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HomeMy WebLinkAbout21265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PFRWT NO. Building Address: ern 21265 wn re Namc. APPLI(ZAHONSUBMIl-lAr A CITYOFCUPERTINO-BUILDING T$[oN v _0 APPLICATION /PERM �'y� Co ctor'e l •� c�No: SS Architect/Eng[ Lk Nm J - APPLICATION /PERM CATEGORY CONTROL If - BUILDING PERMIT INFO —a I rc.r Q9Y - ELECTRIC PERMIT FEE Add--7S q Q PERMFEISSUANCE LICENSED CONTRACTOR'S DECLARATION I hereby affrmthat l annUornsed under provisions of Chapter9(commenc APPLIANCE&RESIDENIIAL ]OB DESCRIVTION Erense leSln full P and le(ed�3 t eguccineuand Pmlusflo'ne Code,and my01 PANELS �/ ' "I"m C)ass_. LIc.M_ �a � `C - .` 1 9 roe Date�p. .�aA CantraRor l �T-���ARCHITECI'g LARAT N p)')M' � a0 2 I understand my plan shallbe used u public records OVER 1000 AMPS SQ.Fr. 00 obCO Limned Professional SICNSELECTRICAL - 5< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M75C ,Z I herebyafflrm that Iam exempt(romthe Contractor's License Law for the ii pp stl�.� following reason,(SectBusiness;an ion 70315,Busid Professions Code:Any city or O y�:. TEMP.METER OR POLE INST. P� cwntywhich rcqulreeaperg4l somasact,alter,lmprove,demoBah,orrepalr , y anystmMm prior to its Issuance,alsorequmotheappliant(orsuch permit to POWER DEVICES CL err. file a aigned statement that he Is limned pursuant to the provbiou or the 3µ Contractors Uceue Law(Chapter9(commencing with Section 7000)ofDlvl- O�' gon3otthe Bugnueand Pro(esslouCade)orthst hekexempttham(romand SWIMMING POOL ELECTRIC a� �-y VAL,�p7p71Q 1 6'S the bane for the alleged exemption. Any tviolation civi of penalty o not m m,any OUTLETSSWITCHal7l /�- 0 X 0 (!• JJJJ - �", ❑ aPPllcanefora perMt subjects the applicant ton civil pealty ofna[mromthan V fv ,adreddollarser1Is owner of the pm petty,or my employeewill their RESIDENTIALELECTR SQ.Fr, STOBJUS TITECONSTRUCTION con,pensation,will do the work,and the structure is nor Intended r offered for O ale(Sec.70Kapply to Business and f property Code'.The Contractors License Law \r 3 does not apply to an owner of property who Wilda or Improves;thercery and ; ' OCC.GNOIBV RFS UNITS whodocesuchworkhimeelf arlhrwgh hieownemplayces,provided thatsuch ' impmvementsamnotintendedoroffemdformle.15hmvevepthebuildingor \� TOTAL: 161). Improvement ksold within one yesrofcomplellon,the mvner-builderwlll have Up-4urden of pmvtng that he did not build or improve for pu nrmle.). QTY, PL ' LNG EMIT FEE LJ Las owner or the property,am exclusively c., air "It Licensed FLOOD TONE APN contractors to coatact[he projM(Sec.7044,Business ami lou Code: J�I ff E -Jb The Contractor License Lw does rant apply to en owner d perry who i r t A -D &VENT-WATER(EA) - Wlkls or Improves thereon, and who contracts for such pro •w�flh'(a, O FEE SUMMARY copjractor(e)Ilceneed pursuant to the Contractor's Llmnse Law. AA BACK FLAW PROT T.D CE IJ I am exempt'under Sec. B&P C far t rmaonDUTSI DE FEES DRAINS FLOOR P, COND. SANITARY Y N Owner Data _ _ RECEIPT FebyWWOR KMAN COMPENSATION DECLARATION (' q re form that I have•cedigale of consent to to eel(-Insure,ora NRESPER IItM a $C7{OOL TAX Y N RECEIVE B cxmfIrateofWmkerxC peuatlonlnuranceora ondifled copy thereof(Sec. GAS EA. - -1 INC.4 OUTLETS PARK FEE- Y N 3800,Lab C.)o [� IZ 7j0' "" ;© RECEIVE- Poliaytl> G FA#SYSTQA-0VER4(EA) CamnaM - BUILDING DIVISION FEES []Certified copy V hemlythene city C _./INDUSTRL