Loading...
22184 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY Building Project Identification �7 PERMIT NO. Bulldln/O 5-'6q 14I&4zlA- - - - 22184 m e ame: ane: - �rC. CITY OF CUPERTINO-BUILDING DIVISION (J —11 APPLICATION i ' Con actor's Name: LIc.Na APPLICATION /PERMIT ES BUILDING-ELECTRICALPLUMBINGMECFUMCAL CATEGORY CONTROL rch act/Englnaer. Lk.No: _`^ i QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Add... �''O J sJa/ 4I�-}a�� PERMIT ISSUANCE _W D D ❑ LICENSED CON ACFOR'SDECLARATIO �(-f I hereby afftrm that l son licensed under provisions of Chapter9(col� APPLIANCES-RESIDENTIAL JOB DESCRIPTION ingwith SecHon7D00)of Dtv sion3ofthe Buain MdProfe onaCode,and my Iimnee le In NB and dhot. //]] a PANELS 1 License Class L'N '�7� Dale Contractor UP TO 200AMPS ARCHITECT'S DECLARATION 20I-1000 AMPS pQ±NO z co I understand my plane shall be used a.public mounds. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ,FT. E d Licensed Professional SIGNS ELECTRICAL «<< OWNER-BUILDER DECLARATION SpECUL CIRCUIT/MISC z affirm that(hereby affirthat I am exempt from the Contracum's License Lawfurthe p qqqq following reaaon.(SeciNn 70315,Businessand Professions Code:An d or FZa'ut ceuntywhichrequimaperenttucowtvM.Iter,bnpmve,dem lWh,ormpalr TF 'NP .MEITX OR('OLE INSf. M<r'S nur 3 anystroe prlorto lis Issuance,also requlresthe applicant for such permit to POWER DEVICES �a fih a signed statement that he h licensed pursuant to the provisions of the Ow CRnlractore License Law(Chapter9(commencing with Section 7000)of Divi-30 VALUATION alon3ofthe Busineasend ProfessionsCode)orthat he h exempt lherefromand SWIMMING POOL ELECTRIC , the basis for the alleged exemption. Any violation of Section 7031.5 by any <S applicant for a permit subjechthe applicant toacivil penalty ofnRlroom than OITILETSSWITCIiFSHXT[1RFS Ove 1,aso earofIdollars(5500). NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSMUCHON ,< ❑Lasownwill oflMe work.,ormy emtorn Iswithwago rtheir sole com(Sec 744,Businetheworkandions Code: knot Intended oroffendfor O doe(Sec 7646,to Businessand property Code:The or impctafs Licenselaw $ does not apply loan imeerofprough who nembuildorimproovidedvacs that such OCOGRO(IP RFS.UMTS wisp ovementsworkMm,elf ed oreugh his own employees,11,ho ea,provided that,rach Improvementsarenot Intended earo(ca forsale.If,hcavev-b deer ilI have 7OTp7,; Improrden ofbeoingtht he did not have tf urdenwner of the Po.did not buOd or lm prove for purpose of sale.). QTY. PLUMBING PERMIT ' FEE FLOOD ZONE APN u L as owner of the property,am exclusively contracting with licensed PFRMITISSUANCE contractors to construct the project(See 7046,Business and Praessbru Cade: The CRntraaori Ldrerue Law don not apply to an owner of property who ALTER-DRAIN h VENT-WATER(E Improve or Improve thereon,and who contracts for such ptojem with a FEE SUMMARY cgpjfacior(s)licensed pursuant to the Cont.d&.License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B k P C for this reason Owner DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N _ ' Dare WORK MAN COMPENSATION DECLARATION RECEIPT NFTA'MRES PER TRAP SCHOOLTAX Y N ❑I hereby affirm that I have a certificate of concent to self-insom,f or a RECEPT N 3800,Laeo(WRrkers CRmpewHonlnsunnca oracortllled mpythereol(ies. GAS EA.SYSTEM-1'WCAOUILEIS PARKFEE Y N Policy lab C.) PCoollq N RECGAS EA.SYSTEM-OVER 6(EA) DING DI N Y BULL DING DI VISION FE ES sniffed copy is hereby te Certified copy h filed withh the city Inspection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE ity CERTIFICATE OF EXE'MTTION FROM WOR