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HomeMy WebLinkAbout24302 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERhIThQ 4 3 0 2 Building Address: 2106. (LF �T, atlrasp�me: �7 ? one: A - - , CITY OF CUPERTINO-DUILDING DIVISION G.rtm �ams: Lie'Nn: APPLICATION if PERMIT D -ass, �Z-- U BUILDING I ECTRICALPLUMBINC-MECIIAMCAL CATEGORY CONTROL If Architect/Feglneen Llc.No: t,..' Q'iY ELECTRIC PERMIT FEE ,, BUILDING E ` PERMIT.INFO - a ' I Address - - PERMHISSUANCE 1:1 ❑ ❑ LICENSED CONTRACTOR'S DECLARATION Ly Iherebyaffiren that l am licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL ]OB DESCRIPTION 'ngwith Section 7000)of IAvision3ofthe BusinemandProfeselonsCode,and my license is In fullforce and effect. - PANES 4 Data CUm ontr � OANU ��, Sky L,-`fiB-S Date Contactor ARCHITECPSDECLARATION 2014000 AMPS as C20C co sh I understand my phaall be used u public records. OVER IOOO AMPS SQ.Pf.fTAOR AREA $/SCS.FT. U Licensed Professional - SIGNS ELECTRICAL r OWNER-BUILDER DECLARATION SPFDLILCIRCUIT/MLSC ® IN 7� IhercbyafOrmlhatlamexemptfrom/he Contrdctoe.Lirenanueaforthe _ qqq following reason.!Seaton7all S,Businessand PmfemWns Code:An ct or IF R F =ntywhlchrequlresapermlttommtmct,altegimpmve,dennlLh,orrepalr TEMP.METER ORIPOLF.INSf. j V tl-� q�y aeystructure priorto Its Issuance,alsorequires the applicant for such pernetto POWER DEVICES I II f]CO file a signed statement that he V licensed pursuant to the provisions of the ' FWj CoMe.corb Llceme Law(Chapter 9(commentlngwith Sen1on7000)ofDlvl- �OS sion3ofthe Buslnemand Profemiom Code)orthathelsesemptthercfromand SWIMMING POOL ELE C VU� ATOfJ,�a� the basis for the alleged exemption. Any violation of Section 70315 by any C'/�� 6 OU LETSSWITCH6SRANRES w �. ape hu ndreda peaM($500)Rs the applicant m a civil penalty of not marc than five hundred as owner of he pr. NEW RESIDENTIAL ELECTR STORIES - TYPE CONSTRUCTION I,as owner of the �,IT. �n property,ormy, employees wmpematlon,will Bothe work andthe structure V nes Intended or offered ler �O In(Sec.7044,Buafneas and Professions Code:The Contnctor's License law r3'$ doesnotapplytoanowner ofpmpertywhobulidaorimproveathe.,and OCCGROUP RES.UNITS EEEE who doeswchworkhmeself orthrough hlsown employees,provided that such improvements am mt lnlended oroffered formle.If,however,the building re TOTAL: Improvement baoldwlthlnoneyearofcomplMiogtha owner-bullderwel have ' 1, en as neerprovingof the prodid perty,am build orImprove for purpose. sale3. QTY, i „ PLUMBING'PERMIT'"„� •FEE )' FIDODZONE APN I,oe owner tr the property,am exclusively Business andcontracting with Is Code: PERMIT ISSUANCE ntnctore to ro LI..the project(sec,apply Business and Professions pro ons Code: Coor imper Uttme law does eat apply tct an owner p property who ALS-DRAIN k VENT-WATER(EA) on do or Improvwd pureon, and who contracts dors for such p�ojem with a FEE SUMMARY( ,,IltRSfIactor(e)Baneed pursuant to the Contnpor's Llrensa Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B k P C for this mason OwnerDate DRAINS FLOOR RODF,AREA,COND. SANITARY Y_ N RECEIPT It WORKMANCOMPENSATIONDECLARATION P ❑l hemby affirm that 1 have a rertiBcate o!consent to self-iIt mora F1K771IIF_S ER TRM SCHOOL TAX Y_ N RECEIPT tl rertiao(Workers'Compensatlonlmunnttora rerci(led copythereo!