Loading...
25295APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPESION RICAL APPLICATION/PERMIT PING PROG-MHCHATIFIC BUILDING DIVISION BUILDING PRUJF.CT IDENT'IFICA'TION PLRM 3 "° 25295 BUIL )INGADDRESX _ UNIT# LOTH SANTT I'ARY NO.APPLICATTIIIONSUBMIT'ALDATI �_� ^1 OWNS AMI:: WC PHONE: ` C NTRACTOR'S NAME: LIC NO: NIC ❑ CONTROhp ARCH, ECfENGINBE LIC NO: ADDRESS: CONTACT: PHONE: QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO B .LE PLUhJB M 7f-PERMIT ISSUANCE LICENSED I hereby atl=l CONTRACTOR under pmvPrionsof Chapter9 (co mmencing with rtethut I am lithe APPLIANCES. RESID JOB DESCRIPTION of Bu 5[CIIon 9UIX1)of Division 3of the Business and Professions Cade, and my license is in full force and eff«e. License Class Lic. # PANE DPT A Baa_ ■�D / ftl> Date Contractor 201- ARCHITECTS DECLARATION 1 understand my plans shall o used az public recmds. R 1 AMPS PwRFA S/SQ._FT. {,OQR ELECTRICAL Licensed Professional SPECIALCIRCUIT/MISC. OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the TEMP. METER OR POLE FIST, following reason. (Smuon 7031.5. Business and Profesaims Code: Any city or county which fia,mres a permit to construct, slier, improve, demolish. or .,if any s.cmre prior to its issuance.alw requires the applicant for..uch Permit o file a signed statement POWER DEVICES that he is licensed pursuant to the provisiorla of Rise Commem's License Law (Chapter 9(commmcing with Section 7000)of Division 3 of the Business and Preasimvs Code) n did he,, eacmpnherefmm and Ne basis for the alleged exemption. Any AnItaimid' Section 7031.5 by any applicant for a permit subjmu the applicarn ... ivil penaltyof SWIMMING POOL ELECTRIC VALUATIOry��y�/s OUTLETS - SWITCHES - FIXTURES no mart than rofve hundred dollars ($500). ❑ operty,mmyemployedorofwagesasthei(sole compensation, ` NEW RESIDENTIAL ELECTR _SQ. FT. STORIES TYPE CONSTRUCTIOD othewrk, and will do thcwons Cad the iso offered Code: The Contmcturs i enspr he Clio se, Licenses note(Sm.in an owner Law does not apply m rd owner of and Prinerty whionx nd who pmpery whobuildsorimproves ch whodoesmuch work himselfonhmugh his Own employees, p rsuch imparr:md not e. If, forshe OCC GROUP RFS. UNITS building or improvementeariff curoHemd ovemenpmvementhin however, the building or improvement is sold within one year ofcompletion, the owner - builder will have the burden of proving that he did not build or improve for purpose of of QTY. PLUMBING PERMIT FEE ale.). ❑ Lacowner of the property,Cm exdusivelycmvacting with licensed mntranonm FLOOD ZONE APN construct the Nojen (See. 9044, Bmincas and Profession, Code:) The Cmao m ., License Law does not apply to an owner ofpropeny who builds or improves themon,and PERMIT ISSUANCE who contractsfor such projects with a contractor(s) licensed pursuant to the Convectors Llcemctaw. ALTER-DRAINffiVENT-WATER HiA) / FEE SUMMARY ❑ 1 um exempt under Sec. , B ffi P C for this reawn BACK FLOW PROTECT. DEVICE Of/TSIDE FS Owner Dom DRAINS- FLOOR, ROOF, AREA, COND, SANITARY YN_ RECEIPT'# WORKMAN COMPENSATION DECLARATION [IIhcmby affirm Natlhaveeccnificme of<onummselLia$.,ore fern cateof Workers'Compenmtian msumned or a certified copy thereof(Sec. 3800, Lab CJ wM1ich revere of l employee's under this permit Policy N SCHOOL TAX YN RECEIPT# IF FlXTURES - PER TRAP '�• pg RK FEE Y N_ RECEIIT N GAS - EA. SYSTEM-] INC. 6 OUTLETS BUILDING DI VISION FELS Company ❑ Cenifled copy is hereby famished. GAS - EA. SYSTEMERn ' ) ii ll r �^^ LA FEE ❑ CmiOed copy is filed with the city inspection division. GREASF/INDUSTRL WASTE RCEPTOR 1 G N- ^. CERT1121CATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE TRAP n FEE (This section need not hecompleted if Ne permit is for one hundred dollar($100) or less.) SEWER SANITARY-dTDRM IPL 'IPL I certify that in the perfonnanu of Ne work fm which this permit is issued, l shall nm employ my person in any manner so as to become subject to the Worsen'pglp Compenmtionl.awsof CNlifomia. Dam Applicant WATER HEATER W/VE /ELECIR WATER SYSTEMiTHEATING Dam Rmeiptp NOTICE TO APPLICANT, If. CfW making this Cedificsa of Exemption, you should become subject to the Workers Compensation provisions of the Labs Cade, you must forthwith comply with such Provisions or this permit shall ba dimmed revoked. NEW RESIDENTIAL PLMB. SQ. FT DOTAL BUILDING FEE T� CONSTRUCTION LENDING AGENCY I hereby affirm that hem is a construction lending agency for the performance of SEISMIC FEE ELECTRIC PEE the work for which Nis permit is issued (See. 3097, Civ. C.) Lender's Name Lenders Address QTY. MECHANICALPERMIT FEE PLUMBING FEE I certify Nat 1 have read Nis application and state Net the above information is PERMIT ISSUANCE MECHANICAL FEE r nect. l agree to comply with all city and county ordinances nod state laws rtlaingm building construction. and hereby audimee mmeas mauvaof this city to enter upon the CONSTRUCTION TAX move-memimed property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments. costs and expenses which may in my wayseemeagainsticad City ce of.h granting Nis permit. ALTER Oft ADD TO MECH. AIR HANDLING UNIT(TO HL" CFM) AIR HANDLING UNIT (OVER I1.000 CPM) �� Slgnat Apeman meammr Dam EXHAUST HOOD(W/DUCq PAID HEATING UNIT (TO IO(LXO BTU) t HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building ocmpxnt store or handle hazardous material Dam Receipt # TOTAL: as defined by the Cuperino Municipal Cork. Chapter 9.12, and the Health and Safety Cade, Section 25532(a)y HEATING UNIT (OVER 100,000 BTU) VENTILATION FAN (SINGLE REMO) ❑Yes El No I Will or future building equip menmuality BOILER- COMP OR 100,000 BTU) p� XIVI$DATE forapplicant inumb by tummy h mous nit <onmminants us defined by the Bay Arca Air Quality Management Manage ant DixWcf7 BOILER -COMP (OVER I(0,000 BTU) Ryy p/� /�Y P A I Y ❑Yes 0 N NEW RESIDENTIAL MECH.-SQ. FT. I have mad the hazardous Sections 5505,25533 under Chat wi 6.95 all theJY�iYy( ifthebuildingdoesnot aman5505,s it is yrutpond 30. 1undnrstmd that if the wilding dh&Safety Coly have ments lyhaveatenant,thatitismymuanceofa enotify the Occupant o[Ne requirements which mon he mm prior m issuance o(u Certificate of �y� �,i L1i uu(-CI 1 NU CIIi OF CUPEHTI Occupancy. BY:� Owner or authovN agent Dae ISSUED n