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HomeMy WebLinkAbout22350 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Address: ^2 3 r 0 � 0�� G G l{/a��J 4vn ja _.yG one: APP=IUN hU BMI I I AL DA 3CITY OF CUPERTINO-BUILDING DIVISION Contractor's Name: Gc.Na. APPLICATION / PERMIT BUILDINGELF-CTRICALPLUMBINGMECI-IANICAL CATFS''ORCO LN rchitect/Engineer. Lk.No: a- QTY ELECTRICPERMIT FEE BUILDING PERMITINFO Address: 61 r LI/ ,,,a PERMITISSUANCE 'tea ❑ 1:1 [1LICENSEDCON ACT OR'SDECLARATION lMmbyaffirtnth tlamlicrosedunderprovislonsof Chapter9(mm mc. APPLIANCFS.RESIDENHAL JOB DESCRIPTIONIngwilh Se ton7000)of Divbbn3ofthe Busincssand ProfesslonsCodga drrry license la Infull d ' PAN©S / License Cbss Lk.k.N Date Contractor �s 'Tie .t ARCHITECPS DECLARATION 2014000 AMPS 1Q+�N:, I understand my plans shall be used as public records. OVERI000AMPS SQ.FT.FLOOR AREA S/SQ.FT. E Z`j Licensed Profeslonsl SIGNS ELECTRICAL < exempt DECLARATION SPECIAL CEtCU1T/M75C 7..,�� I hem g r affirm that l am 31.5,B from the d PAnlessio License Taw for the following reason.(Section 7041.5,Business and Professions Code:Any city or C cauntywhich requlresapenNtmmmtmct,ilteq Improve,demolbh,orrcpilr TFMP.MECER OR POLE INST. anystmdurcprlortolls Lsmance,alsorequirestheapphc ntforsuchper tto file a signed statement that he is licensed POWER DEVICES 3 � Contrd.ra Llcenaelaw(Chapler9(commeencagwtith5ectitianv7000),dDlvl- F,�, 05 sicn3 ofthe Business and ProfessionsCode)orthat he In exempt therefromand SWIMMING POOL ELECPRIC VALUATION '3 the basis for the alleged exemption. Any violation of Section 7MI5 by any <5 applicant for a permit subjects the applicant to a civil penalty of not morethan OUTLETS-SWITCHES-FIXTURES i five hundred dollars WN. NEW AESIDEN]IAL ELECTR FC. ❑1,as Owner of the property,or my employees with wages as their sole S[DIOFS TYPE CONSTRUCTION t 7X compensation,wBldothewark,andthestmcture isnotintended or offered for - 5 ❑ sale(Sec.7044,Buslnessand Pmfesalom COde:The Contractors Llrerue law does not apply to an owner of property who Wilds or improves thereon,and _ OCC.GROUP KIN.UNITS who doessuchworkhlmseEorlhrough hisownemploym,provided that such Improvements arc not intended oroffercd forsals.If,however,the building or T improvement lasold withinoneyearofcomplet ntheowner-bu0derwill have t"Aden of proving that he did not build or Improve(orpurposeofsale.). QTY. PLUMBING PERMIT FEE1LOO mNNE APN L,I L as owner of the property,am exclusively contracting with licensed pFRMIT ISSUANCE contractor to construct the pmjed(Sec.7014,Business and Professions Code: The Contractors License law does not apply to an owner of property who (EA) Wilds or Improves thereon,and who contacts for such ixojects with a ALTER-DRAIN&VENT-WATER ,,NIl�(a emits)licenaed pursuant to the Contractor's License Law. c IT, am exempt under Sec. B&P C for this mason BACK FLOW PROTECT.DEVICE FEE SUMMARY OUTSIDFF FS Owner Date DRAIN&FLOOR,ROOF,AREA.COND. SANITARY Y N WORKMAN COMPENSATION DECLARATION RECEIPT N hereby a(flrm that I have a certificate of consent to seB-insure,ora INURES PER TRAP SCI800L TAK