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HomeMy WebLinkAbout23187 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Prate ct Identification PERMIT NO. Building Address: 23187 O_ Co3 � J�NS C� 1C BLvL� nen : one: A , T�,t l OF F.i�IGA SIO"1$i" CITY OF CUPERTINO-BUILDING DIVISION 111WContractor's Nanta: a.No: APPLICATION /PERMIT 9110111sWICF-O E C 77� BUILDING-ELECTRICALPLUMWNG- CATEGORY Y CONTROL A Itect gineer. Lk.No: MLC}IAMCAL QTY ELECCRTC PERMIT' gr BUILDING PERMIT INFO Address: ' aQLC ��. PERhITISSUANCE ❑ ❑ ❑ LICF.NSP.D CONTRACTOR'S DECLARA ION IL . I hereby affirm that lam licensed under provisions o(Chapter 9(mmmenc APPLIANCESAES[DE JOB DPSCRIPHON l'ngwlth SecHon7000)of Division 3oftheBwinesand ProleslonaC-ode,and my icense le In fuB and d(eR. PANELS License 1. IV Lie.# 3, 3 3 T /sp/ a Date Contractor 1!`—�. (l C..V ARCHITECTS DECLARATION 201.1000 / a07 l understand myplaru shall be used as public remrds. O 1 AMPS SQ.FT.FLOOR AREA S/SQ.Ff. O Licensed Profesianal SI SELEC'TRICAL OWNER-BUILDER DECLARATION SPECL3L CIRCUIT/ IherabyafBrmlhatlamexempt from the Connector's License La the p following reason.(Section 7071.5,Business and Profeslons Code:Any ctty or 021-. TEMP.MET�i DR LE INBT. muntywhich requireaapemdtromrotmct,alter improve,demolbh,orrepalr �e anystructure prlorto Its issuanceaborequlrestheappliant forsuch permit to IV WEA DEV . file a signed statement that he Is homsed pursuant to the provisions of the w� CaniraRoreLkeveLaw(Chapter 9(mmrtencingwith stcB 000)ofDivi- gWBHMNG(VOLELGCRC �Oe sion3ofthe Business and Pro(emlone Code)orthathekexempe thercfromand VALUATION •11 the basis for the alleged exemption. Any violation of Section 70315 by any 65 appBantfor a permit subjectathe applicant to a civil penalty.!no more than OUTLETSSWITCHESEIXTURES 7A� five hundred dollars(IISM. NEW RESIDENTIAL ELECTR �n F1 1,as owner of the property,or my employees with wages as their sole SQ'Ff. STORIES TYPE CONSTR[ TION compensatlon,wW do the work and thestructure is not Intended or offered for sale(Sec.7094,Business and Professions Code:The Contractor's License raw . ESB does not apply to an owner of property who builds or Improves thereon,and OCQGROIIIs RFS.UNITS who dogs such work himself orthrough his own employees,provided that each im .22-5V prevementsare not Intended otoffered forsale.If,however,the building or TOTAL: Improvement b sold with In oneyearofcompletlon,the owner-bullderwlll have tljL�rrden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT .FEE }TppD7pNrp ApN LJ 1,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE contractors to construct the project(Sec.7094,Bovines and Professions Code: The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN AVENT-WATER(EA) Wilds or improves thereon,and who contracts, for such plujecn with a actor(s)licensed pursuant to the Contractor'sLicense Law. BACK FLOW PROTECT.DEUCE FEE SUMMARY I am exempt under Sec. B k P C for this reason DRAINS FLOOR.ROOF,AREA.GOND. SANITARY Y_ N Owner Date WORK MAN COMPENSATION DECLARATION RECEIPT#❑1 hereby affirm that I have a certificate of consent to self-marcFD(TURES PER TRAP SCHOOL TAX Y— N—,or RECEIPT# mrtlBammWorkers'Competuaifon l unna ora certlBedmpythemof(Sec. GAS G.SYSEEM-1 INCAOUTLFTS 38W,lab C.j a(� ��I .��r��*/" PARK PFE Y N Policyp_V- l I.Z RECEIPFIt Com n .{ GAS EA.SYSTt➢s4-OVER4(A) BUILDING DI VISION FE BS M Certified copy Is hercbyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certified copy V filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GRE-ASETRAP PAID COMPENSATION INSURANCE # (ThissecilonneednMWcompletedlftheperMt is(oronehundroddollars SEWER-SANITARY-STORMEA.200PT. Date Recei t# ($100)oify that WATER HEATER W/VENT/ELECTR ENERGY FEE Y N [certify that in .ry person in an the work so as to become eemdt is blued, — I shall not employ any person In any manner ro as to become subject to the WATER SY Workers Compensation laws of California.Date - PAIDO Z Appileant 1 Date Recei t# Z (7 NOTICRTO APPLICANT.If,after making this Certlflateof Fiemption,you NEWRE9 L T. should become subject to the Workers'Compergentlon provisions of the Labor tgas, TOTAL: t�) Code,you at forthwith comply withauch provlalmam1his permit sh.11W B I E > deemed revoked. d. — CONSTRUCTION LENDING AGENCY SEI MIC FEE a I hereby affirm that there Is a construction lending agency for the perform aJ 7 Z ance of ELGTRIG FEEhe work for which this permit It lssuei&c.3097,Civ.Q t-' VQ renders NaMBINGFEE me IL — Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Imrtifythatf have read this application and state thattheaboveluformatlon 1 Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: N relating to bullding construction,and hereby authorize representatives of this Z city to enter upon the above-mentloned property for inspection purposes. ALTERORADDTOMECH. Date Reeel I# — (We)agree to save,Indemnify an d keep harmles the City of Cupertino P agaWtllabNtks,judme ta,"firdexpenseswhleh ylna ywayacenue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: again t said City In cgg�se�uer�a of to granting of this ermit. AIR HANDLING UNIT(OVER 10,000 CIM7 CONSTRUCTION TAX Signature of Appllani/Co=nt-4 or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE WllltheappBcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,(1(10 BTU) Date RCCCI t# material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Health and Safety Cm!eSe n25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: ❑ Yes o Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) JSsjU2'FJlT t1 A'Tc which emit havrdoua air containment defined by the Bay Arca Air f^ 9--.J'i'1Y E Quality Management Dbtri BOILER-COMP©HP OR 100,00 BTU1 4"Yes APR 14 1992 avercad the bazar usnnaterial.requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) the G1lfemla Health h Safety Code,Sections 25505,25533 and 2534.I understand that if the building does not currently haves Lena gthatitlsmy, NEW RESIDENTIAL MECH. SQ.IT responsibllityto notify the occupant of the requimments t mu be met CITY Vr �PUran l sial,/ pnor obutance of CertBkate of Occupancy. �lkehos V 4- 13 �i t �_ Owner or authorlud agent pat ISSllED BY. TOTAL: OFFICE COPY