29821 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING'-ELF,CI'RICAL PERMITNO.
BUILDING DIVISION ' APPLICATIONiTERMIT PLUNBIING-MECIIANICAL'
BUILDING PROJECTIDRNTIFICA110N 29821
BUILDIINGADDRESS: - SANITARYNO. APPLICA'I'IONSUBMI'II'ALDATI
OW NAM �I, PHONE: CO ACT'OR'S NAM - LIC NO:
NIC" , s CONTROL# -
CIIIIECT/ENGINEER: LIC NO: ADDRESS:
6�)L'9_2 / ❑
I✓at kl
CONTACT: PHONE: - BUILDING PERMI.1INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEc'r -PLUMB MECH
❑ ❑ ' ❑
LICENSED CONTRACT'OR'S DECLARATION QTY, ELECTRICPERMIT FEE'
I hereby uffnn that I am licensed under previsions of Chosen 9 feemomm"ag JOB DESCRIPTION
y�I OO a'Z with Scctinn 9IXX)1 of full force and effecn Uivisinn 3ofthc liusimessand Pmletaous Coale,mNmylicens01s PERMITISSUANCI3 : ) RESIDENTIAL:
F
RdE License Class-Lid.#' ❑SFDWI, ❑KITCHFNRF.MODEL
�<L Dme Contractor APPLIANCES-RESIDENTIAL ❑ADDITION QRI.UMBINGRE-PIPE
1„Oy ARCHITECTS DECLARATIONPANF.IS r ❑MULTI-UNIT ❑STRUCTURAL
Z p vn Z I understand my plans shell he used as public records MODIFICATION
O Z r UPT(I RW AMPS s. ❑INTERIOR ❑CHIMNEY REPAIR
FH ui Littmsed Yrolesionnl 201.10MANIPS - IMPROVEMFNT
S�dd -J.1
OWNER-IiU1DDC•R DCCLARA'rION
�yx4' 6 I hereby alfnn that 1 am exempt from the Contractor's LiccnseLaw for the OVER IIXp AMPS CI HAITI RF.MODEUREPAIR DEMOLITION
Y703 0.V following mason(Scctinn7031.5,Business and Professions Code:Any city or arumy SIGNS ELECTRICAL ❑OTHIiR
.which requires a scroll 1u mnHm d,the,improve,demolish,in repair any structure �
y O �priort,,lis issuance,also requires the applicant forsuch permit to file aligned saviour SPECIAL CIRCUIT/MISC.
{K y
an,he is licensed pursuant mthe previsions of the Cnmmctor's License low(Cl I,,)
W GOA (commencing with Section 9000)of Division 3 ofthe Business and Pmfe.sioms Code)or TEMP.METER OR POLO COMMERCIAL:
S q=y' thin he is exempt therefrom and the basis(.,,he alleged exemption.Any violation of - [I NEW BLDG/ADDRION El DEMOLITION
i� LLy, Serv pe
i.,,7031.5 by any applicant for nrit subjects the spplicam lou civil pedaily.1 POWER DEVICES []TENANT ❑i'OOD SERVICE
rn
z2q trot nmre then five hundred dollars(SS(Ifq.
F�
01,as owner of the prop ,,or my employees with wages as their sole compensation. SWIMMING POOLELELTRIC IMPROVEMENT
workstructure,will do the .sad me structure,is netimendednrnffered for sale(Sec,9044,easiness ❑OTHER
3 and Prnfexsiom Code Its,Commerce.License Low docx not apply m an owner of OUTLETS-SWITCHES-FI P
.. progeny who builds or improves mean,and who docs such work himself onhrmgh
If,own rumloy'ees,provided that such Impmvcrnents ora not intended nr offered tin NEW RESIDENTIAL ELRCTR
sale.If,however,the building or improvcluent is sold wiihin one year ofemmpletion,the - SQ.FT.FLOOR'AREA - - 5/SQ.Ff.
owner-builder will have the burden of proving tom he did not build or improve unpin.