Y N ni(lateo(Workeri Compewtionlmuranmoracenifiedmpythereof(Sec. RECEIPT N 38W,Gbj L' GAS EA.SYSTEM-I INC4 OUTLEM PARK FEE Y_ N_ Policy N_ 7 /s �q RECEIPT N Com acv < C 1,R ?JYE 4 ) BUILDING DIVISION FEES Com d-TrYofcopy Is erc furnished. ,GR E/ND L ASTEI _ R PLANCHECK FEE, �Centiiedmpyu Bled 'lh the city inspection division. t CERTIFICATEOFE%EMPEIONFROMWORKERS' PAID COMPENSATION INSURANCE (Thissectionneednetbecomplated iflheperma eforocehundreddollars -SA T Date Recel t# (4100)ar les.) I mnify that in the performance ofthe work for which this permit is i6naa, WATER HEATER w/vENT/o.EcrA - ENERGY FEE Y_ N_ 1 shall not employ any person In any manner all ns to berome subject to the Workers'ComPensation Lawsof Callfomla.Date WATFRSYSIEM/TREATING O Z Applicant PAID Z O NOTICE TO APPLICANT:If,alter making this Cad lale of Exemption,you NEW RESIDENTIAL PLM It. SQ,FT. Date Recei t# - Hshould become subject to the Workers'Compansatlon provisions ofthe Labor - fA Cade,you must forthwith comply with such providoreor thin permit shall be TOTAL: W > deemed revoked. BUIL12ING ••E a o CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirmthat there is a construction lending agency far the perform_Z anceoftheworkforwhich this permit is Issued(Sec.W97,C1v.C.) TOTAL: ELECTRIC FEE U O Lenders Name PLUMBING FEE LL 1— Lenders Addmss QTY. MECHANICAL PERMIT FEE O W Imnlfymatl have readthisapplimtlOnand gate lhcabove in formation MECHANICAL FEE (1 Bournect.l 49matocomplywitha11 dtyand muntyordlnancesand late laws PERMIT ISSUANCE FEES PAID: } N relating to building covtrBodon,and hereby authorlve representatives ofthb F. z city to enter upon the above-mentioned property for inspection purposes. ALIMOR ADDTO MECH. — (We)agree to save,indemnity an d keep harmless the City of Cu pectin Date Receipt# agMfE� nts rte and xpensee whih may In any wayaccrue AIR HANDLING UNIT(To 10,000 CFM) age e granting of this permit. SUBTOTAL: _ AIRHANDLINGUNR(OVERIE,000CFM) CONSTRUCTION TAX velure Appli t ontractor Dale EXHAUST HOOD IW/DUCD CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theappBant orfumm building occupant storeorhandlo hazardous HEATING UNIT(TO 100,000 BTI) materia l as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date ReceI t# I fe❑a It, d a rW Safety Coa25532(A)t HEATING UNIT(OVER 100,000 BTU) TOTAL: Will thexpPlimnt Orfumm building ocmpant use equipment or devices zaVENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hardousau mnlammanta as defined by lho Bay Arca Air Quality Management Distrix BOILER-COMP MIN OR 100,000 BTU) Yeso NN��a have read the hazy oro materials requ lrements under Cha per 6.95 of BOILER-COMP(OVER 100,000 BTU) 1`e a� ' mO California Health&Safety Code,Sections 25505,25533 and 15534. 1 M D understand that if the building don nottomently have atenant,thalitumy NEW ftESIDENUALMECH. SQ.FI. �� rsponsib Pty to N(ru� m tOf the uirements which must be mot prior r ee to�t�or (6 8 oraut nada fit pa TOTAL: ISSUEDBY: i •- t/ OFFICE COPY a n� YIGr/ W O a O Q6 r � .. [IT p� w 1 (t W w ate_ a az M W D 00 0 �9 .... Cil U � Q 1 (Z5 Cs c fL c ZIP II' , f 1 a