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HomeMy WebLinkAbout23592 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Protect Identification - PIgtMITNO. Building Address: r�► c �E ��- f. 23592 nera ante: 4iS one: A A A ipc7 CITY OF CUPERTINO-BUILDING DIVISION Contractors Na : ^A Lie.No: APPLICATION / PERMIT QLA -1_Y .BUILDINGELECTRICALMUMBING-MECHANICAL CATEGORY CONTROL# Architect/Engtneee Lic.No: ` I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO jPLUMB sl[�H Address: lo� 61% Vt 6ajfhot' PERMIT ISSUANCE ❑ a ❑ LICENSED CONTRACTOR'S DECLARATION LF Hadbyafflrm that l am licensed under provisions of Chapmr9(manderadc, APPUANCESRESTDENTIAL JOB DESCRIPTIONIngwith Section7000)of DMa.3ofthe Buslnnsand Profess emiCode,and my license Is In full forceand dfect. PANELS License Chw Lic.0 t 1 Date Contractor UP TO 2DOAMM ARCHITECTS DECLARATION - 201-1000 AMPS 76 in I understand my plashall be used as public records OVER 1000 AMT'S SQ.Ff.FLOOR AREA - $/SQ.Fr. (Cj Licensed Professional SIGNS ELECTRICAL 6 OWNER-BUILDER DECLARATION SPCCIALCItCU1T/MISC L, 7. Thereby affirm that l am exempt from the Contractor's License law for the 7 0 following reason.(Section 7031.5,Business and Professions Code:Any city or county which requ ices a permit to construct,alter,improve,demolish or repair TU'1P'M=ORPOI.EINST. . `'0 anyatrottum priorm its heuance,also mqulresthe appliont larsu<h permltm POWER DEVICES rc V file a signed statement that he V licensed pursuant to the proWlov of the Contractors License aw(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC SVALUATION OS alon3ofthe Bualnessand ProfmiovCode)orthatheisewmptahemfmmand i the basisfor that alleged exemption. Any violation of Scdlon 70315 by any OUTLETS-SWITCHES-FIXTURES applicantforapermlteubjectatheapplicanttoacivilpevltyofnmm mth n ©^s o Ove hundred delhn(fSOV. I as owner of lproperty, employees with wagesas their sole NEW RESIDENTIAL ELECTR F11, kin STORIES TYPECONSIRUCTION compensation,will dothwk ands es tmeturc is na intended or offered for 3 O In(Sex,7044,Business and Posfeselov Code:The Contractors License Law [j S does not apply to an owner of property who builds or lmprovn thereon,and res^ who does each work himself or through his own employees,provided that such GCC.GROUP RES.UNITS improvements am not Intended oro(fered for sale.If,however,thebuilding or T0626 Improvement h sold within one yea r ofcompletlaR the owner-builderwill have th,ckarden of proving that he did rex build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE LJ L as owner of the prop ,am exclusively contracting with licensed FLOOD ZONE APN erty contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE The Contractors Limas law does not apply to as owner of property who ALTER-DRAIN VENT-WATER(EA) Wilds or Improveere Improves thermos,and who contracts for such pLojects with a yTactor(s)licensed punuanuo the Cootnnori License Law. FEE SUMMARY co LJ 1 am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE DRAINSH.00IL ROOF,AREA,GOND. SANITARY Y N_ ® Owner ECL RE)C=# WORKMAN COMPENSATION DECLARATION Fa.�S PER TRAP SCHOOL TAX Y_ N_ ❑T hereby affirm that I have a lmurate of consent to.pytheum,ora RECEIPT N 38W,Lab ofWmken'Compevatlon Wurance ora certified copy therto(f5ec. GAS PA.SYSTEM-1 INCA OUTLETS PARK FFR Y N 3BlA,his C3 Ib11ryN a ------ RECEIPT# C❑CnGAS EA.SYSTEM-OVER BUILDING DI V ISI ON FIT ES edified copy b heed With the city GREASC/INOUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy h flied with the ed.inspection division. CERTIFICATE OF IAEMITION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE SEWER -STORM EA.MOFT. ,Date Remi t# Rhlssettlon need not be completed if the perMt V(Drone hundred dollen (f100 difyt J WATEITIIEATEE W/VENT/ELECTR ENERGY FEE Y N I ll not that o the piro on Is a of the work.as t b thh penult is Mooed, 1 shall not employ any perws 1n any manner n as to become subject to the WATER SYSTIM/TREATI G Worked Compensation hsvi of California.Date PAID O Z NOTICE TO NEWRF9DENTIALPLMB. SQFT. 'Date Recei t# ZD NOApplicant MPLICANT:If,cher makingthb Certificate of Exemption,you shwld become subject to the WorFen'Comper utlon provisions o(the Labor TOTAL: W~ W Cade,you must forthwith complywlthsuch pmvhioro orthis permit shall be BUILDING FEE > deemed revoked. IL o Crm ONSTRUCTIONLENDING AGENCY SEISMIC FEE Ihercbyaf0),farw them hacovtruction ion 3nc.3 Merv. the perform TOTAL: ELECTRIC FEE 7Z ..of Na ork(or which this permit VLssued 6ec.3097,CIv.CJ LL O lender'.Name PLUMBING FEE LL F Iendels Adder QTY. MECHANICAL PERMIT FEE MECHANICAL FEE . O W Icertify that l have read thbappleation and natethatthe above lnfonvtlon hcormct,I agree to comply with all city and county ordinances and.nate lawn PERMIT ISSUANCE FEES PAID: > S relating to building construction,and hembyauthodrempresentativesofthls F Z city to enter upon the abovcmcntloned property for Inspection purposes. ALTERORADDTOMECH. Date RCCCI t# V _ EWr)agree to sive,Indemnify an d keep harmless the City of Cupertino P against labilitie;jYdgmentscossand expenseswhlch nuylnanywayaccu, AIRHANDLING UNIT(TO 10,000CFM) SUBTOTAL: against u City In cosi uencsof a granting of this pe it. 71� GZ ARHANDLINGUN. OVERI0,WOCM) CONSTRUCTION TAX eat ea Applicant contract Date IxHADET.DOD(WIDUCT) CONSTRUCTION TAX PAID: HAp RDOUS MATERIALS DISC O' RE Will the applicant or future building occupant store or handle hazardous .EATING UNIT(TO 100,000 BTU) Date Receipt# material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Heath and Safety Cade Section 25537(x)7 HEATING UNIT(OVER IKOW BTU) TOTAL ❑ Yes r]No Will the applicant or future building occopant use equipment or devices VENTILATION PAN(SINGLE RESTD) ISSUANCE DATE Which emit hazardou.air conhmivnb as defined by the Bay Area Air D Quality Management DOtrict7 B )MEROOMP OMI'OR 100,0W BTU) m p ' Ys g❑No r M haveread ealthhe a Safety rCode, boons 25505, h5533 and 255 4. 1 of BOILER-COMP(OVQi t00,000BN) the Gli.nd h Heath[c Safety Coda Sections 25505,25533 and 75534. I 2 8 1992 undant,nd that iRhfy the ingdon of erequire entatevhL that it dart NEW RESIDENTIAL MECH.' SFT. APR presponsibilityoroatonotifytheoccupantoftherequirementswhich must be met r prior to issuance ofaCcrtilicatc ofOavpanry. tF1111V1 C!' J' Owner or authorized agent Date RUED BY. TOTAL: OFFICE COPY