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HomeMy WebLinkAbout21279 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Bulldin Project Idemifkatlon t PERMIT NO. Building Address: Zz .z-2- cNa�s-ric� �c ��P �iuo . 2127.9'El . nerl!.�Name: - 1�V'�VS !�CG CITY,OF CUPERTINO-BUILDING DIVISION Contrector's Named 'Lie.Np: -APPLICATION /;PERMIT _ . C GTI♦�-�AJ IRC IJ `L BUILDINGELECTRICAGPLUMBING-MFGHAMCAL CATEGORY - - Lk.NoCONTROL M, ArcMtect/Engineer. : - r C , .]r QTY ELECTRIC PERMIT FEE.• BUILDINGPERMITINFQ Address: 173z- ©Qf1 s PERMIT ISSUANCE ❑ ❑ ❑ LICENSED CONTRACTOR'S ECLA TION - ]hereby affirm that am licensed under provision.of Chapter9(commene. APPLIANCESRESIDENML' - JOB DFSCRBa770N IngwlthSe On7000)of Divisim3ofthe Buelne.eand PmfeasionsCode,andmy license lain fuRfa ddied. - Lv - PANELS Llcenee Clam C, Lia g J Dale Contractor ' ARCHITECTS DECLARATIO 201-1000 AMP5 a pmm O I understand my p)am ehaB be used as public record... OVER 1000 AMPS - FT.FLOOR AREA p��uv -. '.SQ $/SQ.FT. 6i z� GGA 6� a ACLned Professional SICNSELECTRIL 6OWNER-BULDER DECLARATION YM Iherebya(frmt f oamesem ptfromthecontracoLlacase Lw(orthe SPECNLCIRCAT - •N Y p) � ' �] � YO 9L.. followingreason, regirection 7031.5,s.prmit to Business and r,imprve, Code:Anytltyircounty TEVIPMETERORA RINST." ' C� anystm mPr$uireaapermitromrutmcyalkr, -Pph ,demolbh°rrepalr - ale 2 signed prbrro it that a 1;licensed re suant t the to vision of t to + !OWER y'o. file a signed statement that he b licensed pursuant to the pon 7000) of the w Con3.fthb License Law(Chapter-C de).ncingwlth Section 70DD)o(Divl- rMn �p� �O abn3o(the Buaineeeand Profeuki,sCode)orthat hebexempttherefromand SWE.tMING IDOL ELECTRI JJ�r VALUATION the halt for the alleged exemption. Any violation of Section 70.315 re any !a'a EIS-" I{ ' ' yyyO fiveapplicantdred zpemNt OD).tsthe.##[leant to civil penalty o(nat more than �/ UTLETSSWITCHFS�HXTUR, }W/.I five hundred dollars(550%. " NEW RFSIDENTfAL-ELECTR - mr r ❑4 ae owner o(the property,or my employees with ova as the,,sole FI. 'STORIES TYPE CONSTRUCTION compen.adon,w0ldothe worn,andthe.fracture lerwHntso eC or o((5md(or Y. fi i{-„- O sale(Sec.70K Business and Pro(esebns Code:The Contreor Licerlik law 9` 3+-'7 j$$ does not apply to an owner of property who builds or imp o thereomatn .00C.CROUP RFS.UNffS r who doe.suchwork himselforthrough Msownempl°yeas, idEdtiubuth improvementsare not intended oroffered for sale,If,how r,tkWuildingor �I. 0 (� ,TOTAL: Improvement I.sold within one arolcorh le[lo thrown r- 'rs'• �! R p M r b.b erwlll�ave th,R,Igvden ofpmWng that he did not build or Improve forpurpose"otsah.). ' Q'p PLUMING PERMIT FEE ,p�ppp PONE L,J J,as mvner of the property„am exclusively conry(acting wlth�licedaed ppRMTf ISSUANCE contractors to corutmct tM project(Sec.7014,Buslnees'and Pro(esslom Code: .t The Contnctots License Lw does cast apply to an owner of property who �•J�DRAM&VENT WATER P(A) W kl,y or Improves thereon, and who contracts for such ptofem with a cgpRactor(s)Btenwd'Pumuanttothe Contractor$Limn Lew. • BACK FLOW PROTECT.DEVICEOUTSIDEFFES - FEE SUMMARY - LI I am exempt under Sec. B&,P C for thi.n, s . OwnerData DRAINS FLDOR RCOF,AREA,COND. SAMTARY .Y_ N_ WORKMAN COMPENSATION)DECLARATION RECEIPT N heieby affirm that I have a certificate of consent to self-Inure,or a FIXTURES PER TRAP SCHOOL TAX Y=,-: N cettificeteo(Worke Comper tion Ir mnwora certified ropythereo((Sec. RECEIPTN GAS EA.SYSfEM-1 INCAOUTLETS PARKFEE Y N Polley py b L r7 ✓ / _ /O .