KERS' GREASETRAP PAID COMPENSATION INSURANCE (rhlssectloreved na becompleed lithe parent hfororehundred dollars SEVER-SANTTARY-STORM EA.WIFE. Date Remi t# (f100)oefm6 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N I certify that In the performance Rfthework forwMch this permit Is Issued, — 1 shall not employ any person In any manner n as to be©me sub0 to the WATER SYSI.EM/TREATING Workers'Compensation Laws of California.Date PAID . O Z Applicant Date Remi t# Z O• NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT. should become subject to the Workers'Compensation provisions of the Labor TOTAL' Q N Code,you at forthwith comply with such provisions or this pemdt�hallbe ` > deemed revoked. E aC CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirm that there is a constroction lending agency forthe perform ELECTRIC FEE 7 Z anceof the workfor which this permit h hawed(Sec.3097,Cly.C.) TOTAL: (,) O Looder's Name PLUMBING FEE LL FS Larder's Address QM TY. MECHANICAL PERMIT FEE MECHANICAL FEE OW 1cetifythat l have readthh applicatlonand Aeration theabove information !L hmrrcct."gree to comply with all cityand countymelinanm and state laws PERMI'IISSUANCE - FEES PAID: >- relatingtobuilding construction,and herebyauthorlumprmntatNnofthb P. city to enter upon the above-mentioned property for inspection purposes. ALTERORADDIOMECH. Date Recei f# (We)agree to save,Indemnify an d keep harmless the City of Cu Exertion against llabl lies,fudgmmta,costsand expense,which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: agalnats CI in nsaryenmofthegrantingofthispemit. + AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX ' g reofAppliallmlContractor Data EXFNUST HOOD(W/DUC•q CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle haunious HEATING UNIT(TO 100,000 BTU) material..defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Receipt Health and Safety Cade Section 25537(a)? HEATING(IMT(OVER 100,000 BTU) a RYes illthe applicant Rr Nre building oavpot use equipment or device, VENTILATION FAN(SINGLE REED) ISSUANCE DATE which emit hau rdous air contaminants as defined by the Bay Arca Air Qua lily Management District? BOILER-COMP(3HP OR 100,000 BTU) QYe, I—I No Tisa Bread the hau ouamamriah requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) '1 the California Health k Sa fety Code,Sectlom 25505,75533 and 25534.1 / •t •{(Tll9 understand that if the building does cut..city have a tenant,that it is my NEW RESI DENTIAL MCCH. SQFf. �A ph/ ry} ,jx�7.71 responsibility to notify the occupant of the requirement.which mu at be men t FT1 prior to issuance asCcdlficate ofOnvpanry. ' Owner ar aulhoAud agent Data ISSUED DY: ' TOTAL: OFFICE COPY `. L07— A. 10s(o47 Miz.c.EP. 2y4 E�hGaF-i. fp 17'0'' .ADIcA (c' SC Ell-•o4 iA S CZ\l L.--- : n =�~I .L LI��LF1F ��N ]B� --- MNG DEPT.L IN ACCORDANCE WITHCI CUPERTINO CODE$AND � ORDINANCI C J . t of plans andt Cl r�b kgtt on the job at all times bis BUST _ I Wk I t o a rtd if un- —_?l{—� r' I!U �EL�,�i6l KL F buiiding Dept C Permis�on from ERE , o atampngof this dY rf Cupertino. `.;'. �` L! NOT bt C'R'id pPea and it�lls ;r as *oval ofto .WjSfV an---- MAY t.. ._ i.- mr C7t �'oidhition,tif Icy ,Proui0 hesi0s; 2Y 0 UIOP " 0. INSPECTION DEPARTMM n '.r CITY Of CUPERTIN®, -- _`F_�` l (r' GDT .2 APS'G 9 MI LLE•!L J I-IF? I (:Ti Siff • ` 1�r� � .P ,Vii' i � � h if iL 1(1 I r Lo7"' cP _• / LOT LvT (o X Co_ Po STS•......... .....�_._. �2 w� f. l • a6� �?D`.� /N • ``tom CoNG2-t.CL S LOT- I - loSKS MI[ • , LOT i — l 0 549 M ' L—OT 9' — l O 537 M I" E oo Is Po5Te -.......... ..._._ ` f . 051 iN -