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HomeMy WebLinkAbout23150 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Preen Identification PERMIT NO, Building Addmss: - 23150 -7756 OJ Oork^lba- PY-A Gv�E•eT vo 9soii� ante: one: ax A S/� DESHPAI✓aE 40�-775 CITY OF CUPERTINO-BUILDING DIVISION CmAradoraName: Lic.N. APPLICATION I PERMIT } BUILDINC:M ECMCAUPLUMBING-MECHANICAL CATEGORY COMROL p Architect/Engineer. Lie.No: BUILDING PERMIT INFO �.+r Qrr ELECTRIC PERMIT FEE Address: - PERMITISSUANCE - LICENSEDCONTRACTOR'SDECLARATION 1:1 11 El Thereb affrmthat l am licensed under provisions o(Chapter9(mmmere APPLIANCES-RESIDENTIAL - JOB DESCRIPTION ingwith Semon 7000)o(DtWsion3o(the Buanemand Profession Code,and my lril_al-���`•VT license t,lncif Co a force and - PANELS Llcenx n Cla _-Contractor ontractor 201-1000 AMPS ARCHITECT'S DECLARATION RA$EAD 0 O I understand my plan shag u p be used public records. OVER IWO AMPS � E Fj Licensed Professional SIGNSELECTRICAL 0 OWNEReBALDER DECLARATION © !22 R IN G F SPECIALClRCUIT/ML9C F, y � Iherebyaffirmthatlam exemptfrom the Contractor's License Law for the O g F following reason.(Scdi.7MI.5,Buai....d Pmfevione Code:Anydty or TEMP METER OR POLE INSP. 5 county which requires a permit to construct,alter,improve,demolish,orrepair ATEq a anystructure prior to its bustancealso requirestheappllcant forsuch permit I POWER DEVICES 55 (Ile a signed statement that he E,licensed pursuant to the provblov of the Contmdori Licer Law(Chassmme 9(mndn ith Section7000)of Divi- �30C sion3oftheBusinessand ProfesslonsCode)orthatheItexem therefromand SWPMNGIDOLF�CCTRC VALUAUO`9 O the basis for the alleged exemption. Any violation of Section 70315 by any g <i applicant for a permit subjects the applicant to a civil pe vltyo(namorethan OUTLETMWITCHESFIXIURFS Y CJ 0 (Lv�e�hut��ndred dollars($50B, NEW RESIDENTIAL:ELECTR SQ.Fr. STOI2165 TYPE CONS'IRIK:'TION' G as owner of the proporty,or my employees with wages as their sole co/Rp--z 7t morin Bothework andthestiudureh Contractors or offeredfor ss.��11 (Sec.70dy Business and Professions Codr.The Contraders Llcerue Law �pp11 $ docs not apply to an owner of property who builds or Improves thereon,and F-5^ who doessuch work himself orthrgh his own employees,provided that such OCC.GROUP RFS.UNTTS w Improvements are not Intended or offered for sale.If,however,the build Ing or TOTAL: - Improvement is sold within one yearo(completion,the owner-wdderwlll have t rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE owner of the FLOOD ZONE APN I,as ocoproperty,oro.704F,Business =trading licensed PERMIT ISSUANCE TheConcontractors to construct the w do (See.appy Business and of property Code: The Coor inni 's License law aces nor apply ct an owner d property who ALTER-DRAIN&VENT-WATER(IA) Wild. a improves thereon, and who malum for such p(ojecb with a FEE SUMMARY evywador(eexempt under Sm.tothe Contractor's License Law. gpIX FLOW PROTECT.DEVICE LII am exempt under Sec. B &P C for this mason DRAINS-FLOOR ROOF,AREA,GOND. SANITARY - Y_ N_ Owner Dae RECEIPT If T r WORKMAN COMPENSATION DECLARATION FO(IIJRFS I'ER'IRA['' SCHOOL TAX Y_ N_ �Mf hereby affirm that I have a aertlBote of consent to self-insure,or a RECEIPT N 4 w Zdifate of Workers'Compensation I vurance or a certified copy thereof(Sec. T r GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE •Y_ N_ �r'lghj� Polis Lab C.)Y RECEPTp Ca GAEA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES - Com any ' cGAS EA. copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE Certified copy b filed with the city Inspection division. CERTIFICATE OF O(EM PTION.FROM WORKERS' CREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200Fr. Date RCceipt# (Thissection need net be compld.d tithe permit isforov hundred dollars ($im)orleaaa WATER HEATER icy/VPIYr/FI.Ei7x ENERGY FEE Y_ N_ I artlfy that N the performance of the work for which this permit Is Issued, I shall not employ any person In any manner w as to become subject to the WATTR�,S. /TRGTING - Workers'Compensation laws.(California. Date PAID - z Z Applicant NEW RESIDENTIAL I'LMB. - SQ}7. Date Revel t# ZO NOnCETOAPPLICAM':ILaBermekingthls CeAgioteof ExemptWn you _ shmid become vubFct to the Workers'Compensatlon provision of the Labor TOTAL: C W Code,you must forthwith comply with such provision orthb permit shall be _BUIL LNG ••E �- deemed voked. W > reCONSTRUCTION LENDING AGENCY SEISMIC FEE CL,F3 I hereby afnrmthat mere is a contrudmn lending agency for the perform E F L TOTAL: ELECTRIC E M Z anccot the work for which this permit Is issued(Sec.3097,CIv.C.) E V O L.ender's PLUMBING EEE Name LL F Lcnder',Addmss QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE OW Icertifythat l have read thisappllationand state thatthe above Information fL. Is correct.l agreeto complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: W relating to wilding com uctlon,and hereby authotlze representative of this � Z city to enter upon the above.mentioned property for Inspection purposes. ALTERORADDTOMECH. " (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt# V agaivtliabilltiea,judgment,,cmtsandexpenx,whtchmaylnanywayaccrue . AIR HANDLING UNIT(ro lo.ow GEM) SUBTOTAL: against said City in onsequence of the grant ing of this permit. � � a let?— AIR HANDLING UNIT(OVER I B"CIII CONSTRUCTION TAX SI#(iaty Applont/Contra r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfunme building occupant store or handle harardous }IFATING UNIT CM BTU) Date RCCei material as defined by the Cupertino Municipal Code,Chapter 9.17,and the I lealth and Safety Code Section 2SS32(a)t HEATING UNIT(OVER 100,000 BTU) TOTA ❑Yen , M No . . Will the appllant or future wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE which rout haurd.us air contaminants as defined by the Bay Area Air ♦c'+�»-y9 Qu a llity Management D�klWdM 7 BOILER-COMP -E'OR1fl0,IXp BTU) ►9 A I D Y. I�NO T'hA'c it the haze materials requirements under Chapter G95 of BOILER-COMP(OVER 100,000 RTU) the C.lQornl i Health&Safety Code,Sections 25505,75533 sad 25534:T 9 JAN 03 1992 understandthatifthebuildingdoesnotcurrentlyhaveatenant,thatItfsmy NEW RMDfi-MALMECH. SQJT' responsibility to notify the oro pa in of the requirements which must be met - priortolasuanceofaCertificateof Ocmpa ncy. /�, •' Owner or auihodsd agent Date TOTAL: ISSUED ,G OFFICE COPY