24889 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEICI'RICA I, PERMO NO.
BUILDING DIVISION APPLICATION/PERMIT 1'LUMBINO.MET'BANICAL !� O(�
BUILDING PROJEC'I'IDENI'IF'ICA1 HIS C o a
9UILDING gppIt F;SS:�� , SANITARY NO. APPLICATION SUBMITI'ALDATE
&SNINN� LOOP UNITp LOTp
PHONE CONTRACTOR'S NAME: O: r
\tel"b/
NIC CONTROLN''ifgg��
• ARCHITCCI/ENGINEER: LIC NO ADDRESS: - ❑ -1
CONTACT: PHONE: QTY. E11Ecr C 0,,'yWT, FEE BUILDING PERMIT INFO
BLDG EPLUMB MACH
PEWT ISSU C
LIC ENSEDCONTRACTOR'SDECLARATION n P q i5 „IDENTI JOB DESCRIPTION
pyy Thereby nffnnthmlam licensul underpmvisinnmfChap¢r9(e)mmencingwith
{^00Senion]IXNI)nf Division3uf Ne Business and Professions Code,and mylicense is in PA
=,u full force and effect.
G z ty License Class Lie.If U 200 AMPS
op y Data Comraa.r 2 1 MPN Z
7FOya ARCHITECTS DECLARATION OVER A I SQ.FT.FLOOA 5/SQ.IT.
OZ—C) ITTnAersmnJ my plas�,ITull be rased as public records. _ ♦�t��� ^r
SIGN !1.1: RICAL t V
FCi.,uJ,11 Licensed Professional
OWNER-BUILDER DECLARATION SI`EjkdfhtcUI TSC.
V2x0dUF. 1 hereby ufrom that 1 and exempt from the Contractors License Law for the
IIAa; following remon.(Section]0J45,Euainev end Prnfcssinnr Cable:Any city or county TEMP, F,TF OR POLE INS I.
Ea-440 which.,movs a permit lu 7031.5,B ulcer,impmvc,demolish,or repair any strucwro
raj�5 N2 Emnrtaln lamawe,al,omquirca Neappli,vm for such permit bfileasigncdmulemau POWER DEVICES
y( <C) tunhe is licensed,...,to Nepm,isinnsoflhe C.nmcmr's License Law(Chapter
d1o�' 9(commencing with Section 7")of Division Sof The Busfupw and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y�yo urtha he is by any.fmmand the parmitonma jecta the applicant
civiny lPlaion of )U]LMS-SWITCHES-FIXTURES 2`/Iw Mp
t _G Section]031.5 by any applicant for u permit subjeos the applicem m a civil penalty of 0 W V
not more shun live hunArtA A.Ilarn(5500): 1E51 I' LIiC' 2 Q.PI'. STORIES TYPECONS'I'RUCI'ION
❑ Lusuwncru0heprnpeny,nrnrycmpinyees with wages astheirsolcenm InIIeeII
a will do the work,and The strocmm is not intcaded oroffemd forsole(Sec.]M4 ekF
and Professions Code:The Contractors License Low does not apply m an�Itrst
propenywhn buiidaorimprovn lhereon.aM whodoeuuchwodhimmlforlh h OCC,GROUP RFS.UNITS
wnemployces,provided that such impr.vetrTems ammo igen hbloruffered fou e.IL
however,The building or improvement is sold within one yemof romple ion,the o``WW��
builder will have The burden of proving that he Aid not build oil improv lar pwp IA 10 1„
sale.).
❑ ],as nwnerofthe properly,amexclusively contracting with licensed comractois t`n'QTY. MIT FEC F1.000 LONE AI'N
construct the project(Sec.]M4,Business and Professions Code:)The Conuamor's PERMIT ISSUANCE.
I.iceme Law does nal apply m an owner of progeny w ho bu i Ids m impmvc,l here.,and
who contmctsforsuch projects with a commcmr(s)licensed pursuant to the Cumtacmis
License
Law. ALTER (FA) /
FEE SUMM
E3eARY
I am exempt under Sec. B&P C far this rectum BACK II.OW PROTIrCr.DEVICE OUI'SIDF. ilA
SANITARY 'Y N
Owner Date RIiCEII'fN
• , IA, .
