Loading...
23685 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PMWT NO. Building Adds _resI Front-.s: 2 3 6 8 5 �wtgr3 C � s-Fo rGl_,�1 rive. l k 1 - -([>✓ ZS —L� L{ ICITY OF CUPERTINO-BUILDING DIVISION f1 r �- - f- Conm ;Name: Lie.No: APPLICATION /PERMIT 3�[o3S BUILDINGELFLTRICAL�PLUMBING-MMC MCAL CATEGORY CONTROLM Architect/Engineer. Lie No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: PFRMITISSUANCE � 1:1 ❑ ❑ LICENSED CONTRACTOR'S DECLARATION I hereby b affirm'hat lam underpovblonsofC ,anenc MPANCESREADENfIAl JOB DESCR0N ingwithctt..7000)o(DlvlM.3.flheB.Mnessand Pettiest ...Codeed my licon.isCInssf! effect' / JS PANELS LICM // • 1L� V Com' Dale Cordractor ARCHITECTS DECLARATION Gl�nf 201-1000 AMPS re0]. I understand my plan sMR be used as public records. OVER]ODD AMPS SQ.FI.FLOOR AREA S/SQ.Fr. O Licensed Professional SIGNSELECTRICALFIN ' <� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST 7f' � fherebyafittemfrom the lam exempt frothe Contractor.License law for the following reason.Section 9031,5,Business and Professions Code:My city or R� O countywhichrequ4 apermittommu cu alter,impmvgde=tah,orrepalr T�P.METER ORPOLE INST. .Era�l( Fq��a anyse ]OWER DEVICES ucture prior to its Issuance,also requiresthe applicant form hperMtto li Mi 2 U file a signed statement that M Is licensed pursuant to the provisions of the 9 �2 Ow Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi- SWEdbfING POOL ELECTRIC the taxis fo Busmnsand Professions Code)Iodati n of exempt therefrom and VA ATIOIy_ ,pJ yy�.'•-t the basb for the alleged exemption.on. Any violation o!Section nor ex re any Wpbs fiveapplicantdred fora permit a.($50jectn theapp0cant toa dull penalty dnot nnrethan OUTLETSSWITCHESFIXT[RFS L O ee five hundred as owner riof the pro NEW RESIDENTIAL ELECTR ❑ease ownerll theproperty,orand he employees inwithwage as their sole �'�' M � TYPE CONSTRUCTION tampensatlon,Businetheworkfeval et Code: mh C Intended oioffendfor 5 � sale(Sec.704y Business andl'rofesslom Code:TM Contractors Licewe law [tjG$ don not apply to an ownerof property who builds orimprovestlerme,and OCC.GROUP RFS.UNITS 44S whodon w suchworkhmeelforthtgh hlsownemployces,providedthatsuch Improvements are not Intended proffered forsale.IL however thebuilding or TOTAL: improvement bsold withmoneyearofcompletion theowner-bullderwill have thElIntrden of proving that he did nor build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN u I,as owner of the property,am exclusively contracting with licensed contrarian to construct the project(Sec 7074,Business and Prdessbra Code: PERMIT ISSUANCE The Contractors License Taw does nor apply to an owner of property who ALTER-DRAW&VENT-WATER(EA) Wilds or improve thereon,and who contracts for such p(ujects with a m dorG)Bmnsed punmmmthe Cpntnctor's License Law. FEE SUMMARY LJ I am exempt under Sec. 8&P C for this myon BACK FLOW PROTECT.DEVICE DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT It WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTA Y_ N_ ❑I hereby affirm that I have o Insurance a c of consent to opy thereof ora RFC®xT N 3800,ab of Workers Comperwtion Insurance ora certifkd ropy thereo(ISec. 3800,Tab C.) CAS EA.SYSTEM-1 WC.40I1TLET5 PARK FFR Y_ N Policyk Z.1 RECEIPT M GAS EA.SYSTEM-OVER 4(EA) Co�any copyIPCI!/1 ��L.�6� BUILDING DIVISIONFEES Cert! a copy be filed hereby the city tra= i GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE EGef11fIM copy V Ned with IM city inspection division. CERTIFICATE OF E(EMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWFRSANITARYSTORM EA 200F1' Date Reeef t# (Thissedlpn need not be compacted iltM permit Is forone hundred dollars (8100)orl Imrti(yththat in the performance o(the work(or which this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N 1 shall not employ any perave in any manner so as to become subject to the WATER SYSTEM/TREATING Wmlve s Compensation Laws of California. Date PAID O Applicant Z NOTICE TO APPLICANT:If,after reeking this Certificate of Exemption,you NERESIDENTIAL PLMB. SQ-FT. Date Recei t# z mN' Fshould become subject to the Workers Compereatlon pro lsioro ofthe Labor TOTAL: N Code,you most forthwith comply with such provisions or thin permit shall be deemed revoked. BUILDING FEE W p CONSTRUCTION LENDING AGENCY SEISMIC FEE Il I hereby afflrmthat there is a comtructlon lending agency for the perform. ELECTRIC FEE Z anceoftheworkforwhlchthIsperrnit Islu (Sec.3097,CIv.C.) TOTAL: O O Lender.Name PLUMBING FEE LL ~ Lender§Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE O W Iurtifytha l have read thls appliationand state thatthe above information u tarrect.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: } 00. relating to building conswdket,and hereby authorize representatives of this F Z city to enter upon the abovnmentloned property for inspection pu rposes. ALTFRORADDTOMIECH. (We)agree to save,indemnify an It Imp harmless the City of Coped Ino Date Reeeipt# V agaimtllab111tln,judgurentn,cossand expense hich nay In anywayaccuue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: a a' told City Nro ence of the grand. of this unit AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX core of Appli nt/Contractor Date IAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID: ATARDOUS MA RIALS DISCI&URE Will the applicant orfuturc building occupant store or handle hazardous HEATING UNTT(TO IOf1,000 BTU) Date RCCCI t# material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code Section 25532(a)2 HEATING UNTT(OVER 100,000 BTU) TOT ❑Yes M No Wilitheappliant or suture Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE which emit hav Nous ab contaminants as defined by the Bay Area Air /y Quality Management Distrid7 BORER-COMP Oil?OR 100,000 BTU) 1� 4Yn n No havemad the baza�ous materials qulremnbunder Chapter 6.95o! BO ER-COMPOVLRID,000BTV) �AY1 the Ca llfcmia health&SafetyCode,Sections 25505,2W3 and 25534. I �� understand that tithe building don not cormotly have a tenant,that it is my N'EWRMDENTIALMECIi. SQ,� (I,2 responsibility to notify the occupant of the requircerents which most be and C�l.r V♦ v7 prior to Issuance of a Certificate of Occopancy. N LUrt Owner or authodmd agent Date ISSUED BY �• / l TOTAL: OFFICE COPY