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HomeMy WebLinkAbout23874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification PERMITNO. Building Address: 23874 3 8 7 2v33 is✓��yoo �✓F. G3 SF C; Se' /cf/J✓may Ilemend CITY OFCUPERTINOLBUILDINGDIVISION A A A contvaora Name: Llc.No: APPLICATION / PERMIT _ BUILDING-EL. TRICALI'LUMBING-M HANICAL CA RY CONTROL Architect/Engineer. Lie.No: pl `_ QTY ELECI'RICPERMIT FEE BUILDING PERMIT INFO Address. /dX e�g';O do J,J �f/j PERtATI55UANCE D'D 1"� ❑ LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am!lend d under provisions of Chapter 9(commnt, APMANCESRFSTDENIAL JOB DESCRIPTION ing with Section 7000)of Division 3 ofthe Business and Professions Code,and my license 1,in lull f and effect. PANELS License Cls LIc.M o1.�-3 4. Y. Date > Cor 201-1000AMPS ARCHITECTS DECLARATION 5/SQ w0wa Z I understand my plan shall be used as public records OVER 1000 AMPS SQ.ET.FLOOR AREA Licensed Professional SICNSELECTRICAL /A� op 6 S OWNER-BUILDER DECLARATION x u `1 L� E © IN 7p 4' I hereby affirm that!am exempt from the Contractor',License law for the SPECIALCIRCUIT/MISC nab I,`//1� ;pI _ following reason.(Section 7mI5,Business and Profession Code:Any city or -�,1 II V J P U � E R OZ,i...8 county which require a permit to construct,alter,ionrepairTI]c1P.METFR ORIOLE INST. F S prior provntfors ch,gr .9 any awcturctatemeIts hissuance,t heir alw reed pursuant t the lorsucen,of to )OWER DEVICES 3 file a signed statement that M is licensed pursuant to the proallov of the [Oil rc Contractor's License Law(Chapter 9(mmmmeing with Section 7000)of Diel- SWIMMING POOL ELECTRICL DAT gO sion3 olthe Business and Pmf. uCode)orthat hebesempntherefromand VALUA]�ON 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCIiFSHKTURES applicant lots permit subjecatheapplicamtoa civil penalty girt rroretha c o five hundred dollars($500). C7¢ OI,as owner of the property, my employees g NEW RESIDENTIAL ELECTR $TORIES nation,wllldolhwrand thestrocture is net W Wended or offered for �� TYPE CONSTRUCTION 9 ❑ sale(Sec.7044,Buslne,sand Profession Cade:The Contractor's Llceve law (jy$ does ndt.ppIytoanowmsner of property who builds orlmprovestherece,and . 0.0. who deassuchwork hielforlhrough hisown employees,pmvidecithatsuch OCC.GROIIP RESUNITS improvementsarenotlntendeorofferedforsale.If,however,theWildingor TOTAL: -� Improvement ftsold within ane year olcompletion,the ownsebullderwill have thEydn of proving that he aid not baud or Improve forpurpenco!sale.). QTY. PLUMBING PERMIT FEE }Tppp ZONE ApN Ll L as owner of the property,am exclusively..trading with license ER ' PMIT ISSUANCE 0 D retractors to nntmn ct the project(Sec 7044,Business and PrafessioCode: The Contractors License!aw it.Ra apply in an owner of property who ALTER-DRAM k VENT-WATER(EA) Wilds or Improves thereon,and who contracts for such ptojects with a elttf leor(,)licensed pursuant to the Contractor's License Law. - FEE SUMMARY IJ I am exempt under See B k P C for this reason BACK FLOW PROTECT.DEVICE • Owner Date DRAWS-FLOOR ROOF,AREA,CONE). SANITARY Y_ N_ WORKMAN COMPENSATION DECLARATION RECEIT`y X ❑I hereby affirm that I have a certificate of consent to sof-insure,or a FveTDRES'PER TRAP eJ b SCHOOL TAX Y_ N_ certiRcateofWorkers'Compev tionlvuranreoramnifiedmpythemof(Sec. RECEIPT# 3800,lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Policy X RECEIPT X Cam any GAS EA.SYSTEM-OVER 4(EA) ffCertlfie Copy V hereby furnished. BUILDING DIVISION FEES ❑Certified copy 6 filed with the city inspection division. GREASE/WrIusI T,WASTE INTERCEPTOR PLANCI-IECK FEE CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER SANITARY (Hussecionneed not bee mplete tithe permit bforomhundred dollars STORM EA.200£7. Date Recei t# ($1 I carifess.) WATER HEATER W/VONT/ELECTR ENERGY FEE Y N [certify that in the performance of work for which this permit Is issued, — Ishall not em 12yp7ry'peraBx*any manner so"47 t b come ct to the WATER SYSTEM Woprkers'Cg mon]efyyQi nmla.DaX o7s y /TREAnNe PAID O Z A Bean //�/d-rl_C_—..� _Z O NOTICET�i'APPLICANT:f,after making this CertRlcam of Exemption,you NEW RESIDENTIAL"B.__SQFL Date Recei t# should become subject to the Workers'Compensation provisions of the Labor~ TOTAL:N Code,you muat(orthwith amply with such provisions orthb permit shall be / _u0 W > deemed revoked. BUILDING FEE CL p CONSTRUCTION LENDING AGENCY SEISM IC PEE Thereby a(0 mi that there b a construction lending agency forthe perform- ELECTRIC FEE fT Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: B LL O !Lender's N. PLUMBING FEE a d p ly 0 <eers Ada ss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W IcenlfythaH have read thlsappBcatlonand statethatthe aboveinformation bcorrect.building complywith ofcity reb countyienropme,and gatelawsPERMITLSSUANCE FEE$ D: �Dq } N relating roI agree ngcovUucilon,and Wrebyauntyoercances and gae laws Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. V — (We)agree to save,indemnify an it keep harmless the City of Cupertino Date Reccipt# against liabilities,judgmenta,costsand expenses which may inanywayacaue AIR HANDLING UNIT ITO 10,000 CFM) against said City In consequ once of the granting of this permit. SUBTOTAL: AIR HANDLING UNH'(OVER 10,000 CFM) CONSTRUCTION TAX Signtureof Applicant/Contraagr Dale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) ruterialas defined by the Cupertino Municipal Code,Chapter 9.12,and the Date ReceI t# I Inalth and Safety Code,Section25532(a)? HEATING UNIT(OVER 100,000 BTU) ❑Y TOTAL: Will the a ❑pplicant orfuture building occupant use equipment or devices VFNIILATION FAN(SINGLE RESIU) ISSUANCE DATE which emit haeardous air contaminants as defined by the Bay Area Air q • QualityMangement QNo BOILER-CDMP(7HPOR100,000BTW r A D 4Yea ❑No have"adtheh dousmterabrequlremmsunderChapter6.9iof BOILER.COMP(OVER 100,OWBTU the California I loalth k Safety Code,Sections 25505,25533 and 75534. I JUN 22 1992 u odersla ed that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT responsibility to notify the occupant of the requirements which most be met prior to Issuance of a Certificate of Occupancy. _ C1 T jr CUPCT1111VV Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE COPY