27588 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-Ic .CTRL AL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C O O
BUILDING PROJECT IDENTIFICATION J o 0
BUILDING ADDRESS: 11 /I SANITARY NO. APPLLIICATIONSUBMI'ITALDA'IL'
DO �uW Rd UNIT# LOT
wNERS NAME: PHONE: NTRACT (NAME: LIC NO: NIC CONq'ROL#
n Cho' 2.- 1100 Scall aoWiker
CHITE-CT iNGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE
BILDO
F PL MB
PERMIT ISSUANCE
W.Z LICENSEDCONTRACTORS ionsufDECLARATION APPLIANCES-R L �r. IO Ij�tl'I`(11 `
Ihercby effrmthatlam licensed under provisionsof Chep¢r9(commencing with V\_
p00 Seedun]000)of Division 3ofthe Business and ProfessionsCode,and my license is in PANELS
a �j tau force and effect.
A
UPTO20I1 PS
aZy`)j License Class Lic.p
No. Date Contractor 201-101 AMPS
I— ARCHITECT'S ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ. .
ZO'A— Iunderstandm I hall beucedas public records. OVER AMPS
OZ-0
my pu 5 SELECTRICAL
It aFa SNd�[Ij Licenced Profoa Tonal
SyvwwQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Oy V 1 hereby affirm that I am exempt from the Contractors License Law tint th
m LLOrFta finlowingrceson.(gemion 7031.5.Business and Rofessiona Cade:Any city or ty TEMP.METER OR POI. 1
which requires a permit to conswe6 alter,improve.demolish,ar repair structure
pd., its ismanre,alsoregoiresthe applicant forsuah permiuofile as nedsmemem POWER DEVICES
pjW C) that he is licensed pursuant to the provisions of the Contractors License ,tamhlr SWIMMING POOL � CfItIC
6 0 f' 9(commencing with Section 7W)of Division 3 ofthe Bummusand Profesit sCode) VALUATION
' ,_y or he is exempt and the basis for the alleged exemptionttivil l "on of
�¢ Seniors than iv hundred
deltas
subjmuthe eppliuntmacivil penal f41; OUTLETS-SWI ES-FIXTUR
m more then five hundreJ dollms(E5o0).
G NEW RESIDE AI.F.L. Q.FT. STORIES TYPE CONSTRUCTION
W�2 ❑ I,da,wrk,afthepropcny,ormyemdendis .(feed formic
compensation,
a3— will Professions
Code:andidiThe Contractor's
License
La do fur of apply
to an,Business
and P ty whioms Code:The Comm.('. .icrose law dors not apply lf an owner
properly who hu it da or improves thereon,and who ares such ward himsel f ar through his
employees,prnviJedtham such improvemenuurtnm imtrndedarofferttl torula.IL OCC.GROUP RES.UNITS
however,the building or improvemem is sold within one yearofm rld1don,the owner- TO
builder will have the burden of proving thin he did not build or improve for purpose of
side.).
❑ I,os owncroOM1eprolKrty.are ex<Imivelymntracting wird littnxJ controctonm QTY. PLUMBING PER IT FEE FLOOD ZONE APN
construct the project(Sec.10,14,Business and Pfafessimes Code:)The Coneacmra PERMIT ISS CE
License Law does not apply to an awnerofpraperry whobuilds mimpm,iwdam mand
who comrectafmsuch projectswith anontmcto(fa)littnxd pursuant tothe Conuecmrs AI TPR-DRAIN&VEN -WATFR(HA) FEE SUMMARY
_
License law.
❑nI am exampi under See ,B&P C for this reason BACK FLOW PROTECT.DC•VICF. OU I D 'E.
SANITARY Y N
Owner Date DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
I hereby affirm that l have o certificate ofconseut m self-insum,ma cinifieam of Fl%TURLS-PER TRAP /� RECEIPT'#
Orden Compensation handsome or D certified copy thetrof(Sec.381p,Lab CJ which PARK FEE Y N
ars all employee's harl"'his permit. - RECEIPT#
Policy# GAS-FA.SYSTEMd INCA OUTLETS BUILDING DIVISION FEES
Company GAS-BA.SYSTEM-OVER 4(EA) PLANCHECK FEF,
❑ Cenifiedcopyisherebyfni fished. It
❑ Certified copy is film with the city inspection division. GREAS NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OR SOILS FEE
COMPENSATION INSURANCE
(This action need not lz completed ifthe permit is Intone hundred dollars($100) SE EA. ENERGY FEE
or less.)
I certify that in the performance of the work far which this permit is issued,(shall WATE H TER W/VENTfCLECIR
not employ any person in my manner so us to become subject to the Workers' PAID
Compensation Laws of Califomia. Date WATER STCM/IREATING Data Receipt#
O z Applicant
z 0 NOTICE 10 APPLICANT:If.after making this Certificate of Exemption.you should NEW RESIDENTIAL PL.MS. SQ.FT. TOTAL
T--m u become subject the Workers Compensation provisions of the labor Code,you must pU1LDING FEE
forthwith comply with such provisions or this permit shall be deemed revoked.
12J " SEISMIC IEE
Q CONSTRUCTION LENDING AGENCY
z I hereby affirm that hem is a concoction lending agency for the performance of ELECTRIC FEE
V O the work for which this Permit is issued(Sec.3097,Civ.C.) ram
Lenders Nome PLUMBING FEE
Lenders Addrces QTY, MECHANICAL PERMIT VFPE
W1 certify that 1 have read this application odd state that the above information is MECHANICAL FEE
correct.l agree to comply with all city and county ordinances and sante laws relating toPERMIT ISSUANCE
y building emiduction,and lumbyit.dumire repteaenmes
fivofthiscity teenier uponthe T CONSTRUCTION TAX
L) above-mentioned property for inspection purposes. LTER OR ADD TO MECH.
(We)agree to save,indemnify and deep hadidess the City of Capmina against
liabildies,judgmrnu,costs§Qit expert whichmayinanywayaccme Umnatxid Cpy AIR HANDLING UNIT(TO 10,000 CFM)
in can uentt or $1/I cry
sc'q�`#�•y/o#/1 h mYl`(inAgv/� AIR HANDLING UNIT(OVER IO,OW CFM)
Signature of ppl1CuntfCmadmemr Dent 9, EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the applicant in future building occupant store or handle hazardom material IIEATING UNIT(OVER I W,000 BTU) TOTAL:
as defined by the Cupcnina Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Section 25532nd? VENTILATION FAN(SINGLE RESID) vl�s
❑Yes ❑No
ISSUANCE DATE
Will theapplicantorfutumbuildingnecupant useequipmemordevices whichemit BOILFE-COMP(3HPORIW.0o0BTU)
zorders air connotations as defined by the Bay Area Air Quality Management BOILER-COMP/OVER IM."BTU) -
stncR C:a R /�
11 yes 11 No NEW RESIDENTIAL MECH. SQ.FT. y r 9 FV /p ID
I have read the hurom ous materials requirements under Chapter 6.95 of the �
California Health&Safety Code,Sections 25505,25533 and 25534. I otderstand NDEC(I '8'9 '(O^
if the building does not currently have a temnL that it is my responsibility to notify the �f.5�(s/`7/ja}ry4'l.(r4T��r#,l(
occupam of the requiremenu which must be met prior issuanre of a Certificate of f `Y
Occupancy. O _ (,
Owner,or authodred agent Data T ISSUED BY-~`'�
OFFICE r