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HomeMy WebLinkAbout24417 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED;LINES — USE BALL POINT PEN.ONLY . guildin,Project Identification - • - PERhIIT.NO. Building Address: - - `244.17; ' oars ams: - - _ one: _ A ' CITY OF NPERTINO-BUILDING DIVISION c° ,^ams: Lte.Nb• APPLICATION /PERMIT. . ✓ rn�e ©/ Architect/Engineer. BUILDING-ELECTRICAI:PLIIMBIN MECHANIAL CATEGORY CONTROL# Na- QTY. ELECTRIC PERM FEE BUILDING PERMIT INFO .. Address: r, �. PERMITISSIJANCE •^ , ❑ LICENSED CONTRACTOR'S DECLARATION Thereby effirmthallam licensed underprovialona at Gaprer9(commen %ANE L JOB DESC ON Inensei into 7000)of DlWslon3 ofthe Buelnsae and Pm(esslonaCade,and y - Ilcenx Ie in lu and effect. ./ 1 {�•� • Lah C�1ss COrlttad.r O/aF �CcG/• { ryV ARCHITECTS DECLARATION pCO lunderetand my plana shallbe used as public records. SQ.Fr.FLOOR AREA, $/SQ,FL., z(/ Licensed Prefessimal.+. OWNER-BUILDER DECLARATION - '' 6C 02 'I io. 4 Iherebyafftrmtbatlam...ropl fromthe Contractor.Licenss Lawforthe - 0O,CIL pp fail. ng reason.(SeMon 7031.5,Business lend Profession.Code:Any cityor TpMp,ME'1FRORPOLE INST. R �� counlywhich es requira permit to construct,alter,improve,derollsh,oreepair any structure price to its issuance,also requires the applicant for such permitt. POWER DEVICES 4 file a signed statement that he Is licensed pursuant to the provisions of the 3w Contractor's License Law(Chapter 9 Ccomem.cing with Section 7000)of Divi- sion3ofthe Busineasand Professiona Code)orthatheisexempttherefmmand SWIMMING POOL ELECTRIC - < the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHVALO ESFIXTURFS - 1 LV 1 AL `, O applicant fora permitsubjectatheapplicanttm toadvll penaltyof not orethan n " five hundred dollars($500). NEW RESIDENTIAL ELECTR - ' �n L as owner of the property,or my employees with wages as their sole SQ.FI'. STORIES' TYPE CONSTRUCTION compevatim,will do the work and thestrudure le not intended or offered for O elle(Sec.7094,Business and Professimu Code:The Contractors Lt..law $ does not apply to an owner of property who Wilds or improves thereon,and 'a ' EEE who doessuchworkhlmsolforthrough his own employees,provided thatsch OCC.GROUP RES.UNITS improvements are not intended oroffered for sale.If,however,thebullding or improvementuaald withinoneyearafcmnpldWgtheawner-bullderwtll have :ttK-buden of proving that he Aid not Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEED FLOOD ZONE APN L�Las owner of the property,am exclusively contracting with licensed PERMH'ISSUANCE t contractors to wmtmd the project(Sec 7094,Business and Profe siouu Code: Th.Contractor.License law does not apply to an owner of property,who WALTER-DRAIN k VENT:-WATER(E,U builds or improve thereon, who contracts for such ptojeds with a • FEE SUMMARY cq ttjador(.)Ikenxd pursuant to the Contractm'e Lkenae Law. BACK FLOW PROTECT.DEVICE, IJ I am exempt under Sec B k P C for this reason ' • OUTSID Owner . Dare DRAINS FLOOR ROOF,AREA,COND. .. SANITARY Y— N- WORKMAN COMPENSATION DECLARATION - RECEII'T# E31 hereby affirm that I hive a mrtifuste,of consent to sect-insure,ora E%TURES PFR TRAP SCHOOL TAX Y N .f certificate of Workers'Compeuuation Insurance or a mrtl0ed copy thereof(Sec. RECEIPT GAS EA.SYSTEM-1 INCA 0UTLE75 3800.Lb C.) PARK FEE Y N PolCom any + GAS EA.SYSTEM-OVER 4(EA) s BUILDNGD VISION FEES oCertifled copy b hereby fu=.'d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE - Q Cerliftd copybf0ed wlthlhe dty Wpectiondiviston. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP - PAID COMPENSATION INSURANCE SEWER-SANITARY STORM EA 200Ff Date Recei t# (0)m lection need not W emnplded BtW permit bfor one hundred dollars ($l ID rdifytJ - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N ' I cenor emploat y the person any manneweakr so as towhich ca permit is issued, - — I shag not employ any person f any manner so u to became sobjed to the WATER SYSTEM/TREATING + „ Workeun'Compeneatlon laws of California. Date PAID O Z Applicant Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.ET,' Date Recei t# should become subject to the Workers'Comperwtion provisioru ofthe Labor - TOTAL: " L Code,you must forthwith comply with such proWlom orehla pertNt shall be deemed revoked. BU ING �+ dCONSTRUCTION LENDING AGENCY _ SEISMIC FEE I hereby efRrmthat there b a construction lending agency for the perform D Z ance ofthe workforwhichthb ELECTRIC FEE permit is issued(Sec.3097,C1v.C.) T �� U O Landers Name PLUMBING FEE LLI— Lender's Addresa - CITY. MECHANICAL PERMIT FEE O W IcertlfythatlMvereadthsappRcaibnau Matethattheaboveinfor tit - MECHANICAL FEE. Iscored.I agreeto complywith all city and county ordinances and state laws PERMTTISSUANCE FEES PAID: } 4 relating to building comtrudton,and hereby authorize representatives ofthS {„ cry to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. .U Z ' (We)agree to save,indemnify an'd keep harmleas the City of Cupertino _ Date Recei tit sgainstliabilitie judgment"exsteande nae.whichrsyinanywayatttue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL: all I C lnconsequenceof, tingojtbiapermit. _ ,#_ AIR HANDLING UNIT(OVER 101000 CFM) CONSTRUCTIONTAX Signature.(Appueant/C°ntrachm - - • - Data „ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE - - Wlllthe.pp8cant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) , Date .'R3ce1 t# material..defined by the Cupertino MuNdpal Code,Chapter 9.11,and the ,71 Health and Safety Code Section 15531(a)7. HEATING UNIT(OVER 100,000 HTE) TOT ❑Yea No417%. LILI Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE , which emit hazardous alt contaminants as defined by the gay Area Air ality Management District? BOILERCOMP(3HPOR100,0MBTU) ID a�LJ Yea. ON. PA 'Ihaveread the h ik Safes materiCale,Se requirements 2555,2553 and2553.1 of 801LER-COMP(OVER 100,00087V) the California Health building Cods,Sections7550.5,25533and75534.! 3 rs 199 understand that n he tify the occupant not errentlyequir have s which4 that It mat - NEW RESIDENTIAL MECH. SQ.FT OCT4 JU prior respoto isaua to of a Certificate occupant of the requirements which must W met \�](}J�j{�)//��(, prior to Issuance oto Certifiate of Occupanry. K/ VV Owner or authodzed agent _ - ! 9. - Date ISSUED BY: TOTAL: OFFICE COPY