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HomeMy WebLinkAbout24110 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification _ PEILAR.T NQ,Z 4 1. 1 0 Building Address: 2011 5.4 weer.Name: , Verna: CITY OF CUPERTTN0.6UILDING DIVISION• G° t 1 Q APPLICATION P RMIT n ra�S�lcm w 7� l : BLRLDINCELECTRLCALM BINCMFGHA CAL CATEGORY CONTROL.N � •, Architedll/�En`�glVveer. f— .SLIcbNo: QTY W ECE �Rl E'RMIT ' .il FEE! t{' Bp!LDING PERMIT.INFP Address: PERMITISSUA, + ,Uj s� IC/I ❑ ❑ LICENSED CONTRACTOR'S DECLARATION _TJ Ihereby affirm that l am ticeneed under provisions of Chapter9(cammrnc AI'PLI C DENTIAL OB DESCRIPTION inm ittcd1ul!fc, fDbtsion3otthe Busimasand ProfesslonsCode,and my license is In full(o de((ect. : Llcen�llca �/1 e Contractor 000 ops ARCHITECTS DECLARATION yj �qq�!!reO z I understand my plane shall be used as public records. OVER I — ©SQ.Fr. O FLOOR AREA SM.FT. E (s Licensed Professional - SICNSE FL CAL r G Q OWNER-BUILDER DECLARATION !uz Z� z Ihereby affirm that lamexempt from the Contractor's I icenae Law for th SPECIAL CIA 1SC \ v pO followingreason. a Pennant S,Budneu and Professions Code:Any u TEMP.# OR POLE IN rountyng res requimsapertNt to ronewcy alleq improve,demoWh,orrepair ' Y nystructurepriortoitsexuance,alsorequirestheapplicantforsuchpermitto POWER .vlcps PATE' W file a signed statement that he b licensed pursuant to the provUiore,of the 3q Comrartor's License Law(Chapter9(commencing with Section 70110)of Divi75 - VAC A - ,.�OQ slon3ofthe Buslneasand Profealone Code)orthat he lsexemp[therefrvmand NC(POOL ELE C GP?gt a•.t the basis for the alleged exemptbOUTLET&SWITCHCSFIXTURFS n. Any violation of Semem 7031.5 by any m , I A p� applicantforapermitsubjectstheapplicanttoacivilpenaltyofnotorethan I. five hundred dollars($500). NEW RESIDENTIAL ELECTR .PT. FlI,as owner of the pmperty,or my employee wfth wages as theU sole STORIES TYPE CONSIRIICTION 5>< compensation,wlll clothe work and thestructure is not intended or offeredfor �n sale(See.7044,Business and Professions Code:The Contradoes License Law does not apply to an owner of property who builds or improves thereon,and OCC.GROUIa. R(S UNITS who does such work himself°rthrough his own employees,provided that such Improvementsare not intended oraffered forsale.](howceer,lhebulldlegor T T improvementbsoldwtthlnoneyearofcompletiogtheowner. uilderwill have . t1'9jNrden of Freeing that he dm not build or improve for purpose of sale.). QrY. ,�' �1',..'PLUMBING kIlM1T,,i .�' ,',!FEE it FIADD70Ne nPN . u L'as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contrado s to construct the project(Ser.7040 Business and Professions Code: 'Me Contractor's License Law dues not apply to an owner of property who ' 1 - builds or Improve thereon, and who comrade fee such pAo)ects with a ALTER-DRAIN V - roec pp((((actor(s)Bcented pursuant to the Contractor's License Law. t� , I 'iFEE'SUMMARY,. E31 am exempt under S . B&P C for this reason BA PROTECT.DEVIC 1 i SANITARY Y_.N Owner Date D S>F[.00$ROOB, v RF 'I X WOR KMAN COMPENSATION DECLARATION FIXTURES PHR TRAP tOOL TAX Y_ N_ ❑ ffi I hereby arm that I have a certlBute of cement to self-Insure,or a SCIRFGEIPT B cenifiuteotWorken Compematlonimuranu ora comfled ropythereof(&c. GAS FA. 'b-I'FM-1 INC.0 OUTL PARK FFE Y N 3800,Lab C.) Policy 11 RECEIPT.a_ Co GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISJbNFE ES - - IBed ropy Is hereby furnished.Certified WASTE INTERCEPTOR PLANCHECIC FEE Certified copy b filed with the city inspection division. - eI GREASETRAP 1 l • CERTIFICATEOF EXEMPTION FROM WORKERS' pAlp COMPENSATION INSURANCESEWER-SAN)TARY-STORM G.]00FT. Date RCCCI [N (This section need not be completed if the permit b for one hundred dollars ($100)orlemJ .' . ]unify that In the performance ofthework torwNch this permit isbsued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING z Workere'Compen®tme laws of CalBomla.Date - PAID - .. ZZ Applicant NEW RESIDENTIAL PLMB. SQ,FL O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Hshmld become subject to the Workere Compereatmn provieioine of the Labor TOTAL: N . Code,you most forthwith comply withsuch provigmescrthls pFinatshall be BUILD f deemed revoked. LU CONSTRUCTION LENDING AGENCY $EI •E. _` I hereby affirm that there lea construction lending agency for the perform- TOTAL: EL CFEE Z once of the workforwhich this parent bLxwed(Sec.3097,CIv.C.) ' O O Lenders Name - PLU NC FEB r Lendersnidmee QiY. MECHANICAL PERMIT`! .' FEE,ii LL MECHANICAL •E O W Iced.I hatlhave rcady with all city that ordina cess and tim laws IL cured.Iagreeto complywlth alltltyand rountyordlnanres and rtalelawe PERMIT ISSUANCE FEES PAID: } Z elating to building construction,and hereby authorize representatives of this ' H. city to enter upon the abovomentloned property for lnepedlon purposes. ALTER OR ADD TO ME- H. _ (We)agree to save,indemnify an d keep harmless the City of Cu ped Inn Date Receipt# ago Inst liabilities,pcigrrents,mks and expenses which may in any wayaccrue AIR HA NDLING UNIT(TO 10,000 CFMj S JBTOTAL: against said City in consequence of the granting of this permit. AIRI{ANDLINGUNIT(OVER 10,000CFM) CONSTRUCTIO TAX Sig of Appllren[/Contractor Date E(HAUSTHOOD(W/DUCT), CONSTRUCTIO TAX PAID: HAZARDOUS MATERIALS DISCLOSURE - _ rWill the applicant or future building ompant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ec6i t# .1000 'material as defined by the Cupertino Mu nlcipal Code,Chapter 9.12 and the - Health and Safety Code Section 75531(.)7 HEATING UNIT(OVER 100,000 BTU). O Q Yes ,L+_—,1,No • Will theappllunt or 2lure building mmpant use equipment or devices VENTILATION PAN(SINCLE RESID) ISSUANC DATE which cent harandous air contaminants as defined by the Bay Area Air - x Qua lily Management Dist dd7 BOILER-COMP OHPOR 100,000 BTU) A ' L 4hYes d No ave read thehazar esus materials rcqulrementa underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) QCT] n•I q(]Q the California Health&Safety Code,Sections 75505,25533 and 25534.1. SEP 21'.1992 understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.1"f. ^ nspernbility to notify the occupant of the requirements which moat he met 1. prior to issuance of a Cenificate of Occupancy. �a�'� CIl Y UI- GUrcn l H�: Owner or authorized agent Date - ISSUED BY A TOTAL: OFFICE COPY