27914 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO
BUIL DI—NG--.MECHANICAL
MECHN FOCAL vERMrrrvo.
APPLICATION/PERMIT PiRi;HoGcr IDENTIFICATION
4
I4U11,11ING DIVISION BUILDING PROJECT 113EN'I'IF'ICAI'ION
BUILDING ADDRESS: SANI FARY NO. APPLIIC�CATIO/N SUBMITTAL DA IT
HOMRSTEAD UNIT# LOT# //q
AkiS Mli: PHONE: CONTRACTOR'S NAME: LIC NO: VV J_
SOUTHLAND CORP 510 4632711 nRF(-. RnRnF.N N/C CONTROLa
. —
ARCHITECf/EIJGINE[R: LIC NO: ADDRESS: ❑
'P_es.taia—'Flue ;-
CONTACT: y1lpNF BUILDING PERMIT INFO
Paul Sarrett 51V 463 ?�I TY. ELECTRIC PERMIT i; �E PLUMB MUCH
PERMIT ISSUANCE p\
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
Ortiz I hcrebyaffirrahat Ili<cnxA unJerprovisionsa[Chupmr9(eammenoinr,with JOB DESCRIPI(ON
m 00 Section 7")of Division]of the Business and Professions Code,and my license is in PANELS
tF<utl— fan(area and effect. PARKING LOT LIGHTI
(¢.,Zm License Class Lic.a_'69.1929= UP T02W AMPSNIG
m=y Das Contract nf _ 201-1000 AMPS
,QNz ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OZ—�O understand my plans shall be used as Public reauds.
FTsF-ou SIGNS ELECTRICAL
QY.7,, Liccmed l'nfe,ional
�xw< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
ZOp,E 1 hereby affirm that I am exempt linin the Contractor's License law for the
u1 :Wont following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METJs.R OR POLE INST.
F-LLJy J which requires a permit to cunstryet.utter,improve,demolish,or repair any mmmure
priorto its issuance,atm rcyuireslhT Wif"fire
nucM1 permitmfileesignrA staemem POWER DEVICES
y�jC�Om That he is licensed pursunnuo nn PrnoConvaclors License law(Chapter
X "I 9(com am,with Section] Sof the Business end Professions Gde) SWIMMING POOL ELECTRIC VALUATION
ort ath rapt s a t Ihthe alleged exemption.Any violation of
Q See n L yn p' bject,th- loco civil penalty of OUTLETS-SWITCHES-FIXTURES
�'� not m an red offers',
llurs($500). /y,►��''�'°
`4F. ❑ 1'. ernRheProperty,m y m swi}h a olecampearm, n, NEWRESIDENVALELECR SQ.PT'. STORIES TYPECONSTRUCION
a. wi lJmhc rk,andt','Itucmrcixnn de (feted rsale .]B14,Business
and Pro as as Codcft,':,,Ixx11��^^ Cnyyrra Ion's sc Law does nn ePply m an owner of
propenywho builds orittlp, ;?h e,and whodoes such workhimxlforthroughhis
employees,provi( th.tsuchimprovcmenustrcnotintendedunsffemdforsale.if, OCC.GROUP RFS.UNITS
however,the building or improven ad is sold within one yearef completion,tfieowner- T
builder will have the burden of proving that he did not build or improve for purpose of
sole.).
❑ 1,as owneroflM1e propen�exclusively comhowing with licensed contractors la QTY' PLUMBING PERMIT FEE FLOOD_ZONE gpry
construct the projot ISec.IT Business and Professions Code:)The Contractor's pERMI'1'ISSUANCE
License Law docs not apply m an ownerof property who builds opro
Imvesthemon,and '
who comment for such projects with a connotations)licensed pursuant lathe Committees
License Law. ALTER-DRAIN Ar VENT-WATER(P.A) FEE SUMMARY
❑ I em exempt under Sec. B&P C for this..an BACK PLOW PRO'T'ECT.DEVICE 0UT,TDF;FE
SANITARY YN
Owner Date DRAINS-FLOOR.ROOF,AREA,CONE. RECEIPT'#
WORKMAN COMPENSA'TTON DECLARATION SCHOOLTAX YN__
❑)Q hereby affirm that I have a certificate ofconsennoself-inure,ma mni0cate of FlXTURlS-PER TRAP RECHIPI'a
Workcri Gnnpenution Insurance nracenified copy thercaf(Sec.3g00,Lab C)which PARK FEE YN_
covers ell employer's under this permit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT a
Ibsy a BUILDING DIVISION MMS
Compwy C+TGAS-EA.SYSTEM-OVER 4 A)
[ICenilicJ copy is M1ereby famiSNed.n'�U � (EPLANCHECK FEF.
❑ Certified copy is fled with the city insPenion division. GRFASR(INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGRHASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisxction need not be completed ifthe patmit is far one hundred dnllam($100) SEWER-SANITARY-STORM EA,2WFT.
less.) ENERGY FEE
I certify that in the Performance ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any person in any rammer so as to become subject to the Worked PAID
z Compensation Laws of California. Date
WATER SYSTEM
/1'REA'1'ING Done Rerciptp
Applicant
zQ NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should NEW RES]DENTIAL FLMB, SQ.ET. TOTAL:
E U) Itecone subject to the Worker's Compemwdon provisions of the labor Code,you muss
forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING TEE
ps O CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affimt that them is s construction lending agency for the performance of
L) O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL ELECTRIC FEE
Lender's Name
OU Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 certify that I have read this application and store that the above information is
F1 correct. l agree to comply with ull city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICALFF:F.
fn building construction.and hereby amhorim rcprexnmtfves ofthis city to enter upon the
L„) 'Z aWve-nmmiancd M,,,ny for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)arra,to vve,indemnify and keep harmless the City of Cupenino against
larniines,juJrmgnw ons and expenses which may in any wayaccmeagainst aid City AIR HANDLING UNIT{TO I0,000 CEM)
a.canc< 1 graining of Imit.
i si O / AIR HANDLING UNIT(OVER I0,"CTM)
Si awre ofA p]icaMO' EXHAUST HOOD OODUCTI
PAID
HA" OUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) tDate� Receipta
Will the applicant or mune building ocupaut,store or handle hazardous material
as defined by the Caperton Municipal Cale.Chapter 9.12.and the Health and Safety HEATING UNIT(OVER 100,000 BTU) � � J TOTAL.
Code,Section 25532(x)?
❑Vias 1)No VENTILATION PAN(SINGLE REMD)
Will the applicant or future buildingoccupanmsamquipmenteadeviceswhich emit BOILF,R-COMP(3HPOR 100,000 BTU) t,�/Y IS, �E DATE
has udi os air contaminants as defined by the Bay Area Air Quality Management (k `.
District? BOILIiR-COMP(OVER 100,810 BTU) UfJk'zr/ �11�
qF ❑Yes ❑No
NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazuNuus materials requirements under Chapter 695 of the
California Health&Safety Code,Sections 25503,255]3 and 25534, l understand that
if the building Jos not currently have a tenant,that it is my responsibility m notify the
occupant of the nNuimments which must Ix met prior to issuance of a Cenmcate of
Occupancy. /)
Ownc,or ounfir
used agent Date �1(w
TOTAL: ISSUE BY:
OFFICE