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HomeMy WebLinkAbout22033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Idemlf"tion PERMIT NO. BUOdtng Address: (1/"1 O/"� I"[ +5-1 I Fiwwaa� �rwa GG l{ 3 —] eName: Ira ('D one:ne- �/�l Y'(y mn,�+I�(/% a0CITY OF CUPERTINO-BUILDING DIVISION Ceatrtdar.N.' �pN (r+ ' I Lb N¢ APPLICATION I PERMIT �J CATEGORY CONTROL DER - K Archlled/Fa veers Lit, N. �/ + Qtr ELECTRICPERMIT FEE BUILDING PERMIT INFO Addrtv: 'Sa0 .S. SKFs� 1yI PERMITISSUANCE • El F-1 11LICENSED CONTRA RS DE RATION I hereby afflrmlhat l am Uersed order pruvis.i.dChapter9(mrtunrn APPIIANCESREMENML BDE'CRITION Ingwth Sectbn7000)of DMMm3ofNeB"drc dliofea Code,andmy Ibenue lbGt+oefgo,�u.{�p]��a affect. �y� /7 PANF]S 7 � �r� 5'-/d'aj./_C ntraRor -"'_-� IM TO 200 AMPS ARCHITIC'S DECLARATION MI-I"AMPS 02 I understand my plane shall be used As publlc rends OVERIODOAMPS SQ.Fr.FLOOR AREA O Lkensd 1'rdrsbvl SIGNS ELECTRICAL 6 OWNER-BUILDER DECLARATION Iherebyafftrmthatl..eIerpt fromthe ComractoroLlanslawforthe SPECIALCIRCGT/hISC 6gF foflo lgreason.5eaton 70315,Bushes and Pmfevbts Code:Any city or TpMW.MECROR POLE NS. county which rNotres a permit lomnslruct,alter,improve,demolish,orrepalr anye mmpr tolbbeuamgalsorequl theappUo tforwehpe tm Ole a signed statement that he b llant naed pursuato the provisions,d the (OWER DEVICES O u,G Cm,md is License Law(Chapter 9(mmmencingwith Sectbn7000)ofDlvl- 1,.,';05 sion3 ofthe Bushes and Prdmtonu Code)orthat he b esempt therefomand SWIMMING TOOL ELECTRIC VALUATION�s the Wsb for the albged exemption. Any violation of Seetion 70315 by any B // eppBnntfora permit wbfectelheapplfunt too dull penaltydeat mortthan OUTLEfSSWITCEESFIXTIIRES i(lD D Rv.£,hundred dollars(S.SM. C/ �L as owner of the property,or my employees with wags a their role N RF5INFN]IAL©'FS'fR SQ T. fbIORIES TYPECONSTRUCTION mmperuatlm,wWdo titworkandthe.tr mlaseriImeMedorofferedfor O d lsec-7054,Bushes and Prdmbn Code:The Comnctorehereon Law �IS@ and whodoessuchtoan imeerdpmpertywM holm oyees,p Beatlrrmn,uch OCC.GROUP RES UMI5 0. finny oeachwork mien/ edorwferedlth o sok.lfhow,pr,thel lluinger Improverrcms arc nd Intended orolfued lorsaY.If,hwvevcr,thebulWing rc TOTAL bnpmvcrrcld bedd wbhlnorcyearofmmplatbn,the wvner-0ollderwW WBz t relenofprosdngthat hedld notbuua orlmprove forpurposeofule.). QTY. PLUMBING PERMIT FEE LL u owner of the property,am exchisively mnt—...I,wBh B crud FLOOD ZONE APN rsmtncton to mnuwdOu pmJM(Sec.7044,Bushes and Pno(eselon Code: PERMIT ISSUANCE The Comrade.Lkeni law don not apply to an owner of property who ALTER DRAIN&VENT'-WATER CEA) or improves thereon, and who mmracb for A,,& pt,o(eGa with a a j[ .,moImnpnt to the Contna ds Llarse Law. BAIX PLOW PROTECT.DEVICE FEE SUMMARY U I xeadusoa mpt oder Sec B k P C for this reason DRAINS FLOOR ROOF,AREA,OOND. SANCTARY Y_ N_ Owner Date RECEIPT♦ ��{{ WORKMAN COMPENSATION DECLARATION FI)CEURES PER TRAP SCI400L TAX Y N_ ii hereby affirm that 1 love.