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HomeMy WebLinkAbout22457 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prom Identification PERMITNO. r naming Address: iI$SS' OA�U:ew 22457 one: AITUUA]ION A M /py *2 F370 9,71 CITY OF CUPERTINO-BUILDING DIVISION Co a aN me: Lie.Nu: APPLICATION / PERMIT L Caw Sf• t�/09 BUILDING—MECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL# .� Architect/Engineer. - LIc.Na; -' / QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. a O. DY JO PERMITISSUANCE - t ❑ ❑ �({ ❑ LICENSED CONTRACTOR'S DECLARATION LP I hereby afnrmthat l am licensed under provisions of Chapter9(commenc- APPLANCES.RESIDENTIAL JOB DESCRIPTION ingwithSectlon7000)o Division3oftheBuslnessandProfeodmexCode,andmy linenle In full ore and dfect. PANES V DateLima ���a i Cohtract6/d/off oma. ' ARCHITECTS DECLARATION OV-F1.RI000� _ SQ.Fr.FLOOR AREA $/SQ.FT. rc0 y I understand my pBru obeli be used u public records CO mm z Licensed Professional SIGNS ELECTRICAL © W <6ro OWNER-BUILDER DECLARATION / C C... E D I N G (X SPECIAL CIRCUIT/MISC F, Ihercbya ..(Sallam31S,B(rh.a C Professio License law lw the ER F F countywreason.(Sectionrmit to Business and Pro(essioas Code:Any dry or TpMp.MEI'FIZ OR POLE INST. . county which regi Ins a permit ro constmd,alter,ion prove,demolish,or repel r a anystructure prior to its becance,alsorequireslheappecant for such permit to POWER DEVICES , e• I' yi U file a signed statement that he B licensed pursuant to the provisions of the g 169 IDATEContractors License Law(Cha er 9(commencin with Section 7000)of Dist' N O V., sion3ofthe Bualnesaand ProfemiomCWe)orthaghe Bexemptthemfmmand SWIMMING POOL ELECTRIC F' Sn S the baste for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHFSHXTURES �5 appu.ntforapemutsub*l.theappUcanttoadvilpemltyf.m.o than five hundred dollars($50(). NEW RESIDENTIAL ELECTR _- ❑I,asownerofthe roe e.Q.FE STORIES TYPE CONSTRUCTION property,l ya or my employees with wages r there sole C < compensation,wWdotheworloandtheetmdti Th Contractor or offeredlaw , 9 ❑ vie(Sec 704y Busbies and Profenlons Code:The Contractors Lirense Law r$ do.not apply to an owner of property who Wilda.r improv.thereon,and whodocaeuchwork himselforthreugh hlsownemploye.,provided that such OCC.GROUT' RES.UMTS impmvemcnb are mot intended oroffered for sale.If,hcwever,thebuildiog or TOTAL: improvement iisoldwithte oneycarofeompletlogthe owner-bullderwill have ' tn,!Trden of proving that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN L�1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to ronstrud the project(Sec.7044,Business and Professions Code: �,00 The Contrectori License Law does nor apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA) builds or Improves thereon, and who contracts for such En jects with a dor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY ret 1 am exempt under Sec. B k P C for this reason BACK FLOW PROTTLT.DEVICE OUTSIDE If,ES DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N�1^v�('/' . r ' Owner Date RECEn'1'M ISL\`s� WORK MAN COMP F2JSATION DECLARATION FTXTVRES PER TRAP SCI100L TAX Y_ N_ ❑I hereby affirm that I have a.rtifiote of consent to cal(-inmre,or RECEEPT# certificate o(Workers Compensation Insurance or a ceeifkd copy thereof Eke. GAS F.A.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N 3800,Lab C.I I'oltry N—/ 376/a - 9'/ RECEIPGAS EA.SYSTEM-OVER 4(FA). BUILDING C�any�_t—srG e.- eU1LDINGDIVI510N Fr.ES stifled copy is hereby famished. PLANCHECK FEE ICedined copy is filed with the city inspection division. CREASE/INDUSIRL WASTE INTERCEPTORl`�}� CERTIFICATE OF EXEMPTION FROM WORKER$' GRFA'SE TRAP PAID COMPENSATION INSURANCESEWER-SANITARY-STORM EA 200FT a00 Date RCCCI t# (fhb sectloo need not be completed lithe permit isfor ane hundred dollars ($100)mIest.) WATER F3FA77A W/VENT/ELFGTR ENERGY FEB Y_ N_ , I celfythat rtin the performance of thework(or which this permit is Baird, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING . Workers Compensation Laws of California.Date PAID N0710E TO APPLICANT:If,after making t his Certificate of Fxempbon,you NEW RESIDENTIAL PLMB. SQFf. Date Remit# licant Z Z 0 should become subject to the Workeet'Comperoatlon provisions ofthe Labor TOTAL: N Code,you most forthwith comply with such provisions or this permit shall be BUILDING ••E W > deemed revoked.CONSTRUCTION LENDING AGENCYSEISMIC FEE Il I hereby affirm that there B a construction lending agency for the pedarrry /.�4 ELECTRIC FEE M Z arm"Ithe work for which this permit B Issued(Sec.3097,CIv.CJ TOTAL: / / Ov 02 Lender's Name QTYPLUMBING FEE LL I- Lindera Addre. . .MECHANICAL.PERMIT FEE MECHANICAL FEE Ow Icedlfythat l have read that appncationand watethAtheabove Information FEES PAID. (1 is correct.I agreeto comply with an city and county ordinances and date laws PERMIT ISSUANCE >. relating to building construction,and hereby authorlu representatives of this (A city to enter u Pon the abovo-mentioned property for Inspection pit rposes. ALTERORADDTOMECH. ? (We)agree to save,Indemnity and keep harre e.the City of Cupertino Date RCCCIPt# L) against liabilities,judgments,msn.rd expenses which may many wayaccrue AIR HANDLING UNIT(f01(L000CEM) SUBTOTAL: agai Id City in cyhsryuence oRM gra.ting of thio permit. p/ AIR HANDLING UNIT 10,000C F) CONSTRUCTION TAX Ig umof App/antt//Coonntradorr - Date/ ETAUSTHOODN/DUCn CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will theappltmet or future bulldingocceparat stare or handle hazardous HEATING UNIT(TO 100,000 BTT)) Date Receipt# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ' Health and Safety Code Sedion25532(a)7 HEATING UMT(OVER 100,000 BTU) ' TOTAL: 177.0a, ❑Yes MN. ' Wllltheappllont or fumm building occupant ussequipment ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which coat hazardous air contaminants as defined by the Bay Area Air Quality Management DBWd7 BOILER-COMP OI-R'OR 100,000 BTU) uL� Yes ❑Na �A Ihavcrcadlhehazallous materials requirements under Chu pter6.95 of BOILER-COMP(OVER 1 W,0008TV): the California Health 6 Safety Code,Sections 25505,25533 and 25534.I N'1u ((}} tied erste rad that if the build Ing does not currently have a tenant,that it is my NEW RESI DENTIAL MECH. _SQ.TT. J 1sT1 9 responsibility to reality the occupant of the requirements which most be met //A��., • a prior to Issuance ofa Ccrtiflcale of Occupancy. a�sa est Owner or authorized agent Date 1SS(ED1311 VI TOTAL: OFFICE COPY '