S 2678 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 2678
- BUILDING PROJECT IDENTIFICATION lJ
BUILDING ADDRESS: SANITARY IN APPLICATION SUBMITTALDATF
10151So. &AA101 Aug. 3-x•99
OWNER'S NAME: PRONE: CONTRACTOR'S NAME: LIC NO:
t045 8/E9MQke II o EG7� ye' NIC CONTROL#
\R HITECT/F.NGINEER: LIC NO: ADDRESS:-
lJClAfe asscr�A�S ° 2 0 0
�WIIIQ� �`NPlS U MlSe ��PHOIj'F� S2o� BUILDING PCR LU INFO
(Cd_C1 NT-4 G ❑ Consultant Fees Paid by Applicant(Initial) 6LU ELECT PLUMB/ ME
ARC#-�oY RAvn+u�oo V r4aL_-T/
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 mm licensed under provisions of Chapter (commencing JOB DESCRIPTION
"Z with ScOma7000)afDivisicn3ofthe Businessand Profusion.Cele,andmylicenseix RESIDENTIAL:
W C'0 PERMIT ISSUANCE. n�O
F+� in full force mm eBect. ❑SFDWL ❑KITCHEN REMODEL
�U[�,,31 License Class CAPPLIANC17S-RESIDEN'1'IA), E:1 ADDITION El PLUMBING RE-PIPE
m a Dnle Commit...
GS
ARCHITECTDECLARATION DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
Z O Nrn 7� 1 understand ml'Plans shall be used as public Taco#. MODIFICATION
py,,p UP T02(p AMPS El INTERIOR [I CHIMNEY REPAIR
F 4tIa1 Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER�100),ATM
AMPS [I HATH REMODEVREPAIR DEMOLITION
�j^ 1 hereby affirm that I am exempt from tire Contractor's License Law for the
W'3"GWi V following rwxon.ISectinn 90315,Rwiness and Prnfessier,Code Any city or ceumy SIGNS 11 F.CTRICAL El OTHER
W an which requires a penny to construct,alter.improve,demolish or repair any structure
F❑❑"�i�inn< prier taus issuance,also requires the applicant for such permit to rile a sigaed.stawment SPECIAL CIRCUIT/MISC.
2 pthatheis licensed pursuant o the provisions ofthe Contractor's License Law(Chapter 9
W 60 (commencing with Section 9000)of Division 3 ofthe Business and Professions Caic)or TEMP.METEROR POLEINST COMMERCIAL'
d c tG that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
"^
Section 703115 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
w ❑TENANT ❑FOOD SERVICE
F5pnotnmre than live hundred dollars($500). IMPROVEME T
❑ 1,as ownsr nT the Prnpetty,nr my employee.with wages us dalr-sole mmpensadon, SWIMMING POOL ELECTRIC
F will do the work,and Nestructure is not intended or offered for sale(Sec.9044,Business 01 OTHER epnn����ss dd
mand Professions Crile The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTUR /w/•Y/QW
property who builds or i al hot
such improvements and who doe.soca work hl d ,,or through
his own employeese provided that seen ssold are nor Recoiled nr plrercd Tar NEW RESIDENTIAL Lf.N,CI'
sale.If,however the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
eobuilder will have the burden of proving that he did not build or improve fn
or pu
owe of sale.).
1,as owner of the Sec.property,am exclusively contracting with licensed contctors i- •] �
construct the butt(See.,,co Business and professions Codes)The Contmetods Li- Ok
cense Law drcsnotcapply man ownerofpmpeuy whosedpor bnprovu Corton,and QTY PLUMBING PERMIT PEP.
