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HomeMy WebLinkAbout25500 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILUIM1G-ELECTRICAL PERMIT NO. n C C APPLICATION/PERMIT PLUMBING-MECHANICAL. 2 5 J O O BUILDING DIVISION BUILDING PROJECT IDEN'e1FICA'PION BUILDING ADDRESS _ /1 / SANITARY NO. APPIAcAALoN SUBMITTAL DATE �,7 O p�� h ivri UNIT. OWNERS NAME. PHONE: COrAC}QRS NAM 7 t7 2fF OrJli`! (-.e(� ,v rv/c coNlxoLw RCHG CT/ENGINEJfW LIC NO: ADDRESS: O^slbo ettile MS rvo WJ CONTACT: PHONE: RUELECT PERMIT INFO QTY. ELECTRIC PERMIT NEE BLDG ELECT PLUMB MECII PERMIT ISSUANCE El El 11 LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDEN'HAL - 100 DESCRIPTION 1 hereby aHlmnbatl amfIll.licensedunder provisions ofChaple. (co mmencing is iM1 QI+1 ad Scmi< 7000)of Division o[tM1e Business and LProf easions Code.and Pay license is in PANELS -U� Lice©rut and c[fcet. Lic.4 •u� �I CJ• UPTO2MAMPSZif �P ec¢m Daly ComtrSD 2U1-1000 AMPS S fl f \ AREA $/SQ.IrI'. ZONZ ARCHITECTS DECLARATION OVER IWU AMPS. Q O Z—❑ undcmlunJ my plans shall he used us public records. fiD y F; SIGNS ELECTRICAL Licensed Professional mel; OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. OaO I hereby affir that I Pon exempt from the ormmerora License Law for the ad a. following reason.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE,INST. _ on J which requires a permit m connruct.Phar,improve,demolish,or repay any almcare ofprig t I .. Is requiresIM1applicantf suchp 'u flsigned,ttment POWER DEVICES _W Op thot hI' . if s ,t thep . fit C b I U . L (Chapter d6 �L Y(c g IM1 Section 9b)0) fD" 3 ftM1 B dPr f. ' Code) SWIMMING POOL ELECTRIC - VALUA'1 " fid, Orthat bexempuM1e f nand the bass f IM1allegedexo exemption.Any violation of OUTLETS-SWITCHES-FIXTURES \`/'\��—w lt- ' Section 9031.5 by Pty applicant for a permit subjects the applicant a civil penalty of vV���((V// not mom than fisc hundred dollars($500). wt= NGW RESIDISN'HAL EL[CTR _SQ.FT. STORIES TYPE CONSTRUCTION K F_p ❑ Cue ownernphepmpeny,ormyemployees with wagcsaatheirsolecompensutiory per„;22 will do the work,and the structure is not intended Proffered for sale(Sec.0094,Busimax and Professions Code:The Contractor'a License Law does not apply to ase owner of properly who builds or Improves lhercom,and whodoex such work himselforthroughhis _ ` cmployces,proviAed thP.wchimprovcmcnu are nmimended proffered forsale.if, OCO GROUP RES.UNITS however,the building or improvement is sold within one yearofcompletion,the owner- TOTAL: ' builder will have the burden of proving that he did not build or improve for purpose of sal°')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN ❑ I,as awnerofthe Property,am exclusively contracting with licensed contractors to mel IM10 project(Sec.9099,Business and Professions Code)The Contractor's License law docs nm apply mPnownerofpmlho peny w1mmild,or improves rcon.and PERMIT ISSUANCE "* 'wh000nuaetsfor such pmjeetsoth acmntractods)licensed pursuant to he Contractor's License Law. pL'fER-DRAIN&VENT-WA ER( ) ES MMARY f 4 ❑ 1 um exempt under Sec. .B&P C for this reason BACK FLOW PROTECT.DEVICE Uq'SIUF.FF,F_S NI YN Owner Dat° DRAINS-FLOOR, ARF. ,GOND. R CF,IPf. WORKMAN COMPENSATION DECLARATION 1 l Y N ❑ I hereby affirm that l have acenificuteafcousent mself-insure,or a certificate of FIXTURES-PER TRAP GEIPrw Workers Comperswien Insurance or a candied copy thereof(Sec.3800,Lab C.)which PARK PEE V N rowers all emplayee'ntmder this permit. ]VISI b GAS INC.INC9OUTLETS BUILDING DDIV 151 NFE'S Policy. Company GAS-EA.SYSTEM-OVER 9(EA) PLANCIIECK FEF, ❑ Cenilicd copy is horcby famished. ❑ Ccnifed copy is Eled with the airy inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE COMPENSATION INSURANCE (Thisxconm need not be completed ifthe peril is for one hundreddefies($100) SEWER-SANITARY-STORM M.200FT. ENERGY FEE lase') I comity that in parformanecofthe work for whichthis permit isissued.I shall WATER HEATER W/VENT/ELECTR not employ any person in any manner,so as to become subject to the Workers' PAID Compensation Laws of California. Date WATER SYSTEM(fREAI'ING Date Receipt# O Z Applicant NEW RESIDENTIAL PLMO. SQ.FT. TOTAL: Z O NO TICE TO APPLICANT:If,aper making this Cenificrd,of Exemption.you should (q become sullied to he Workers Compensation provisions of the Labor Code,you meal TT C4 ; forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE W CONSTRUCTION LENDING AGENCY SEISMIC FEE IL Q 1 hereby affirm that there is a construction lending agency for the Performance of U O the work for which this porit is issued(See.3097,Civ.CJ TOTALELECTRIC PEE : Lenders Name PLUMBING FEE u-' F Landers Address QTY. MECHANICAL PERMIT FEE U 1 certify that 1 have read this application and sale the'the move information is MECHANICAL.FEE 7s W comet. l agree to comply with all city and county ordinances and state laws Palating to PERMIT ISSUANCE I" building construction,and hereby authorize representatives oflhia city to enter upon the CONSTRUCTIONTAX U Z abuse-menlioned Properly for inspection purposes. ALTER OR ADD TO MECH. - (We)d an , indemnify and keep harmless the City of Cupertino against lixbiliOslo)ad custc�nar cons which harmless any way of egamen,aigiity AIR HANDLING UNIT(TO 10,(100 CPM) in cons Ihcg ing of ihrsperit. D AIR HANDLING UNIT(OVER BLOW CFM) nature of Applicant/omret te Das EXHAUST HOOD(WMUCIO PAID IIAZAROOU$MATERIALS UISCLOS E HEATING UNIT(TO 100,0010 BTU) Dale Receipt w Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,(100 BTU) T as dammed by the Cupcnino Municipal Code,Chapter 9.12,and lbe Health and Safety Code,Section 25532(a)? VENTILATION PAN(SINGLE RESID) ❑Yes ❑'No ISSUANCE DATE Will the applicant orfuture buildingoecupantuxeequipmentordeviceswhicbemit BOILER-COMP(3HP OR Hallam BTU) azardous air contaminants as defined by the Bay Arca Air Quality Management BOILER 100,000 BTU) )istrill? P p D ❑Yes Cl No NEW RESIDENTIALMECH. SQ.FT., v 1 1 have read the haurdous materials requirement's ander Chapter 695 of the q,IG 2 California Health&Safety Code,Sections 25505,25533 co19 d 25534. I understand that r/ if the building docs mot currently have a small,that it is my responsibility to notify the 1J Omaupant of the rcquiremd,which must Is,and prier to issuance of a Cer ificule of C11 I I�t- ceupaney. Owncrmummull.cold'un - Dme TOTAL: ISSUED