¢rttnute of cmaem to opythwre,or a RECEIPT I",Lab WorAYeri Cron lwtlon lyruurana ours mdil4d ropy lhereot(Sec CAS FA.SYSTEM-1 INCL OUTLETS - PARK FEE Y_ N_ 38110,`b C)�H rl'r -1��.{t ftC(.'E NI C. GAS F.A.SYS I7 M(OVER 4(EA)Y BUILDING DIVISION FEES Cedtfied miry b Wrebyth the cid. CREASE/AIDUSTRL WASTE INTERCEPTOR PLANCHECK FEE CedBled ropy b tBcd with the city Ivpectlon divistm. CERTIFICATE OF EXEMPTION FROM WORKERS' GRECSETRAP PAID COMPENSATION rodNCE SEWER-SANITARY-STORM EB 2DBFT Date RCOCI [# (Chs aedton need na W complded tithe pemdt b/ororc hundred do][. (91OD)orlmJ WATER HEATER W/VENT/D.ECTR ENERGY FEE Y N lentntify that Inthe persounrnof tharine,An As to htMa ompemdteboats, 1 shat not enripby any person la any manner so v m become sb)ea to the WATER SYSTE M/tRFATING Warken'Canpenaatlon[awe of Gl(omla. Data PAID OZ Appaont NEW IiE4DINIlAL PLMB. SQFI'. Dale Reuel t# Z O NOTICETO APPLICANT:If,after making this Cedllraleof Eaemptbn,yw Fy should benne wbjrd to the Wo.ten'Compensatbn provlabmafthe Labor TOTAL: Ir _ Code,you mwNh comply with wch pnovbbnu orchis pemdt shallW O deemed revoked.l,crd. BUILDING —,Zs - CONSTRUCTION 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE B TOTAL m I hereby afOmn ttat there b a eurutmcurai lending agencyfor the pedamf = enm of e woZfor which thi"'=b b ed TS 3097,CI,C.) ELECTRIC FEE V O Lendee.No. PLUMBING FEE LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W I certify that l hove mad thbappfioloo.nd state that the above into m b mused.I agree to comply wrhal etyard musty ord nous and to laws PERMIT ISSUANCE FEES PAID: } f1 relating to IdingmmlroBMan,and Wrtbyauth repress dl F N city to cote Eon the above-mentbrcd ptopniv _Pedbn rpo.ea ALTERORADDTOMFLH. ? to save,Indemnify an d km ha es the C of Atop Date Recei t# V •gal b d ment,mstsandex Id may wa accrue AIR HANDING UNIT(TO 10,ODOCFM) SUBTOTAL- aga said City eroe.fthe g /1 Z MR HANGING UNIT(OVER 1 "CEM) CONSTRUCnON TAX w V IgraturedApplcant miredor ie EXIIAUSCHOOD(W/DUCT) CONSTRUCTION TAX PA ID: HAZARDDUSMATERIA DISCLOSURE WOTtheappBmmmfutunboilding pant store rtor Wndleharudou. I EIFATING UNIT CTO 100,000 BTU) Date Recei t# merbl ere ae0rcd by the Cupertim Mu Ndpal Code,Chapter 9.17,and the Heahh AM Safety Cade Ion 25531(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL: ❑ Ye ,fin Wllltheappilo d or Whom bu 0ding omnpart use equipment«devlm VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE whkh emit W rardoua it eonumbunte a defined by IM Bay Arca Air C omma lity Management IXs NO BOI.ER-ODMP PI-I'OR IOO,IXq BTU) ' 4 Yn No Wvcreol the h.—,,T..m.tcrtab rtqulremcnts onderCWpter6.95of BORER-COMP(OVER IKOD0 BTU) APR 1 1 ] the C.Efomla Heald&Safety Code,Sections 25505,75533 and 25534.I undersand that if the bu0ding does rim ently have.tenant,that it bmy NEWR®DFNIIALMECH. SQFr nspom@Ilfty to notify the o pain of the requtrtmems which must be met prior to 1,auame da Cedifloteof O¢oparlcy. ft of,upl rhn Owner or authorlred agent Date ISSUED BY: If� 't"¢`ar`•-�1 �kjAV TOTAL OFFICE COPY