who contracts for soca projects with a commensals)licensed pursuant to the enmmctor's p�
License Law PERMIT ISSUANCE pJ
❑lama ///�nder sv _,B Se P C for thisreamn A -7
,� AFTER-DRAIN&VENT-WATER(EA) ? O VALUATION
D R 1��WiWORKER�'M�— 1 105 WO
t WORKER'S COMPENSATION UfthefRAIION BACK PLOW PROTECT.DEVICE
u Inereby affirm under penalty of perjury one of the following dcclumtions: �
❑Ihavc and will mainmin aCertificate of Cnmenno.cif-ioxurofor Wader's Compen- DRAINS-FLOOR,ROOF,AREA,CORD. STORIES TYPE CONSTRUCT ION
sation,as provided for by Section 3100 of the Labor Code,for the Perform trice of the a-� ^ .�/�E V
work liar which this permit is issued, FIXTURES-PER TRAP `r
❑I have cad will mainmin Worker's Compensation Itnurunte as required by Section
37M ofthe Labor Code,for the performance of the work forwhich this permit isis,ued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP RE My Worker's Compensation Insurance carrier and Policy number are: -
Cartier Policy Na: GAS-EA.SYSTEM-OVER 4 WA) riff
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVIN USIRL WAS'1'-INTERCEPf
BUILDING DIVES ON FEES
(I'hls sedioa need not bocomplemd iRhepermit is for one hnndreddollurs($1001 GREASETR
or less.) pLANCHECK E
I ceriry that in tneperummence ofthe work for widch do,tteman is issued,l shall SEWER-S RY-STORM.FA. 00� ENERO
not employ any person in any manner se as to become subject nt the Worker..'Cmnpem ,,rr ZO
ZZ cation Laws of California.Date WATER HE R W r.r EELTR GR N
Q Applicant
rjl NOTICE TU APPLICANT:if,after making this Certificate err Exemption,you should WATER SYS /TREATING
I"1 became subject to the Worker's Compenxutloe previsions of the Lobar Cale,you mon S(
Wfico In comply with such provisions or lhis permit shall be deemed revoked. WATER SER E@
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. S r PAID
V Q 1 hereby affirm that there is a wnxwdinn lending agency for the performance of Dam ecolpt#
the work far which this p annit is issued(Set.3097,Civ.C.)
CU Lender's Name A
WLender's Addres.a TOT '^
1 cemi If that 1 have rend this oppiie,vtom and nate that the above information is B I D 'E V
Val correct.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE �`O
building construction.and heroby authorize representatives ofthis city toentunpon the SE IC FEE .J
above-mentioned property for inspection purposes. / PERMIT ISSUANCE �jb
(We)agree to save,indemnify iced keep harmless the City of Coleman against 'LE E
74
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTI3R OR ADD'I'O MECH. PLIIMRI G Pf O
sequence flhegraming ntlhis permit
APPLI NT NDERSTANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO III,WOCPM)
SOUnCP ULATI(/ST MECH E
AIR HANDLING UNH'(OVER 10,000CFM) CONSTRUCTIONTAX
Signature of
HAZARDOUS
O Dam EXHAUST HOOD De/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
as WillCofuture building at more 2nunde hvmMOaHEATING UNIT(I100.0010 BTU)
defnal by the Caperinn Municipal fid,Chapter 9.12,adthe Health and Safety
Coda Section 25532(n)p HEATING UNIT(GVHR 100,000 RTU) -
❑Yes LON. PAID
VENTILATION PAN(SINGLE RBSIU) —Dam Receipt#
Will tnc applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Manegement BOILER-COMP(3HPOR 100,000 B'I'In
Uisaiet[ BOILER-COME(OVER IM."BTU)
�Yex
I have read the mtus m
enanateriels requirements under Chapter 6.95 of the Cali- ISSUANCE D TE_
lomia Health Safety Code,Secaons 25505,25533 and 25534.1 understood that if the NEW RESIDENTIAL MECH. SQ.FT.
build tcurmmlybucatenanb tbet it lx my responsibility mnotily the occupant
Wt ch, .at 'h " w pdor laissuanceofa Cu3cmO�cy///gnyy.
O authorized irized agent 7 fIg9fDnt�(� C� TOTA ISSUED BY:
OFFICE