WORKMAN COMPENSATION DECLARATION DRAINS-FL00RROOF,ARCDSCHOOL TAX Y N
❑ en'Coraffirmon Insuancecertificate ofmmcnnoself-insure,.,oathcertificate.)which
RF,CEIPTN
Workm'Compensation lnsuruneemvicenifiW copy thereof(Sec.3800.LuM1CJwhiah FIXTURES-PER TRAP. PARK FEE Y
covers all employce'a under this pemtit. GAS-EA.SYSTEM-1 INCA LrfLETS RECEIPT#
Policy IT BUILDING DIVISION FEI S
Company GAS-EA.SYSTE (U
M-OVP ' A) PLANCHECK FEE
C1Cenifhdl oFyHherebyfumished. ��
❑ CeniriM copy is GlN with the city inspection division. GRGASERNDUSTRI. ASTH INTERCEPT OR GRADING FEE
CERTIFICATE1 OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE T
(I'hissecTionneed nothecompldW ifthepemtit lsforonehoodraldollars(SIM) SEWER-SAN'ARY-STORM EA,200FT. ENERGY FEE ataa�
odes.)
I certify Nal inlhe perfamunce of the work for which this perm,is issued.I shill WATER HT TF,R W/VENT/r.LEm
not employ any Pawn in any moaner so as to become subject to the Workers' PAID
Compenautool.awsof Califonau. Date NoYS'I'FMfrREAI]NG Dale \
0 z Applicant
z C) NOTICE 1'0APPLICANT:If,after making this Certificate of Exemption,you,should NF. ESIDI:N'I'IAI.PLMB. SQ.PI', TOTAL:
become subject to Too Worker's Compensation provisions of the Leber Code,you most
� > forthwith comply with such Inmisionsor this permit shall be deemed revoked. BUILDING FEE? �]
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE V
ft 15
Z
I hereby affirm that there is a commuction lending agency fur the performance.(
V the work for which this permit is issued(Sec.3097,Civ.C.) 10I`AL: ELECTRIC FEE
V. r- Urch,,'s Name
I.der's Address 1'Y, MVCNANICAL PERMIT FEF, PLUMBING Flip
V I certify Iha 1 have read this application and stem That the above information is
carted.logrcemcomply with all city wd roomy ordinances and amelaws rtlmingm PERMITISSUANCE MECHANICAL FEE
ti building construction,and hereby outhodn mpoesenwlivesof NLs city 1.enter upon the CONSTRUCTION TAX
V above-mentioned progeny for inspection purpose.. ALTER OR ADD TO MECI i. �.�.
(We)agree m save,mdemnl fy and keep hurmles the City of Cape.in..,.I
liabilities,judgments,costs and expenses which may i a any way accrue ugniaa said City AIR HAND[.]NO UNIT(TO I(),(X)II CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER TO."CFM)
Signature of ApplicanVContractor Date EXHAUST TRN)(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE11EATING UNIT(T0 toomo IITII) Dom Receipt#
Will theapplicant or future building oco.forn w.oa or handle bamrdoaa mamdal HEATING UNIT(OVER 100,000 6'N)
m definai by the Cupanino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Salina 25532(a)?
1:1 yes 13 No VENTILATION FAN(SINGLE!RESIDE
BOILER-COMP(3HP OR 100,IXTU) ata.B � ISSUANCE DATE
Will the npplirnm urfmurchuildingoccupant u0eeyuipmentor Aevices whichemit .,S rs A 1 D
hazmdous air contaminants as defined by the Buy Arca Air Quality Management BOILER:COMP(OVER I00,BI10 BTU) +N
Gamut?
I3NT' 2
❑Yes ❑NoazaNEW RESIDIAL MECI I. SQ.FT. MAY '" 19931 have mad the hazardous materials requirements under Chapter 6.95 of the
Calimmia I c4h&Safety Cole,Sections 25505,25533 and 25534, I Understand that
ifthe bulldinEdoes an000putly haven tenant,that it ism,responeihility to nnlify the CITY Vr VUI'C
cupmt of the rcquir mems which as,be at prior to issuance of o Certificate of
whufilisL
Occupancy.
Owner or mdmnxed age., Dale I ISSUED BY:
OFFICE