Loading...
22461 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Praect Identification /1 111--1 PERMIT NO. Building Address: 1.7 F+ 22461 p 'L 00 vic. ve*% A t3L� ELL. p. SH _ era ane. afyLfa CITY OF CUPERTINO-BUILDING DIVISION Com rsName: Lie.No: APPLICATION / PERMIT 1 BUILDINGMECTRICA4PLUMBING-MECHANICAL CATEGORY hQR .`N[J^) �• Am7 mer. CO Lie.N. l0("7 1 I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address I PERMITISSIIANCE LICENSED CONTRACTOR'S DECLARATION I,L1J 1/Js' I(J_ Ihereby affirm that l am licensed under provision of Chapter 9(commenc- APPLIANCE -RESIDENTIAL JOB DESCRIPTION Ingwdth SectImi7000)of Dtvh,t.3 ofthe Buslnessand Prefession.Code,and m license Is In full force and effect. PANELS SF�L License Clam Lica Date Contractor ARCHITECT'S DECLARATION 2014000AMPS ox c records.Zp I understand my plana shall be used as publids. OVER1000AMPS SQ. BOOR AREA f/SQ.FT. Licensed Professional SICNSELEC / , `�' / «<�6 OWNER-BUILDER DECLARATION SPECIALCIR ZV cT/ fp, a I herebyafRrm that l am exempt fmm/he Contractor's License Lw forthe + OZ follawlogreason.(SMIon70'i1S,Buslnessand Profemlone Code:Anydtyar TEMP.M t NS . Pr 4 county which requreesa pernottocenatrus,alter,Improve,denioltsh,erespair yy a nystmmmpMrtalreW ame,alaorequlrestheappUmntfwauchper tto POWER DEVI W ilio a signed statement that he Is beensed pursuant to the providers of the 0µr Contractors License Law(Chapter 9(commenctng with Section 7000)of Divi- `` 30:1 .don 3ofthe Business and ProfmbmCode)mthat he 13 exempt therefromand SWNLWfl[iPOOL ELECTRIC VAU rat- ,N k5 O...777 the Exists for the alleged exemption. Any violation of Section 70115 by any OUTLETSSWITCHESHXTURES -� applicant for a permit aab)ectsthe applicant to a civil penalty of not more than five hundred dollar($5001, R NEW RESIDENTIALELECIR_SQFI. SfOWFS _TYPECONSTACTION GGGG1111 �n I,as owner of the property,or my employm with wages a there sole mmperwHon,Business work andthestmdurebnot Intended or offered for O role(Sec. pply to an owner df property Code:The Contractors Llcerae law $ docs not apply torn owner ofp rough who builds mpoyeprwnted that such OCC.GROUP RES.UNITS EE whodoeusuchments am nothimself dedorughhLown ale.If owevrovldedthatach Improvemenlsarcd withi oneyestrofcdforsale.themonveg deer ldl scar have TOT I - ImprovementtssoldsvithinoneyxarofcempldleM theownerbudderwill love ' t14r,blydm of proving that he did not build orlmpmve for purposeofsale.). QTY; PLUMBING PERMIT FEE FLOOD TONE APN �iyly as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE //yy�� tractom to construct the project(Sec.7044,Business and Professions Code: W The Cantractors License law does not apply In an owner a property who Wilds or Improves thereon,and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA) cj5actor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY 1_1 I am exempt under See B&P C for this reason BACK FLOW PROTECT.DEVICE Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ ' WORKMAN COMPENSATION DECLARATION REC�'1'a C]I hereby Ofbm cese that I have a rtificate of consent to self- FIXTURES.PER TRAP SCHOOL TAX Y_ N Inert,or a RECEIPT If certiflceleo(Workeri Compensation lnauranaore emitted copy thereof(Sec. GAS,PA SYSTEM-1 INCA OUTLETS PARK FEE Y N 3800,Lab C.) __ RECEIPT a Policy p GAS EA.SYSTEM-OVER!(EA) Com any BUILDING DIVISION FE IS ' Cerfiled copy is heed withformatted.city CREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE Certified copy b filed with the city Wpectbn division. 1 CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP r1...a e k C�PAID (.� COMPENSATION INSURANCE ! 29As (Thbsection need na be completed l the permit ts for hundred della. SEWER-SAMTARY SCORN FA'X107' Dale Recel N Iceutrtifyify that in the performance of rhe work forwhlch this permit is issued, WATER HEATER W/VENT./ELLCTR ENERGYFEE Y�-L7(II w loos I shall not employ any person N any manner n as to become subject to the WATER SYSTEM/TREATING +J C. T1 Worke.'CompensaHenlawsof Gidfomb.Date PAID V O Z Applicant NEW RESIDENTIAL PLMB. QFT. Date Rem, the Z 0 NOTICE TO APPLICAM:I,after making this Certificate of Exemption,you should become subject to the Workers'Compenaatlonprovision;of the Labor T7 / � TOTAL. t y Code,you must forthwith comply with suchproviamuorlhtspermNshallbe tue, 360 UIZ-8 LA -U 5 FMS05 J1---� qt pl W deemed revoked. �^ �Yl CONSTRUCTIONemIs on LENDING AGENCY 1V SEISMIC FEE G O >•"'-�'a� 1 C Ihfthb affirm thatthem . trualond(SNg.3Wagency fort) perform IL TOTAL: ELECTRIC FE p 0 2 enceofthework!erwhkhthtspermittslawed(Sec.3lN/,CIv,CJ O �4 5l LL O Lc.dera�Add Q PLUMBING FEE m LL Lenders Addmm QTY. . MECHANICAL PERMIT FEE MECHANICAL FEE ! OW Irertifythatlhavcomply sappllnty andcrmayoatthaabavelnformation �ey 4 Escorted.I agree to complywith all and county ordlnanm and slate laws PERMIT ISSUANCE q, W PEES PAID: N relating to building construction,and hereby authorla,representatives of this F Z city to enter upon the above-mentioned property for Inspection pu rposes. ALTERORADDTOMECH. Date Revel III V - (We)agree to save,Indemnify an d keep harmless the City of Cupertino against BabNtlee,judgmenfs,mkund ezpsnm which maylnanyway.oma AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL: p�mu Id Ci Inco a lthe artm dlhi permit. / P ! AIR HANDLING UNIT 10,000 CFM) - CONSTRUCTIONTAX ([7 /a3 gnature f p cent/ omsador r 4 EXHAUST HOOD(W/DI1CT) CONST g LTAX AI HAZARDOUS MATER LB DIS If '��l• D Will the applicant or future building pants an Ic haz nio a IdFAHNG UNIT(TO 100,000 BTU) Date matedalasdefined bythe CupertI.Mu.I ode, 9.12,and the .-- - Heahh and Safety Code Sedion 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL Yes M No ei" t Rill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) EpgTE which emit hazardous air contaminants as defined by the Bay Area Air • Quality Management District? BORER-COMP OHP OR 100,000 BTU) 4r�� Yes No z 4 to havereadlhehn❑ SEP BOILER-COMP(OVER 100,000 BTU) Ivg� the Californb Health&Safety Code,Beetle.25505,25533 and 25534.I understand that If building doe.not currently have a tenant,that it le my NEW RESIDENTIAL MECH. SQFT Clgr asL/tMT„ responsibility to notify the occupant of the milu mmu eents which ni be met C*Yg IJ"n4 prior to Issuance of a Certificate of Occupancy. S1 1 q0 _ T Owner or authorized agent Data - ISSUED 'TOTAL: j0 OFFICE COPY