichrequlmaper Ntwmnseruct,altegimpmve,dennWh----- lr ATE U (/ g anystructure prbrtolts issuance,also requimtheappliant forsuch permit to POWER DEVICES E5 file a signed statement that he b llansed pursuant to the provisions of the O� Contractor's License Use(Chapter 9(mrrurcncing with Section 7000)of Divi- SWIMMING TOOL ELECTRICVALUATIO s.30rn .Ion3ofthe Buslne.sand Profeado.Code)orth.t he is exemp"hemfmmand moo - 'n DODY the bads for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSSWITCHFSFIXTURES S applicant fora permit subjects the applicant to dvil penalty of not more t..n O five hundred dollars(fi. . NEW RESIDENTIAL ELEC7R SQ.FT. STORIES TYPE CONSIRIICHON ❑I,as owner of the property,or my employees in with wage as offir ered fo compensation,70 witdot..workfeand the t Cede: hcommendedor Lofferedfar CO sale(Sm.70K Business and Profeniom Code:The Contnctats License Law B does notapplyto an owner of propertywho buildsor improveathereon,and OCC.GROUP RFS.UMTS who does such wa rk hlm+elf or through Ms own emp layers,provided that such impmvements am not Intendedomffered!onsets.IL however thebuilding ar Improvement bsold withinomyearofcompldion,t..owner-builderwlll have ttl9purden of proving that he did not build or improve for purpose ofaale.). QTY. PLUMBING PERMIT FEE FLOODZANE APN U L as owner of the property,am exclusively contracting with licensed PERMITLSSUANCE contractors to construct the project(Sec.7064 Business and Professions Code: The CoMmeter's License law don not apply to an owner of property who ALTER DRAIN h VENT-WATER(EA) Wilds or Improv"thereon, and who contracts for such p(ojects with a FEE SUMMARY �gnf(ader(s)licensed Forecast to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJI am exempt under Sec B k P C for thb reason DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_ Owner Date RECEIPT X WORKMAN COMPENSATION DECLARATION FIXTURES,PER TRAP SCHOOLTAX Y_ N_ ❑I hereby affirm that I have a certifimm of consent to self-inmm,ora RECEIPT X certificate of Woroms!Comperuatlon Insurance macertlfied mpythereof(Sec. GAS,F.A.SYSTEM-11NC60UILE75 PARKFEF- Y N 3800,lab C.) RECEIPT X policy GAS PA.SYSTEMOVER 4(FA) BUILDINGDIVIS NFEES cam ray [r Cert IS doepybherebyfumbhed. GREASE/INDUSTRL WA57E INTERCEPTOR PLANCHECK FEE �Certlled copy b Bled with the city iwpection division. CERTIFICATE OF E(KM PTION FROM WOR KERS' GREASE TRAP PAID It. COMPENSATION INSURANCESEWER-SAMT,ViY-SIDRM FA,IBBPT, Date ecei ted (rhbsectlon need not be completed ifthe permit b f=one hundred dollars ENERGY FEE Y N (9100)or less.) WATER HEATER W/VENT/ELECTR — I certify that m the performance of the work forwhich this permit Is bused, I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID_ Workera'Compensation Lawsof California.Date a ReCei tR O Z APpllam NEWRESIDENTIAL PLMB._SQFT. Z O NOTICETO APPLICANT:ILafter making this CcAiflcom of Exemption,you TOTAL: should become subject to the Workers'Compere atlon provisions of the Labor N Code,you most forthwith=reply with such provisions or this perrnit shall be B G a^ > dermed revc--d( SEISMIC FEE IL G / fi CONSTRUCTION LENDING AGENCY - a Ihereb (mon that there ba=mt=Issuic(Sec. agency for W,Ci ,C,l perform TOTAL: ELECTRIC FEE 7 Z area of thl rkforwhichthb permit bb=ed(Sec.3097,Civ.C.I PLUMBING FE (� O lender'.t; LL Lenaerae 'e" QT'Y. MECHANICAL PERMIT FEB MECHANICAL E LL W Ir,,:`. tlbve .dthbappBatlonadetatethattheabovelnfor tion FEC•S PAID: b correct, ee to comply with all city and county ordinances and date laws PERMITISSUANCE 7. IL reLoing to �ding=mtruction,and hereby authorise representatives ofthb ,... N city to enh ton above-mentioned for inspection ALTER OR ADDTO MECH. Date Recei ted Z propertypurposes. (We)a It..ave;Indemnify and keep harmless the City of Cupertino AIR HANDLING UNIT(TO 10,ODOCFM) V agalmtllal ea,jadgmenb,mrtsand"Tenses which may In anyway accrue $ BTOTAL: ag.imtsal ty in emsequence of the Ba cling of this permit. - CONSTRUCTIO AX ' AIR HANDLING UNIT(OVER 10,000 CFM) gm Pei azHEATING UNIT ,000BN)ppbant/Contractor Date EXHAUST HOOD(W/DUC7) CONSTRUCTION X PAID: HAZARDOUS MATERIALS DISCLOSURE G U0100 �\ Will th IpBant or future building occupant store or handle h ardous Date R material., fined by the Cupertino Municipal Code,Chapter 9.17,and the HEATING UNIT(OVER 100,000 RTU) TO Iinithann i(My Code Section 25537(.)7 ❑Ynl f No VENTILATION FAN(SINGLE RF SID) ISSUANCE DATE Willtti pliant or tore building occupant use equipment or device which,ml prdousdr contimlru t.ae defined by the Bay Are,Air BOB,FR-COMP(31IP OR 100,0(0 BTU) - pp�q pp Qu I1Itym, meet District? B' pq ^� µY" 1 ❑No BOILER-COMP(OVER 100,000 BTU) I navel the hazallous maledab requirements under Chapter6.95 of the Califor 'IT"llh k Safety Code,Sections 25505,25S33.ed 25536.I 'JUL ty undcrstani it if the building does net=vently have.tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT o r" II onetifytl occopant of the requirements which must be met CITY X., u to of !late ofOccupanry. \ CI7Y OF CiUjE'CI, y or, dagent Date �/ ISSUEDBYV�1��l�V�l/\� OFFICE COPY