Loading...
HomeMy WebLinkAbout24231 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Bulldm Prp'en Identification PERMIT NO. - BulldingAddmsr. /pr, , sca lc_ C-r. cvae,­T� . 24231 Q. DoA� gvri ZSS- 0811. sera ams: _ w,LaOaM .5g2T CITY OF CUPERTINC-BUILDING DIVISION q _Q Contractors Name Lie.No: APPLICATION I PERMIT ( � ( 2 BMDING-ELECTRICALPLUMBING-MECIAMCAL CATEGORY CONTROL M Archlted/Engineer: Llo No: 104.34 SCE+ /c CT errs , QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO, Address PERhRTISSUANCE ❑ ❑ ® ❑ LICENSED CON3RAC DECLARATION I hereby af@mthat a Bcmounder provisions ofChapte mevc- APPf1ANCESRESDEN7IAL IngwthSecon7000)pfDivslo3ftheBusinenandPro(esloneCode,andmy JOB DFSCRBs770N license Is In tuB forTPyxnd effect PANELS I b, u��l f4 Lt...Cl.. CJY Lk.N 62o 34Z (/ /`/ —UP TO 2DOAMPS �Contnctar •' ARCHITECTS DECLARATION 201-1000 AMPS q�v tuO ZpC l understand my pbre.l KII be used as public records OVER1000AMPS SQ.FF.FLOOR AREA s/gQ,FT. ZU Licensed Professional SIGNS ELECTRICAL <6 OWNER-BUILDER DECLARATION © I .Grl'c, BPECIALCFRCUIT/MLSC i.., owing yasom. that 7031mp[fro ntheossa ContradProlctor'sLl Code: Any fort he ZO ❑p�( following reason.(Smiles 7e31S,Business and Professlana Code:Anycityor C . ^❑ countywhlch requlresa permattococotmet,alter,Improve,demolish,orrepalr TEMP.METIER OR POLE INST. _ S`'0 7 anystmnure prior to its issuance,also requires the a pplicant for such permit to POWER DEVICES ) ��i I�-J 11 II U � � 4+ file a signed statement that he b licensed pursuant to the providers of the l••/ OContractor's License law(Chapter7(corturencing with Section 7000)o(Dial. SWIMMING]X]OL ELECTRIC VACUA ON 0I sion3aftheBusinewandProf.se .Code)orthathebexemptthemfmmand O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITC}ICSFTJ(TUA' Ba{ apptlant fora permit subjects theapplicant to a civil penaky of not room than piQ five hundredsowner of NEW RESIDENTIAL ELFGTR SQATF, STORIES TYPECONSTRUCTION 00 �n ❑I,as owner o!the property,or my employee with wages a their sole comp.naatlon,willdo the work andthe structure Is not Intended or offered for M sale(Bee 7014,Bunnav and professions Code:The Contractors Licerse law ESQ does not apply to an owner of property who builds or improves therms,and OCC.CROUP I UNUS who doessuch work himself or through his own employees,provided that such improvements arc not Intended proffered for sale.If,however,thebuilding or TOTAL: improvement hsold withinoneyearofcompletion,the owner-buaderwill have thVLLmrdeo of proving that he did not build or improve for purpose ofade.). Q7y. PLUMBING PERMIT FEE 14DOD ZONE APN LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE Dcontract..to construct the project(Seo 7044,Business and Professions Code Q The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) Wilde or improves there on,and who contracts for such ptojects with a cq➢Ifactor(s)Bcensed pu.uant to the Contractor's License Law. BACK PLOW PROTECT.DEVICE FEE SUMMARY I�I am exempt under Sec B k P C for this reason FEES DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N� Owner One RECEIPT R WORKMAN COMPENSATION DECLARATION '7c, SC[100L TA% Y N ❑1 hereby affirm that I have a cortificate of consent to self-invars,or 3 FIXTURES I'ER TRAP (d RFCEITTcortiN 3800, ate bo(Warken'CompewHonlnaurance ora certi(kd copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK IEE Y N Policy fab CJ Poilcy N GAS EA.SYSI'EM-OVER 4(EA) RF-CEIPT N Com any BUILDING DIVISION FEES tp Certified copy b herebyfumle city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ICI Certified copy b(lied with the cicity inspection divblpn. 'P' CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE3RAP PAIDCOMPENSATION INSURANCE SEWER-SANITARY-STOMA EA.200FT. Date Receipt (Thissenion need not be completed lithe permit ts(eros.hundred della. ($100)or las') WATER HEATER w/vExr/ELEcrR ENERGY FEE Y N certify rtify that In the pef morunce of the work for which this permit is issued, I shall not employ any person in any manner so as to became subject to the WAT[R SYSTEM/TREATINX; Workers'Compensation Lawsof Califomla. Date PAID Applicant SQJ-7, ___Date Reml t# _Z 0 . NOTICE MPLICANT:If,aher making this Certificate of Exemption,you NEW pIMB. should become subject to the Workers'Compensation provbbrs of the Labor TOTAL: N Code,you=at forthwith comply with such provisions orthis permit shall be S j deemed revod. .QUI DIN 'E W ke F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE tl C Ihereby affirm that there b a mnstmctlon lending agency for the perform- ELECTRIC FEE Z sore of the work for which this permit is bsred(Sce.3097,C1v.C.) TOTAL: �Q 02Lender.Name PLUMBING FEE 3-U IL H Lender.Addes. QTY. MECHANICAL PERMIT FEE`' MECHANICAL FEE O W Iunify that l lsvemad this appliationand nate that theaboveinformatlon IS Is carred.]agree to comply with all city and county ordinances and Mate laws PIRMUNSUANCE FEES PAID: relating to building construction,and hereby authorise representatives of this U) city to enter upon the abovementloned property fou inspection purposes. ALTER OR ADD TO MFCH. (We)agree to save,Indemnify an d keep harmless the City of Cu pert[no Date Recelpt# O against liabilities,jodgments,amts and expenses which mayln anywayaccrue AIR HANDLING UNIT(TO I0,000CFM) SUBTOTAL' against said CityIn ronsryuencp of the granting of this permit. �+a•+ 9/j`/qy AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store brhandle hazardous HEATING UNIT(TO 100,000 BTU) Date Recti t# material as defused by the Cupertino Municipal Code,Chapler9.12,and the Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BIM TOTAL; 3, 1 ❑Yes MN. Will the applicant or fatten building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSU Nf;E UkTE which emit hazardous air contaminants as defined by the Bay Area Air P f1 1 Quality Management D❑'etrict7 'BOILER-COMP OiIP OR 100,000 BTU 4 Yes d No �jj havercad Healthe h a pusCode,Sereond255nts under 5533aChapter. 1 of MOILER-COMP(OVFR100,000 BTU) SEP J-S 1992 the California at lith k Safety Code,notcione 25045,have a t and 25534. I V understand that notify the not a requirmnts tenant that It met NEW RFSIDEN77AL MECH. SQ.iR. priorto responsibilitytonotifythe occupant.ftherequirements which must be met T prior to Issuance o(a CertAificate o(Ompanry. 411iTY.,UF yUf GG1LIlYU 'AC <z e. I Ar/ z 4 Owner or aulhorlud agent Dale- TOTAL.: ISSUED BY:'`�-y� OFFICE COPY