� OVER4(EA) RECEIPT If Com an GAS FA.SYSTEM' .HOLDING DIVISION FEES [PCs M mpy V hereby furnlahed. '- GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE erti(ied copybflled with the tity impaction divlelon. ' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID ' COMPENSATION INSURANCE SEWER-SANIIARYSTORhf EA.200E 1'. (0)r$ectlon need nor be completed lithe permit bforone hundred dollam Date Recei f# (g1(0)rtifyt.) WATER HEATER W/VFN7/ELECTR' ENERGYFEE Y N ]cent that tithe peps ninan thewner an as tocb camehis emNtis Ito the I shake not employ any Ie wg.In any manner eo u to became subject to the WATER SYSTEM/TREATING ' Workers'Compensation Laws o(GlRornh.Date -PAID O Z, Applicant ' NEWRESTDENTIALPLMB.` - Z - NOTICE TO APPLICANT.If,after making this Certificate o(Exemlrtiory'you sQ.Fr. Date Recei t# Fshould become subject to the Workers''Comperuatlon provisions ofthe Labor TOTAL: N Code,you moat forthwith comply with such provlsiuru rthis I.I permit shall be LU > droned revoked. BUILDING E G - t170 CONSTRUCTION LENDING AGENCY r SEISMIC FEE M . Ihereby affirm that there is a construction lending agency forthe perform 4 Oance of the work for which this permit is lesuai(Sac.3097,Civ.C.) TOTAL: ELECTRIC FEE V _ Lender.Name PLUMBING FEE. - LL F Lenders Addres. QTY MECHANICAL PERMIT 'FEE O W Icertfythat I havereadthls application and rtakthattheabove information MECHANICAL FEE 6 bcomet.oagreetocomplywlthalltltyandcountyordina.cesandrtatelaws PERMIT ISSUANCE - FEES PAID: } U) relating to building cormbuctlen,and herebyauthorlze represents ivesofthi, I'.Z city to enter upon the above-mentioned prop n see. ALTER OR ADD TO MECH. (We)agree to gave,l Ify an d ba eas ci (Cupertino - Date Receipt#. against liabilities,N nts,cortsa penseswhl ma It nyway, AIR HANDLING UNIT(To 10,000CFM) SUBTOTAL: against said conaeq en granting is pe 1. _ - AIR HANDLING UNIT(OVER 1om0CFM)., CONSTRUCTIONNAX SlgmMre of Applicant/Contractor N, Dat -. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:' HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO I OD,ODO BTU) material as defined bythe Cupe Ino Municipal Code,Chapter9.17,andthe Date ReCei f# Health and Safety Code Se n25537(a)7 HEATING UNIT(OVER 100,000 BTU)' - TOTAL: ❑Yes - o Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) DATE hlch emit haaardous air contaminants as defined by the Bay Area Air uulity Management D R7 BOILER-COMP PHI'OR 100,000 BTU) OCT 12 � gQ 4 Yee No have read the h us uamaterlalsrequimm nteunder Chapter6.95of' BOILER-COMP(OVER 100,000 BTU) / the California Health&Safety Code,Sections 25505,25533 sad 75534.1' Understand hat l(t .building r yl aknan4 that it is my NEW RESIDENTIAL MECFI. SQFI' �jlsa asB/k.a , responsibilityt fytheo pant oft lilt nt.whkh the a�li(I ML•BLdt prior to Lsau of a ce ate of pan /A ` u tkb neror authorixed agent — d Dat _ 'V f•]f Q,eVe„J . TOTAL: ISSUED BY: OFFICE COPY