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HomeMy WebLinkAbout22589 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identi(katlpn - - PERMIT NO. Building.-Address: 22589 7 V- Mead w C;E- wnera arrc: ,. 11honeA. Lay CITY OF CUPERTINO-BUILDING DIVISION cp APPLICATION /PERMIT 7 l BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY - CONTROL N PF Architect/Englecer. Lk.No: / QTY ELECTRICPERMIT FEE BUI ING PERMIT INFO Address: PERMITISSUANCR El ❑ + LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am licensed under provisions ofChapterg(comerere APPLIANCESRESIDENIIAL JOB DESCRIPTION Ingwlth Sect1on7000)of Divislon3ofthe Buslenuand Profese lonsCode,and my license is in full and dfeet. PANELS s C L IE Date Ges 201.1000 AMPS ARCHITEHITET'CDECLARAJJ N' OVERIUXAMPS FT. REA S/SQ.FE q�q�vv 00 I undrstand re plaro shag he used as publich<orcls. - � k Z Licened Professional SIGNSELECTRICAL FTN 4D IN Q OWNER-BUILDER DECLARATION T E R ,�� l hereby afIrenthat l am exempt from the Contractoes License Law for the SPECLILCIRCUIT/MMC n�I P O 7. folk,wing reason.15ectlon 70315,Business and Professions Code:Aey city or TFMP.MEITlt ORPOLE INST. 114x, onetywhich requires a permit to construct,alter,improve,demollsh,or repair e�11FFES,a anystructure pdorto Its aseance,alaorequlrestheappliant foisuch permit to POWER DEVICES y U file a signed statement that M V licensed pursuant to the provkvloro of the 0 Contratora Lkevelaw(Chapter9(ronurcnWgwlth Section 7000)of Divi- VALUATION 30rn s(on3ofthe Business and Profemloru Code)or that he b exempt therefrom and SWIMMING POOL fl.ECTRIG $"y the bash for the alleged exemption. Any violation of Section 70315 by any OITILETSSWITCFTFSFIXTURFS 4!// ©ail �I O applicant fora permit subject the applicant to a civil penalty of net more than •i/1/V— (/ rave hundred aesmra asap). sQ srowEs TmeeonsTRucTTON I ea owner ofthe NEW RESIDENTIALELEGTR Ff. �2 ...... nation,w1hdothe work andthetructure V nINlNtended or offered for - 5 p saIs&c.7094,Business and Profe taimss Code:The Contractor's Lt..Law ' 3 does not apply to an owner of property who Wilda or Improves thereon,and OCC.CROW RFS.UMTS whodocs sechwork himself orthrough hisownemployees,provided that such - Lnprove,me.am nest intended proffered for sale.If,however,thebuilding or TOTAL: Improvement issold withlnoneyearofcompletlon,theowner-bullderwlll have t��x+rden of proving that he did not bund or Improve fm purpose of sale.). QTY, PLUMBING PERMIT FEE U L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN contractors to construct the project(Sm 7094,Business and Professiom Code: PERMIT ISSUANCE . The Contractor's License Law does not apply to an owner of property who Wilda or improves thereon, and who contracts for such p(ojets with a ALTER-DRAIN&VENT-WATER(EA) yy�B{�TaOur(s)hcensed pursuant to the Contractor's License Law. BACK FLOWI'ROTECI'.DEVICE FEE SUMMARY LL 1 am exempt under Sec. B &P C for thin reason OUTSIDE IT DRAINS FLOOR ROOF,AREA,CONT. SANITARY Y N_ .� Owner Date RECEIPT WORKMAN COMPENSATION DECLARATIONSCHOOL TAX YN ❑1 hereby afflrm that 1 have a certificate of consent to self4rature,ora FIXTURES-PER TRAP _RECEIVENN certificate of Workerd Compensation Insurance or a certified copy theroof(Sce. GAS EA.SYSTEM-]WCAO(TILETS PARK FIE Y_ N_ 3800,1ab C.) �/ Policy N�C LSO 3 ,-6 - RECEIPT N ' - GAS FA.SYSTEM-0VER 4(EA) Com any BUILDING DIVISION FENS L_JCertNed ropy V hereby(urn shed. CRCASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE er Ted mpybfllcdwiththedtyimperrondivision. CERTIFICATE OF EXEM PTION FROM WOR KERS' CREASE THAI': PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2(pF1'. Date RcC i t# (rhlssMlon need notbe completed if the permit 0 for one hundred dollars ($IW)or lase.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ I certify that In the performance of the work forwhlch this permit is Issued, I shall not employ any person In any manner as as to become subject to the WATER SYSTEM/TREATING Workers'Compewtlon laws of Califomh.Date PAID O Z Applicant NEW RESIDENTIAL PLMB. SQb7. Date Recel [# Z O NOTICETO APPLICANTe If,after making thisers'Comper ationkroate is Exemption,you should Code,you forto thwith co Workers'such proatbnpmvbiomrmit of s Labor TOTAL: CC N Code,you muet(orthwith comply with such provisions or this permit shall be BUILDING seemed revoked. W FoFo CONSTRUCTION LENDING AGENCY SEISMIC FEE M Therebyafnrmthat there bammtmctlon lending agency for the pedomm Z ELECTRIC FEE ance ofthe workforwhlch this permit b bwed(Sec.3097,CIv.C.) TOTAL: U O Lender'sName PLUMBING FEE ' U. F Lender's Add cu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U lcerifythatlhterreadthbappliatlonandatatethattheabovemE.rmrtton O W iscorreet.l agree to comply with all city and county ordinances and state laws PERMTTISSUANCE FEES PAID: r a relating to building construction,and herebyauthorl erepresentativesofthb ' F !A city to enter upon theaWvcmantWnd property for inspection purposes. . ALTERORADDTOMBCH. ' Z (We)dgee to save,lndemnlfy an keep harmit-.the City of Cupertino _ .Date Receipt# V agalmtliabilitlea,pdgmpnte,meta pensee which may In anywayaccrue AIR HANDLING UNIT 10,"CEM) SUBTOTAL: a al CI in con- a grantin fthbp . AIR HANDWNG UNIT(OVFdt IO,000CFM) CONSTRUCTION TAX Slgmwmof Appli ontrad.r to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: I1 RDOUS MATERIALS DISC SURE Will the spoil t or future building occupant store or handle hamrdous HEATING UNIT(TO IW,W0 BTU) Date Recei t#� material as def ed by the Cupertino Municipal Code,Chapter 9.17,and the - Halthar, lety Cdr Section 25537G)7 HEATING UNIT IWM BTU) TOTAL: . ❑Yea ri No ' , Will the applicant or future building occupant use equipment or devices VFNHLATION FAN(SINGLE RESID) ISSUANCE DATE which emit havrdoes at.mntamlnants as defined by the Bay Area Air Quality Marugement District? -- BOILER-COMP OHI'OR 100,OD BTU) P 4YcsNo hsveread the h.9usmaterlabrcqulrementsunder Chapter6.95of BOILER-COMP(OV1RlW,0WBTU) the California Health&Safety Code,Sections 75505,25573 and 75534. I (Jw � . understand that if the building does nes currently have a tenant,that It k TI my NEW RESIDENTIAL MELT �." 5Q !.I 1r91N responsibility to notify the occupant of the requirements which must he mat '401 prior to Issuance of a Certificate of Occupancy. ss Owneror authorised agent Date ISSUED TOTAL: OFFICE COPY