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HomeMy WebLinkAbout21519 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Addreas:ISrec4y • 21519 - ner ante: a on A A CITY OF CUPERTTN4BUILDING DIVISION cnno-adnra Name: Lie.No: APPLICATION /PERMIT BUILDINGELECTRICAT PLUMBING-MECHANI {aj CAL CATEGORY CON ll NI•) Itect En er. � Lk.Nie •a..,. QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO Address:�il G!�✓,4j Gp; - � �' PERMITISSUANCE —app fit 7 LICENSED CONTRACTOR'S DECLARATION tJJ I hereby afflrmthat l an,licensed under provhslorao&Chapter 9(on.. APPLIANCES-RESIDENTIAL - JOB DESCRIPTION incense Is Ntten force and effecn3otthe Bualr�euandlPro(eaelonsCode,and my license lams, force and Ic.0 PANELS LicenseCku Date C,rfta onhactor UP TO 200 A1,115V w9a_ix1`L ARCHITECTS DECLARATION 201-1000 AMPS l O Z I understand my plata shall be used as public records. OVER I000 AMPS SQ,Fr.FLOOR AREA - $/'SQ.Fpr, Licensed Profeutonsi SIGNSELECTRICAL / I [�� F�, �D1Q ct ca{{'•`a 'a- OWNER-HOLDER DECLARATION SPECIALCIRCUIT/MISC Iherebyseen.(hallam exemptfrom the Contractors License Lw fort he �0L =ntynhichreuiman703wBuslnessand Pro(euione.=Ikh,ydtyor TpMp•METERORPOLEINST. sC � I"' muntywhtchPrior was Issuance, the apmve,demsuch permit rmitto 14416 any atructure statement ahat a Is also requlrersuant t the provisions 11 a POWER DEVICES C5 4 1(e] file a signed statement that M Is llcenaed pursuant to the pmvbbv of the 30t�, Contractor's License Law(Chapter 9(commencing with Section 7000)of Dtvl- SWIMMING POOL ELECTRIC dlon3ofthe Businessand Profemlon Code)orthathekemmptlherefromand - VALUATION" a'g the bask for the alleged exemption. Anyviolationtolacivi of Section 7N1S applicamby e any OVILETSSW[.ICHESHXTURES �t 11 H ) "7111 ©G G five nt fore dred doerrs($50ent jeck the applicant toe civil penalty o(nU more than �l (We I,as ownerofhepr. NEW RESIDENTIAL ECTR SQ.FT. -STOMFS, TYPECONSTRUCTION �n mpe as owner of the property,or my employees with wages their dole compensation,70 n,wildo the cess and Fr stagend structureode:Th.Cunt Intended or coffered for p�O ale(Sec 704y to Busan iness and f property Code:The or impedord License Taw �,I R doeswho not apply rkht owner ofpmpe hhis o builds nemplaymppo idedthat;thereon,and , OCC,GROUP RES.UNITS CC.• 'whodoementsw not Intendedorough hieowne.If,hoeq however,the building _ �'{d,� improvements am not intend yearofc=roffered oraale.thho veplflderwdingo TOTAL: Ll'TJ Improvementksoidwithln oneyearofcomplelbn,theownervbullderwlll have rden of prov(ng that he did build or improve for purpose of sale.). QTy, PLUMBING PER FEE FLOOD ZONE APN 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE �a� n ...'s o construct the project(See.7044,Business and Professions Code: Contracture License Law does not apply to an owner of property,who ALTERDRAIN&VENT- .Wre builds or Improves theon,'and who contracts for such ptojem - with a ) actor( s)licensed pursuant to the Contractors License Law. FEE SUMMARY I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE Owner DRAINS FLOOR RODE,AREA,GOND. SANITARY .Y N Date RECEIPT N WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP 1/3 SCHOOLTAX Y N i> []I hereby affirm that I have o lmur n of aoftif to pythemof or a L`-'1 RECEIPT N certifIcab C.) rken'Compensatlon[nsurance rnacertlfled mpythereof(Sec. GAS PA.SYSTEM-1 INCA OUTLETS 11 CID PARKFEE .•.y N 380,IabCJ Pollry p DINGRECEDf p Com any GAS. SYSTEM-OVER WASTEA) BUILDING DIVISION FEES �CertNed copy k herebyth the city GREASE/INDUSTRL WASTE IIVTERCEI'TOR PLANCHECK FEE - � Certified copy k filed with the tlty Inspectbn division. I Q' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAIDGZ QC) 9 igl 2C COMPENSATION INSURANCE —L (Thlssection need not becompleted tithe permit kforonehundreddollars SEINER-SANITARY-STDRM B.A."Fr, Date 'Recei t# (,lvsG (91I))rnle».) WATER HEATER W/VENT/ELECTIR 2slJ[/ ENERGY FEE Y_ N ' I certify that o ance the performof the work an as to b this permit I.issued, — I shall not empty any person to any manner as as m become subject to the Workera'Compenutlon Laws of California. Date - PAIDO"�d O,Z Applicant - WATER SYSTEM/TREATING - Date Recei t#I '�•� Z G NOTICE TO APPLICANT.lf,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. should become subject to the Workers'Coreperuatlon provisions o(the Labor TOTAL: fd' Code,you=at forthwith comply withauch provisions orthk permit shall be BUILDING deemed revoked, W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE —7 CaLL Cast Z Thereby a(flrmtlut there isaconstruction lendingagenq for/M perform- TOTAL: ELECTRIC FEE a(W anre of the work forwhich this permit k issued(Sec.3097,Civ.C.) 02 Lender's his me PLUMBING FEE QOd' !1 ~ Lenders Address e QTY. MECHANICAL PERMIT FEE MECHANICAL FEE0 LU ' a is wire tobuileetocomplywith all ndhereb muntyordinances and elate laws PERMIT ISSUANCE �� FEES PAID: >. relxtingrobupongea vacton,and hereby au orizerepreaenpurpos otthk ' H Z. ci (Wa)aeree to thea ve-menso pm or Wee Z� �04 it of Cupar ALTER OR ADD TO METH. C8 Date Recei t#' lW a)agree to uv nde ked a i the n a of ayaccrw P agalmtllabll e P menti, of yin any wayaccme AIR HANDLING UNIT CFO 10,000 CFM) .SUBTOTAL: against 1 ronaeq or of apermit. 7-9 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX ' igna pliant ntra oDate IXHAl15THOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS RIALS DISCLOSURE Will the applicant orfumrebuloccupant store or handle hazardous HEATING UNIT(TO 1p1,000BTU) Date. Recei [# material as tlefi dbythe Cupertinicipal Code,Chapter 9.1 2,and the Health and Safety Cod con 2 )i HFATING UNIT(OVER 10,000 BTU) TOTAL: Yea No Wlllthe applkant (u rebuiocmpantuee equlprnentrn devisee VEMDLATION PAN(SINGLE RESID) ISSy,��NCE DATE which emit luurdoua air contamiace defined by lM gay Area AlrQu lityManagement Istrid7BOILER-COMPQHPOR100,000BTU) v-Ikl(�4YeaNo hawe read the haxamatequire ntdunder Chapter 6.95 of BOILER-COMP(OVI7t 100,0008TU)the Californk Health&Safety Codions ,25533 and 2'x534.]understandthatift Wildin cco yhave tenant,thatltkmy NEW RESIDENTIALMECH. SQ.Fr r®pomibllityto (y the pae which must be metofreseOgentDate ISSUED BY: TOTAL: OFFICE COPY