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HomeMy WebLinkAbout22713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Pm'm IdenH(I.tion PERMIT NO. Build in Address: 2271 3 o Owner's ams nG one: A w � rte/ i3� CITY OFCUPERTINO-BUILDING DIVISION c, c ntnnnr' .No: APPLICATION /PERMIT ova 171.� BULDINGEL, TRICALML BING-MEC LAICAL CATEGORY CONTROL# to /En neer. Lk.No: QTY ELECCRICPERMIT FEE BUILDING PERMIT INFO Addceas: PERMITISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby.affirm that l am licensed under provisions of Chapter 9(cemmenc- APPLIANCES-RESIDENTIAL JOB DESCREIIION tngwith Section7000)Of DiWslon3ofthe Bminesaand ProfessioraCcalC and my licenseisie a effect. PANELS y ��� License Cha Lic.N �O v l/(�—�11` Date//f/ "�_Y_- ( Contractor_ ARCH ITECFS ECLARATION 201-IODOAMIS �ppu 9z I understand my place shall W used as public records OVERI000AMPS SQ.IT.FLOOR AREA S/SQ.FE W Z Licensed Professional SIGNSELECTIUCAL T q © ' OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C J M Lo., Ihercby affirm that Iam exempt from the Contractor's License law for the ' U 70 2 following reason.(Section 7011.5,Business and Professions Code:My city or TEMP METI R OR POLE INST. �,J T E R t"' cauntywhlch requiresa permit tocenstme,alter,Improve,denonish,or repair Y anystmc mprlortolb Lsarame,aLsorequirestheappBcanlfwsuchper tto QYmpy POWER DEVICES E.µ•o (Ilea signed statement that he is Licensed pursuant it the tion 7000) of the ' 3µG go.3.ft a UceceeLaw(Chapter9(cerurenctnt elswitSection7000) ..d SWIMMING hgNG POOL ELECTRIC DA it _.AL ON O slon3of the Buslncmand Professions Code)orthat hebexempt thercfromand Sm S the basisfor the alleged exemptton. Any violation m(Sectlon 70315 by any rore OUTLE1SSWITCFIFSFlXTURES applicant permit subjects the applicant civil penalty of nor than five hundred dollars($51)(1). 1 FT. ❑1,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION �7 compensation,will do the work and the structure is not Intended or offered for 0 sr le(Sec.7044,Business and Professions Code:The Contractor's Llceme Law j $ does not apply to an owner of property who builds or Improves thereon and OCC.GROUP RFS UNITS µ's^ who does suchwork himself or through hisown employees,provided that such improvements are not Intended oroffemd forsale.If,however,thebuildingor TOTAL: Improvemant Lssoidwithin oneyearofcompldbMtheowner-buBderwill have tfIt,burdenofprovingthathedid not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN L�L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE centradon to construct the project(Sec 70K Business and Professions Code: The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN VFM-WATER(EA) Wilda or Improvm rcmn the , and who contracts for ouch projects with a FEE SUMMARY rynt.[ Licenseaw ad.,(.)licensed pursuant to the Contractor.License l . BACK FlAWPROTECT.DEVICE LJ I am exempt under Sec B h P C for this reason OUTSIDE FEES DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y_ N_ • Owner Date RECEB' WORK MAN COMPENSATION DECLARATION FLXIlIRES PER TRM SCHOOLTAX Y_ N_ ❑I hereby affirm that 1 have a certl0ate of consent meet(-Insure,ora I RECEIPT N certificate of Workeri Compeceatlon[nsuravce ora certl(4d copythereof(Sec. GAS EA.SYSIFM-1 INCAOUTLETS PARK FEE Y N 3800,Lab Q REC=N Policy N Com ny CAS PA.SY9HM-OVER 4(EA) BUILDING DIVISION FEES �a Ca Ified copy Is hereby furnished. GREASE/INDU5ML WASTE INTERCEPTOR PLANCHECK FEE RKcdillcd ropy Is filed with the city impaction division. �1 CERTIFICATE OF RI(EMI'FION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWTXSAMTARY.STORM EA 200FTq Date Recti t# Qhissedion need nal hu completed lithe permit h foronc hundred dollars ($10(l)ories.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ Ie, ifythat In the performance of theww k for which this permit is Issued, 1 shall not employ any person In any manner so As to become subject to the WATER SYSTEM/TREATING Workers'Compensation Lawsof California. Date PAID 0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date RCCCI t# Z U NOTICE TO APPLICANT:If,after making this Certificate of Exemption,You should become subject to the Workers'Compensation provisions of the Labor TOTAL: W Code,you=at forthwith comply with such provisions orthls permit shall be BUILDING FE CC devoted revoked. W a CONSTRUCTION LENDING AGENCY SEISMIC FEE d Ihercby affirm that there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE M Z ante ofthe work forwhichthis permit b Issued(Sec.3097,Clv.C.) 00 Lender.Name PLUMBING FEE U. Icndar'sAddrcss QTY. MECHANICAL PERMIT FEE MECHANICALFEE b�a U I certifythat l have read this appBation and gate thatthe above information 0 W bencrect.I agmatococeplywlthallcily and ceuntyordmamcesand statelaws I PERMITISSUANCE aU FEES PAID. } M relating to building construction,and herebyauthoriaercprcsentativeso!this F Z city to enter upon the above-mamioned property for Inspection purposes. JALTERORADDTOMECH. Date Receipt# V _ (We)agree to save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UMT(TO 10,000 CFM) agaWt lbbllties,judgments,notes and expenses which may in any way accrue SUBTOTAL: _ against-­7 'ty in nseJ)u the gra ming of this pertnitin neglu the grassing of this permit. P/ AIR HANDLING UNIT(OVER IO,WOCFMI CONSTRUCTION TAX //— 9/ CONSTRUCTION TAX PAID: Signamreof AppBom/Cant r Date FXFLIUST HOOD HAZARDOUS MATERIALS DISCLOSURE Will the appliam or future building occupant Wore or handle havrdous HEATING UNIT(T0100,W0 BIIq Dale RCCCI t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilealth and Safety Cade Section25532(a)2 HEATING UNIT(OVER 100,000 BTU) ,OU TOTAL: •UQ ❑ Yes M No Willtheapplicant or foram Wilding occupant use equlprmnt ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE which emit hazardomair cant.MAantsm defined by the Bay Arca Air p Quality Management District? BOILER-COMP(3HP OR 100,0(9 BTU) S�N1 A I D 4Yea nn No h.veread the hazarQusmaterials requiremenisunder Chapter 6.95of BOILER-COMP(OVER IM,000 BTU) the California Haith&Safety Code,Seatom25505,75533and2S534.I = 7 1991 understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. PT NOV SQ. ropomlbility to notify the occupant of the requirements which must be AwlpriormLssuance catsCertificate of Occvpanry. CIIeY IFVY `..rttflINIJ Owner or authorized agent Date TOTAL N /�/x ISSUE DBI: V• •` Vaa-x OAG V OFFICE COPY I �