WASTE INTT]RCFPTOR PLANCFIECK FEE C]Certified copy bfiled with the city ty inspection division. l/,5� CERTIFICATE OF EXEMPTION FROM WORKERS' E7RAIV PAID T COMPENSATION INSURANCE Na-SANITARY•STORM EA.200Fr. Date RCCCI tN (This section need not be completed if the per for one hundred dollar P (f100)orless.) rr�B`�\ WATER HEATW/VENT/ELECTR ENERGYFEE Y N I certify that In the performance of the work for whir's the pennll b/sued; ER I ehaB not employ any pemaon in any manner n u to me abject to the WATIR SYSTPAf/TREATING Workers CompensationlAwsof Callfomb.Date .J/� PAID Ct Z Applicant / NEW RESIDENTIAL PLMB. SO.PI'. Date Remi til Z O NOTICE TO APPLICANT.It,after making this Certlfkate of Exemption,you ' 'F should become subject to the Workan'Compensation provelou of the Labor •TOT AL: � N Code,you must forthwith comply with such pmvhiou orthis permltshallW BUILDING •(9b LU � deemed revoked. CL p consTRumoN LENDING ACFwcv - SEISMIC FEE y I hereby affirm that there is a cont action koding agenryfor the perform I^ ELECTRIC XO Z sore ofthe work forwhkh this permit k 097,Lvared(Sec.3CN.C3 _ TOTAL: FEE Bb. L'/ O Lender.Name PLUMBING FEE Do U. F Leeder'sAddmss Q'rY. MECHANICAL PERMIT ,' FEE' MECHANICAL FEE OW Iced ify that l have read this application and state that the above information - a iscorrect.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID: } Wrelating to building construction,and herebyauthorlu representetivmorlhh F Z city toenterupon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECH. Date Recei Ip — (We)agree to sense,Indmio!i the City of Cupertino art ntllabNtlea,pdgmenlmay In anywayamae ALR HANDLING IIMT(TO 10,0h)CFA[) SUBTOTAL: ail sa CI teconseqhispermit. XARHANDLING UN (OVER 10,000CFM) CONSTRUCTION TAX Slg of Appllant/Cont Date EIXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building oavpart atom or n ehanrdoue HEATING UNIT(ED 100,ODO BTU) Date RBC01 o moterfalasdefinedby the C pertino Municipal Coda,Cha r9.t24tdlhe - HealthandSafetyClore nZ 5532(a)2 'I HEATING UNIT(OVER 100,000 BTU) ,TOTAL: 6 1 Ym No Wftifl, appllcanlm Nm building occupant use equipment or devices VENTILATION FAN(SINGLE BESIDE ISSUANCE DATE which emit hanrdous a4co antlanb asdxfinxd Iyth.Ray Area Alr Quallly Maagement Distrl BOILFR-COMP OHP OR 10QDM F1TU) T� 4 Yes a the 21havereadthehaaa ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,00 BTU) (; 1�p0, vemla Health&Sat Code,Sections 25505,75533 and 25534. I I, l d J 99 ondenend that l(thebuildingdoeanot ntlyhaveatenan4 that It is my NEW RFSIDEMIAL MECH. SQ.Fr responsibilityriorino notifythe sopa to qulrcmentswhich mustW met prioroto of ythe to of - D , Ownero anal rN agent Date ISSUEDB G IOTA L: OFFICE COPY ( 144 1 - 32 - 1 - 64 I I IX kP CD 1 '^ W I ; o I , ; 40- ' -►� _2 - m \j 7 � Ln ` 2 APPROVEDIN r ITH THE CITY of CUPERTTIINOOCODES ANCE WAND ORDINANCE I 144 DATE (8 Q p SIGNEDyV 3 This set of pians and specifications A S1 10 be kept on the job at all times and it is un 3 2 lawful a make any changes m aonfrom ! � m� 2 r thesame wrthuui w:ittan permission from The bw.dpn Dapi., Cty of Cupechno. qK !t\�` m The stamping of ,hrs p;an end specifications ki75 SHALL NOi be he c to pe mit or to be ar �1 -p approval of the violation of any provistow Of any City Ordinance or State law_ 1 D - 0 G T J 1993 • --- - BLDG. INSPECTION DEPARTMEN1 CITU Of CUPERi1NQ � OFFICE Copf, 32 -- 1 -- 32 - I --- 32 - l --