Loading...
22486 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PM!,BT NO. Buuding Address: ^^ A F.5 es !) 224xV a nere aces: one APPLICA nON 9URMIAL DAM ni� S —D3 CITY OF CUPERTINO-BUILDING DIVISION Z�—Q ContnetaaName: Lm.Ne APPLICATION /PERMIT BUfLDING-FLECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL# Architect/Engineer. Lie.No: ✓IOnf' QTY ELECTRIC PERMIT FEEBUILDING PERMIT INFO naereaa PERTISSUANCE ❑ ❑ LICENSED CONTRACTOR'S DECLARATION ,W Iherebyaffrmthatlam BcenseiYnderprovislonsof Chapter9(ammenc ANCES-RESIDENTTAL JOB DISCRII.1 ION inenseiSection force of Dialect.sion (the Business Professions Code,and my 21^3 To ^y tbrl� license la In full force and effect. NFLECTR e/` License Class Llc.p Date Contractor j3a4T1�Roams ARCHITECTS DECLARATION 7 IYndentand eryplansshallWused aspublicrecord& W SQ.ITT.FLOOR AREA 5/SQ.Fr. ZG D Licensed Professieal - LECTTUG �G OWNER-BUILDER DECLARATION CIRCUIT/M 7 t"' a 1hereby.ffirmthat l am exempt fromthe Contractor's License Law for the fallowing reason.(Section 7031.5,Business and Professions Code:Any city or f', counlywhichrequlresapermittoanstmdalter,improve,demolbh,orrepair ETER OR POLE 5�a anystructure prior to Its issuance,also requires the a ppBont for such permit to POWER DEVICES O I '- 3 0 5 file a signed statement that he b Ikena d pursuant to the provisions of theO q Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- ING POOLELECTRIC O en3ofthe Businessand Prof lens Code)orthat helaexecepttherefeemandVALUATION tM basis for the alleged exemption. Any violation of Section 7031.5 by anyxsT m C"i applicant for a permit subjMsthe applicant to a civil penalty of not more than SSWITCHESFI%7'URFS q^� a_Y five hundred dollars(5500). SIDENTIAL ELECTR❑I,as owner of the property,or my employees with wages as their sokS ES TYPE CONSTRUCTIONcompensation,will do the work and the structure 6 not intended or offered for sale(Sec.70"Business and Profevlv Code:The Contractors License Lawdon not apply to an owner d property who Wilds or Improves thereon,andOCC.GROUP RFS UNITS who doessuch work himself orthrough his own employees,provided that such improvements are not Intended oroffered for sale.If,however,thebuilding orTOTAL: i provement lasoldwlthm oneyearo(completlogthe owner-bu0derwlll have thA,urden of proving that he,did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE ---,IpO w7p npN LJ I,as owner of the property,am exclusively contracting with ilce sed PERMIT ISSUANCE antradm to comtruct the project(Sec.7094,Business and Profsasiov Code: The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) Wilda or Improves thereon, and who contracts for such pUo)eta with a ,9Sfactor(s)licensed pursuant to the Contractors License Law. BAQ(FIAW PROTECT.DEVICE FEE SUMMARY L j 1 am exempt under Sec B k P C for this reason Owner Dale DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N= WORKMAN COMPENSATION DECLARATION RECEIPT# ❑I hereby affirm that I have a certificate of consent to self-insure,or aT��PER TR^I' SCHOOL TAX Y N certificate of Workers Comperaation laurance ora certified copy thereof(Sec. RECm•1'9 38W,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N Policy# RECEIPT# ISI Com any GAS EA.SYSITTR-0VER6(FA) BUILDING DIVON FEES Certified copy is herebyfhMshed. sGREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE fJlCetifd copy b filed with the city inspection division. s , Pj CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE (Thbsetionneed not be completed lfthepermit isforms hundred dollars SEWER-SANITARY-STORM F.A.IWFT. Date Recoi t# (51 W)etifyt.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N— I that In any person In restworkorer so as to become eesubjec blued, I shall not employ any person In any manner m ss to become subject to the WATER SYSTEM/,TREA,DNG OWorkers Compensws ation laof California.Date PAID Z Applicant Z o NOTICE TO APPLICANT.If,after raking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,Fr. Date Recei t# F should beams aub),ct Rothe Worken'Compensation provbtons ofthe Labor TOTAL: W Code,you=at fort hwith comply with such roubles or this permit shall be W > deemedme.lmd. BUILDING FEE d G CONSTRUCTION LENDING AGENCY SEISMIC FEE t = Z I herebyaffirmthat there b a construction lendingagency,teethe perform TOTAL. ELECTRIC FEE ance of the work for which this permit Is issued(Sec.3097,Clv.C.I & 02 Lcndee.Nam PLUMBING FEE LL r- Icndcra Addmas lk ECHANICAL PERMIT FEE MECHANICAL FEE O W Icenifyth.Uhavereadthisappllatl...odstatethattheaboveinf.dation S bmrvl.l agree to comply with all cityand county ordinances and state lawsISSUANCE FEES PAID: } N relating to Wilding mnstrutim,.rd hereby authorise represemativesofthb F Z city to enter upon thstxo oned ,pery for Inspection purposes. RADDTOMFCH. V _ (we)agree m saan a p harmless the City of Cuperino Date Reeei t# ruga WtllabiWiea,pxpensnwhlchmayinanyway... DLINGUNIT'(TO10,000CFhD SUBTOTAL•against said 'ty1ft granting of this permit.j_ NGUNTT(OVFRIf WDCFM) CONSTRUCTION TAXSlgatu of Appli omrator Date TH D(W/DUCT) CONSTRUCTION TAX PAID:HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfutom Wilding occupant store or handle haudomG UNIT 1W,OJOBTU)material as defined by the Cupertino Municipal Code,Chapter 9AZ and the _ Date ReceI t#IIrAth and Safety Codg.ectim 25532(.)? GUNTT(OV 1W,DDOBTU) ©`TYes I.S No TOTAL: L NWill the a ppliant orfumre building occupant use equipment or devicesTION FAN(SIN ERESID) ISSUANCE DATE which emit h.rardoue air contardanba.defined by the Bay Area Ale Qu lity Maagnment tnct? OMP 0HPOR 1W, BTU) 4Yn No have read the lasses ore materials requirements under Chapter 6.95 of BOILCR-COMP(OVER IW,ODOB the GlBemht Health 6 SafetyCode Ions 25505.25533 and 25534.1 PAZ understand that lithe building doe notes entlyhaveamnanQthatitiamy NEW RESIDEN➢AL MECH. S'Q.FT. responstrauth noti theocapa to(the requirnments which must be art II II D'! 4 9 prior tyrtl HEate Occupancy. sSM4 4,� V e ower agent Date y TOTAL, ISSUED BY: OFFICE COPY