(Sec. GAS F.A.SYSTEM-]INCA OUTLETS 3800,,Lab CJ PARK PEE V N Policy p — RECEIPT p Com any GAS-EA.SYSTEM-OVER4(EA) - BUILDING DIVISION FEES” [rCehifled copy is hercbyth the icy GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE ❑CedlOed copy V filed with the city inspection division. CERTIFICATE OF EXEMPTION FROM WORKCRS' CREASETRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2DOFT. 'Date Remi t#- Uhbsectlon need not becompleted Nthe permit b forom hundred dollars (5100)orly that WATER HEATER W/VENT/ET-ECTR ENERGY FEE Y N_ ]certify thatoy an persnInanerformance fthewnerse,ork whichtmensshis mject t theed, I shall not employ any Laws In any manner at as to become subject to the WATER SYSTEM/TREATING ' Workers Compensation laws of California. Datc PAID . Z Z Applicant Z0 NOTICE boON'PLTCANT:e ager making lMsCerdfkateisions Exemption,theLyou NEW RESIDENTIAL PLMB.__SQXT. Date Recei til F Code, oumos eforth it the Work an'Comprovisio provisions permit s Labor be TOTAL: W Code,you most forthwith comply with each provisions orchis permit shall be I DIN LU j deemed revoked. W — CONSTRUCTION LENDING AGENCY SEISMIC FEE C FEE a O Ihercbyvc,kfthalthem becomtmcbulending agency for W,Civ.C.) perform ELECTRIC FEE � 0 once a(the work!or which this perMtis Issued(Sec.3097,Civ.CJ � TOTAL: L) Lender's Name PLUMBING FEE LL h Lender's Address QTY. }'" MECH_ANICAI.PERMIT•"� '' ;'FEE']. MECHANICALFEE O W orIrertifythatl havereadthbappllatlonand statethatthe abovelnformsams crect.I agree to comply with all city and county ordleances and pate laws PERMIT ISSUANCE - FEES PAID: 1 } reladngtobullding construction,and herebyauthorize repreacntativesofthls Zcity menter upon the above-mentbmd property far Wpectlon purposes. ALTERORADDTOMECH. Date RCCCt tq — (We)agree to save,Indemnify and keep harmless the City of Cupertino against llabilltMa,pdgments,ceps and expenses which may In any wayareme AIR HANDLING UNIT CFO 10,000CIM) SUBTOTAL: agzimt Id Clty lnwnsequenanof}}h nting of this peen I. Y P a AIRHANDIJNG UNIT(OVER I0,000CFM) CONSTRUCTION TAX gmturc of Applicant Contractor Dat EKHAUSTHOOD(W/DUCT). CONSTRUCTION TAX PAID: HAZARDOUS MATCRIALS DISCIASURE Will the applicant or future building occupant store or handle hazardous HEATINGUMT(TO10),"11TU) Date Recei tN material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - �_ .w Ilealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,0(10 BTI)) TOTTi ❑ Yrs M No Wiiltheapplimat orfuturebulldingoccvpant us,equlpment ordevices VFNTILATION pAN(SINGLE RFSID) ISSUA whichemnts il hardousai,cmtaminanasdeMed bythe Bay Area Air NCE DATE PS A Quality Management Dutdct7 BOILER-COMP©EN OR 100,M BTU) P IV ❑ Ym n(�Nv . Ihavc read the hazar�souaroatcrlals requlrcments under Chapter 6AS.f BOILER-COMP(OVER 100,000 BTU) ' OCT . _ the Glifornla ITealth k Safety Code,Sections25505,2,5533 and 255M.1 understand that if the building docs nor currently have a tenant,that it is my NEWRESIDENTIALMECIL' SQ.FI' J� responsibility to notify the occupant of the requirements which must be met prior to issuance of aCertlfkateolOccepanry. } CITY Ufa\r.-�gC.(��IYy`l.�fT111 Owner or authorized agent DataISSUED BY: v`-'J�/ ^/ TOTAL: OFFICE COPY .