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HomeMy WebLinkAbout20932 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — US ;841AL POINT PEN ONLY Building Ism eat Identification' - PERMITNO. Building Addrenn: BLVD" (i J� 2 0 9 3 2 re ante. e: - 4 - A CITY OF CUPERTIN0.6UILDING DIVISION �/ i actor's Name: I APPLICATION I PERMIT — BUILDING-ELECTRICAI.PLUMBINGMECHAMCAL CATEGORY CONTROL X rchltect/Engineer. Lk.Na .QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add. PERMITISSUANCE ❑ ❑ (� LICENSED CONTRACTOR'S DECLARATION I herebyion7Dthat)am licensedunderprovisions Pmfmlpler9(ead APPUANCESRESIDENI7AL ^ TOB DESCgRRI��p��pppp�y �.a. ingwith SIR 1000)ot Dielf.173ofthe Inensan Pro/eulonsCode,and my •L B= is In e(lecL- PANUS Limn C Llcp ' Date Cantnctor RCHITE ECLA 1 701"000 8 0 Z l understand my plaru shag be usedes v public records. C V i PS FT.FLOOR AREA $/SQ.FT. qO N(/ Licensed Professional C lnQ LG7 OWNER-BUILDER DECLARATION ]AL T/ - ) pp�s�s� Iherebyaffrmthat l am exempt fmm the Contractors License law for the g..t 7p following manon.(Section 7(115,Business and Professions Code:Any a ty or "' " ''' '• 'a• \\ O y i.., TEMP.M POLE INST. �� muntywhich requlmsapemNt to construct,alter improve,demnith,or repair qqp�y S any structure prior m its became,also requires the applicant for such permit to POWER EVICES VI'saC f5 file a signed statement that he Is licensed pursuant to the provisions of the 06 3 u, Contnctorb License Law(Chapter 9(commencing with Section 7000)of Dlvi- !�n SWIMMING POOL ELECTRIC thesIobusfthe the usiness Femption. Any)viothat lation (exempt therefrom and VALUATION 6 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHES-FIXTURES O (We hundred unreddeea.($50 jeMtheapp8canttoativll penaltyanamorelhan live hum s owner of hepr. NEW RESIDENTIAL ELECTR SQ.FF, STORIES TYPECONSTRUC'HON p, m I,as owner of the property,or my employees with wages r their sole C compensation,will do the Business and Professions Code:e EA The Cn intendedo License ed for Law 5 O sale(Sec.apply Business property Code:The or Improves threose law does notapply torn owner of property who builds orImprovesthereon,and hat such OCC.CROUP RIS.UNITS 0.0. who doessuritprovemnts Am net mself or dedorwgh Meown employees,p ,the b ilding or Improvements arenot Intended earofred for sale.11,however, deer ill have TOTAL: Improvement(mid within M did not ttcompor Improve for prposerwillhave the burden owner ing of the p he dm nabexcl or vnpmve for ting with licensed cQTY, " PLUMBING PERMIT FEE FhOp MNNE ppN Ltr[as owner tr the property,am.7044,Busively coness nd Pro with sCode: PERMITLSSUANCE TheconContract mnatmn the L project set apply Business and Professions who 'Wil Contractor's Improves; L;(herst,Law don ash apply to an owner a property who ALS-DRAIN&VENT-WATER(EA) Wilds or Imprwn thereon,and what mntnab (a wN p�ojecta with a gNfactor(a)Ikensed pursuant to the Contractor's License Law. FEE SUMMARY o LJI am exempt under Sec B&P C for this reason gpQg FLOW PROTECT.DEVICE OUTSIDDRAINS-FLOOR ROOF,AREA, SANITARY Y N_ Owner Date RE-CERrT X s� WORKMAN COMPANSATION DECLARATION FDTIURFic PER TRAP SCHOOL TAX Y N �(II hemby affirm that 1 have a mrtilicet of consent to opy mare,ora RECEIPT'N c ifinteo/Worken'Compereatlan��ln11suranm certlfled copy thereof(Sec. CAS EA,SYSIiM-1 INCAOUTLEI'S PARKFEE Y N 3800.Lab CJ — 11 —© Pdi M T CAS EA.SYSTEM-OVER4(EA) DING DLIV Comany_ /�X BCKFEGDIVISIONFtES Certified copy ll�(witth the d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK PEC ertlfied copy t filed with the tlty Irupecd II division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID COMPENSATION INSURANCE (Thlssetonnoed not becomplumd Bthepermit tforonshundred dollars SKIVER-SANITARY-STORM EA.200FT. Date Recei t# (811 nitythat in) WATER HEATER W/VENT/LLECTR ENERGYFEE Y N (certify employ any personhe i anye of lmanhe work so As to become eemnle t to the I shake not employ any person in any manner at v m become aubjea to the Wmrkenntl 'Compenon Laws of California. ATER SYSTTIM/ la.Date TREATING PAID - Z Z NOTICApplicaE NEW RESIDENTIAL PLMB. SQ.FT. Date ReCel t# O OTTCE TO APPLICANT:IL akar making thio tice/e Certlof Exeption, Hshouldld Wmma subject to the Worker?Comperuatlon pmvtlosumyou of the Labor TOTAL: N Code,you must forthwith comply withauch provisions ortht pemdtshall be BUILDING W > deemed revoked. FEE CONSTRUCTION LENDING AGENCY SEISMIC FEE Q. a IherebyafOrm thatthemta t Wconstruction Lending agency forthe performm ELECTRIC FEE Z. ance ofthe work for which thieperent ued(Sec.W117,C1v.C.) T C) O Lender.Nome PLUMBING FEE lyF Lorder.Addrea Q'Y. MECHANICAL PERMIT PEE MECHANICAL FEE OW 1certifythat]have read thtappllcationand statet heaboveln(ormatlon f1. (correct. reeto cmmplywlthall an o car,bl..c.AImdsutr I.Ws PERMTTISSUANCE / FEES PAID: W relating bu Ing mrsatmctlon,a to representativesofthis F Z city to r the above-me for rapeRlon purposes, ALTER OR ADDTO MECH. Date RCCeI t# V — (W to e,Inde a ss the City of Cupe Ino - P .galAl- Iltln,fa as, an r Ichmaylnany ayac a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: .galIn con.equenceo n s f Kiat permit. AIR HANDUNG UNIT(OVER 10,"CFM) CONSTRUCTION TAX SignaoTApplicant/CastfractaT EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Dale RCCCI t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and SafetyCod ctlon 75532(.)? HEATING UNIT(OVER 100,000 BTU, TOTA /a Yn No Will theapplicanlor tun building occupant use equipment ordevices VEN71LA71ON FAN(SINGLE REBID) ISSUANCE DATE which emit hanrdom air contaminants as defined by the Bay Area Air y Quality Mawgemert D'utrlct? BOILER-COMPOIIPOR 100,000 BTU) !^ f ❑ Yes o 1 J Ihevereadtheth& uty C.de,Stct. irementunder Chapter 6.95 of BOILER-COMP(OVER 100,0008N) ��� the er(and t Health 4r didin Code, of cu ru 255(5,have a t and 25574.I understand that lithe bulldingdon not mrrently haveatenant that ittmy NEW RESIDENTIAL MECH. SQ.Ff. 9 Jq rnporoibilityto ce of aCeheocmpantoftheeequlrcmeaswhich must be met CIIr�,r 19"3 �i �9 priorns Lssuanmofay theoau a tof the req Lur� n '� Owner or authorized agent Data ISSUEDBY:- OFFICE COPY