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HomeMy WebLinkAbout23580 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY --Building Project Identification 7 PERMITNO. B° 'L,-Lz 0 C-71, Ck e,, -IIx r g,5-0i 23580 rentMane: A A A C1 . 9:y 7 CITY OF CUPERTINO 1JILDING DIVISION c°nban,rdName: Lic.No: APPLICATION /PERMIT BU DING-ELECTRICALPLUMBINGMECHANICAL CATMORY CONTROL N Architect/Engineer: Lic.No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address PERMITISSUANCE �r d� ❑ ❑ ❑ LICENSF.DCONTRACTOR'S DECLARATION I hereby affirmthat l am licensed under provisions of Chapter 9(commene. APPLIANCFSRESIDENTIAL JOB DESCRIPTION ingwith Sedion 70D0)of Divisi°n 3ofthe Businessand ProfesslonsCode,and my license is in full to.and effect. PANELS Claic.N D Dateto ss LContractor IM IQ MIT ANTS ARCHITECTS DECLARATION 201-1000 AMPS OVER 1000 1030 AMPS SQ.Ff.FLOOR AREA f/SQ.FT. O COC I understand my glare shall be used u public records. U Licensed Professional SIGNSELECTRICAL © IN p, N <c1°. OWNER-BUILDER DECLARATION to SPECIAL CIIZCNLSC T/M L., 7 Thereby affirtn<hat lam exempt from the Contractor's License Law forthe ^ FO�O.. follcounty which requlmapemNt to coristmct,alter,improve,dennikh,orrepair owing reason.(Section 7031.5,Business and Professions Code:Any city or R 2 t- TEMP.METER OR POLE INSI. I anystructure pooch,its lasuance,atorequlrestheapplicant for such permit to POWER DEVICES ,/ 4z q O file a signed statement that he is licensed pursuant to the provisions of the `1 �3 Contractor's License Law(Chapter 9(commencing with Section 7000)ofDWI- SSL\(A9NGIOOLELECIRC DATE Gooll fthe Business and Professions Code)orthat he u exempt therefromand VALUA <$ the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHFSFTXTURES Z, 5� applicant fora permit subjects the applicant to a civil penalty of not morethan M five reined dollars($500). (?j.. ,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION 7�r p petty,or he employees with wages r thele dole n compensation,wesiness and Prendthes Code; Contactorctereled or offered for $ O sale(Sec 7654,to Business and f property Code:The Contractors Lt..Law $ does not apply loan owner ofpropertywhobuildslo improvesthereon,and �^ who does such work hlrtueUorthrwghhis own employees,provided that suchI p OCC.GROUP RES.UNITS improvement are net Intended proffered for sale.If howevegthebullding or TOTAL: .L.>7 12• improvement esold within oneyearofcompletion,the owner-builder will have the en of proving that he did not build or improve for purpose of dale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN [jMI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE contractors to construct the project(See.7044 Business and Professions Code. I the Contnnor's License Law does not apply to an owner of property who Wilds or Improves thereon,and who contracts fm such pZ,jects with a ALTER-DRAIN&VENT- WATER EEM _ ctor(d)homead t t°the Contractor's License Law. ''FEE SUMMARY -ff1 puer Se BACK FLOW PROTECT.DEVICE . L_j I am exemp( der Sec. B k P C for this reason Own ate DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y_ N RECEFT N WORKMAN COM SATIO ECLARATION ❑I hereby affirm that I has a certificate of consent to self-Insure,or a FIXTURES-PER TRAP SCHOOL TAX Y N RECEIPT x motiflateC.)ofWorkem''ComperuattonlnsuranamaadifJed copytheme(Sec. 3800,Gb CAS F.A.SYSTEM-1 INCA 0UILETS PARK FEE Y N RECETTN PolicyM GAS En.SYSTEM-OVER 4(EA) - Com any BUILDING DIVISION FEES n3Certified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE ❑Certified ropy is filed with the city Inspection division. CERTIFICATE OF EXEMPT ION FROM WOR KERS' GRF-ASE TRAP PAID. COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200F1'. Date Recti t# (This section need not becompleted if the permit is f,e one hundred dollars ($100)or less.) WATER HEATER W/VENT/ELECTR - ENERGY FEE Y' N_ I certify that in the performance of the work forwhich this pemdt is issued, I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING Workers'Compensati,n Laws of California.Date PAID Z Z Applicant you NEW RESIDENTIAL PLMB. SQFT. Date Recei Hl Z O NOTICE TO APPLICANT:](,after making this Certificate of aemption, shuuld become subject to the Workeri Comp msaHon provisions of the Labor TOTAL: F y Coda must forthwith comply with such provisions or this permit shall � j deemed rew,ked. Py P P° BUILDING FEE - W — CONSTRUCTION LENDING AGENCY SEISMIC FEE a Ei I herebyafBrmthat there is a construction lendingagencyforthe perform- - TOTAL: ELECTRIC FEE S D Z ante of the work for which this permit t tsvcd(Sce.lleW,Civ.C.) 02 lenders Name PLUMBING FEE F U.der.Addrem QTY. MECHANICAL PERMIT FEE LL U Immtymatt have reaatnwppuau,nano GazethG meabove mr,rmatmn MSCI-IANICAL FEE O W iscorteR.I agreetocomplywith all cityand county orinanowand Gate laws PERMIT ISSUANCE FEES PAI D: } a relating to building construction,and hereby authorize mprewntatives of this ~ N cit to enterupon the abovcmentl°cod rofor W Ion ses. ALTERORADD]DMECH. Z y(We)agree o save,indemnify an d keep Mea the City o c�pert1. Date Receipt# V Instlubillties d t,.,andex hichma roan AIR HANDLING UNIT 0010,000 CFM) ago gmer pende.w y ywayamroe SUBTOTAL: . agxl IjCI nconsqu (egrantlegofthl.permit. AIR HANDLING UNIT(OVER IQWDCFM) CONSTRUCTION TAX signatureAppbcant/conn r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: I 'Co MATF.RI SDISCLOSUeE Will the a pplicant m fu building occupant store or hand le hazardous HEATING UNIT(TO Jail"BTU) Date RCCCI t# material.,defined by the Cupertino Municipal Code,Chapter 9.1 2,and the - IleallhandSafety Ceder�uSection 25532(A)? HEATING UNIT(OVER 100,000 BTU) TOTAL: F1 Yes No Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE which emit hazandouaalr contaminara s defined bythe Bay Ate.Al, y- A 1/ 0 Quality Management District? BOILER-COMP OHP OR 100,000 BTU) Yes No 4�r 1� have read the haze pus materials requirement 00 u nder Cha pter 6.95 of BOILER-COMP 1 ,000 BTU) APR �+ 1992, the Glif,rnt health h SafetyCode, ect Sio^,25505,25533 and 25534. I understand that if the building does nen cammtly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.F7. ' responsibility to notify the occupant of the requirements which must be met Cld,r,U-, prior to issuance of a Certificate of0coupancy. V �a VI'CT�I JA,II1Ve�J Owner or authorized agent Date ISSUED BY:�w /LV TOTAL: OFFICE COPY