-
❑ Lowner owner of the Stpro,am,,. exclusively contracting with licensed cnnactor,s to TOTAL:
onstmet the project(See.9044;Basilic..and Professions CodeO The Contrnetnr's Li-
rinseLuwdoesnotapplytoanownerofprnpenywhohuildsorimprovesmerson,anf QTY• PLUMBING PERMIT PEE -
who conimcis forsuch pmjecu with a contmctor(s)licensed pursuant n the Commcmes - -
License Taw. PERMIT ISSUANCE
❑I on exempt under Sce. ,B&1'C for this reason
Owner ALTER-DRAIN&VENT-WATER(EA) VALUATION
DpLC '
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perjury one of the following declarations:
•❑Ihaveand will maimaina CenificateofConseniwwlf.insumfor Wmkees C=Nn- DRAINS-FLOOR,ROTE AREA,COND. STORIES TYPE CONSTRUCTION
smion,as provided for by Section 3900 of the ladn Code,for the Nrfummnee of the r Q
work for which this permit is issued. PI%T'URF.S-PERTRAP _
I have and will lnumnin Worker's Cmnpensaton Insurance,m required by Section -
39Wnl1heLaborCode.for the sirformaneeofthe work for which this permit is issued, GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Work otgpe��eyWx�Insumnm cario,mil Polic int o
Cortico k��•-�-1�L�•1:�/ Policy NuGAS-EA.SYSTEM-OVER4(EA) ,
CERTIFICATE OF EXEMPTION FROM WORKER.
COMPENSATION INSURANCE GREASOINDUSTRLWASTE INTERCEPTOR
(This scetion need not be ttmtpletvl if the#emit is f amm hundred dollms(SIM) BUILDING DIVISION II?BS
or IcvsJ GREASC TRAP
PLANCHECK FEE
I eerily Nat in the any mormse, n as 1 work for which this Permit r issured,Co]shall -
' not employ any person in any manner so as to become nuM1jceno the Workerv'Com en- - SEWER•SANITARY-STORM EA.21X1 Fr.
Y s - _ F.NF.RGV TLE
O ,$ snood Luws of Cullfnmiu.Dme P WATER HEM ER W/vEmr/ELECTR
z Applicant GRADING FEE -
y NOTICIi TO APPLICANT.If.after making this CeniOcme of Exempiom,you should WATER RY.STEMORLATING
a ? become subject to the Worker's Compensation provisions of the hailer Code,you must SOILS FEE
ISl forthwith comply with such provisions or this permit shall le deemed revoked. WATER SERVICE ,
Q
7z CONSTRUCT ION LENDING AGENCY NEW RESIDEN'T'IAL PLMB, SQ.FR ' PAID
L) Iherchy affirm thus there isemnslmcOnn lending agency for the performance of Date - Receipt#
Ir. the work for which this permit is issued(.Sec.3097,Civ.C.)
O V Lemdees Name - a TOTAL:
Lender's Address T0TALJ
t� y I certify that I have read this application and sloe that the chose drouratinn Is BUILDING PIiE
,.i...f70 cortca.l ugreemcamply with all city and counry ordinance.and.mte lows relatingm Q'rY. MECIIANICALPHRMIT• FEF,
U G building construction.and hereby mommize representatives of this city to enter upon the SEISM IC FEE
above-mentioned property,for inspection purposes.
(We)agree to save,indemnify and keep hamdea the City of Carina,against PERMITISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue uguinsl said City ALTER OR ADDTO MECIV - - '
in consequence of the gr riling of thta t. PLUMBING FEE
' APPLICANT UN ERTANDS D ILL OMPLY WITH DLI,NON-POINT AIR HANDLING UNIT CFO IBM)CFM) MECHANICAL FEE
SOUR_ CE RFS' A 1
—� AIR HANDLING UNI'T(OVER IO,INNI CFM) CON STRUCf10N TA%
Signa oApp an/Cuntrk Dote EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
^' " HAZARDOUS MAI'17RIAM DISCLOSURE -
Wiillthe applicant orfuture building oecupeatsome orhandle hizurdausmaterial HEATING UNIT(TO 100.00 BTU)
as defined by the Cupcnmo Munici led Cale,Chapter 9,12,and the Health and Safety -
Code.Section 25532(u)9 I .. HEATING UNIT(OVER I W."BI Of
[:I ye" -❑Nn' I„ VIiN'TILAI'ION PAN IgINGLE RL'SIO) PAID .— Fn It-�
Will the applicvnfor future building occupant use equipment or devices which Damn x'"Receipt#
vial histaminic an contaminants re defined by the Hay Area Air Quality Management - BOILER-COMPOHPOR 10QW0 BTU)
❑Yes ElNo,' _ BOII:LR-COMP(OVER IW,0001171H APR 3 41'
.
I have read the haunions materials is under AIR CONDITIONIiR -
requiremen Chapter 6.95 of the Cali- ISSUANCE DATE)
forma Health&Safety Code,Sections 25505.25533 add 255M.1 understated that if the NEW RESIDENTIAL MECH. SQ.FT. �I I
building does not currently have a e raaat.that it is my respmsibility in notify the occupants
of the requirements which must he met prior to issuance of u Certifcate of Occupancy. n�
Owner or authorized agent Date TOTAL: ISS
OFFICE