28264 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY or cuPERTINo BUILIIINC:-ELECTRICAL PERMIT NO. ^ ^ ^^4
APPLICATION/PERMIT PLUMBING-.MECHANICAL L tSJ[ L Vh
BUILDING DIVISION BUILDING PROJF,CI'IDENTIFICATION
IILDING ADDRESS: ,r SANITARY NO. APPLICMI'ION SUBMITTAL
aDATE
_`W7(J/�_VI UNI'ra I.OT#
JVWNERS ME: PHONE: NT CfOR'S NAME: LIC NO: N/C CONTROLN L J
I IHINGINHHH: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMITINFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT P.UMB MECH
PFRMI'1'ISSUANCE ❑
LI thaNSEDremedwCI'OR'SUECLARATION APPLIANCES-RESIDENTIAL.
py�z, Thereby affirm that um licensed underpmvisions of Chapter9(commencingwith LOB DESCRIPTION
0.1001- Section 701 Division 3 of the Business and Professions Cade.and my license is in PANELS
tat fall full tome and eft«t. UP T02W AMPS L 1
pQ„Zm License Class Lic.p
to=y Dae Contractor 301-IOIXI AMPS SQ IT.FLOOR AREA $/SQ.FT.
Foz ARCHITECTS DECLARATION OVER 1000 AMPS
OZ�O 1 undcmanA my plans shall be used us puM1lic records.
Fyl-W SIGNS HIJUI'RICAL
Li,ensed Professional
OWNER-BUILD ER DECLARATION SPECIAL CIRCUIT/MISC.
KO yU I following
affirm that 1 am exempt from the Cocoons Ca License Inc for the
m�+ta-vIa"i which out i aeon.(.ii to co.LS. ,, sass and Professions Code:Any city caraway l'I1.1P.METER OR POLE INST.
FWI;:] which inquiresn pe ithoormre,Ileaheg ret rmve,demolish,ore an,anyswaam
WM<0 Prior mirsicensed pursunttotsthevisios of the ch Contractor's
License
La siternimChapter POWER DEVICES
K that heislicensed purstantmthe)of Provisions the the Bio tor's.rad Pae Law(Chapter
y—y Q� SWIMMING POOL ELECTRIC VALUATION
X e LL. I,(commencing wish Section flacrel .and the
he Division J ofthe ed,,o ss and Professions Code)
Smithin 7031.5 by uyappliant for
basisfmthecu,the applicant to Anylpernion of OU'I'IAiI'S-SWI'PCHES-
F-i,¢ Section 203 LS by any applicant hnapennit vthjccts the opplicanuoacivil penalty of PI%Tl1RE5
R2a< maroore than five hundred dollars(SSW). NEW RISIDENTIALELECTR _SQ.Fr. STORIES TYPE CONSTRUCTION
atm EILasewnernfthepmperty,ormycmployeeawith wegesastheirsolecompenxaion,
y3_ will do the work,and the structure is not intendM or offered for sale(Sec.)044,Business
and Professions Cade:The Cantilevers License law docs not apply to an owner of
pmpeny who builds or improves thereon,and who does such work himself or through his
employees,pawned that such improvements are not immndualmoffered forsale.IL OCC.GROUP RES.UNITS
however,the buddingor improvement issnld within one yearnfcompletina.the owner- TOTAL:
builder will have the burden of proving thin he did not build or improve for purpose of
rel the propcny,am exclusivelYcantrnaing witmicensed n,mraevorste QTY. PLUMBING PERMIT PI3E FLOOD ZONE APN
rename thenpen, (Sec.)(H4,Business and Professions Cade:)The Contractor's
License Lawdoesnot apply m an ownerofpropcny%lowly ldsorimprovcs thcmon.and PERMIT ISSUANCE
whocomence forsuch projects with acontracions)Licensed pursuanurahe Contractor's ALTER-DRAIN&VENT-WATERFA
License Law. ( ) FEE SUMMARY
❑ I am exempt under Sec .B&P C for this mason BACK FLOW PROTECT.DEVICEQIR$ID EIIS
SANITARY YN
Owner Date DRAINS-19.00R,ROOFARBACOND. RECEIM#
WORKMAN COMPENSATION DECLARATION , , . SCHOOL')AS Y N
❑ Thereby affirm thalhavc ucenificme of consennoeclf-insure,-tircoificamef Fl%TURES-PER TRAP RECI3IPI'a
Workers CompensaionlnwranceoraceniriMcoythereof(Sm.3BW."b C.)which PARK FEE Y N
covers all empin cc's under this t. HCEIPI'p
Y pcmn GAS-IiA.SYSTEM-1 INC.INC40lDLLTS
Policy N BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 BiA PLANCHECK FEE
❑ Cenificdcopyislanhyfnsished.
❑ Certified copy is filed with the city inspection division. RBASFJINDUSfRl WASTE.IM'13RCBPfOR GRADING FEB
CF,ItTII§CA'I'13 OP E%EMPTIUN FlROMORKBRS( GREASE TRAP I tot .A SOILS PEC'
COMPENSATION INSURA
(Thissection need not he completed if the permit itifur Wehunddollars ) SE ER- A TAR - 1 MIiA.2WFjT. ENERGY FEB
or less.` 1 ( L -
1 coy that Bthe rown erfony..act
t so as
farwhichesu h I' .W lFRiH'�ER 'LECfIt
C.employ o 1.vo rf in any manner so as m badme subject mo Wvrkers'Y f 11 PAID
Cumicant sen Lews u(Califomia. Date �t(�� I -;nk WA TE TING Date Receipt#
Q7. Applicant \�
Z * NOTICE.TO APPLICANT:If,after making this Certificate f Exemption,you should 1 .FT. TOTAL:
Iq beeome,aljecun the Workce's Compensation pruvisiuns yktheL her Crede,��trl1t�iy:E,
a ; forthwith comply with such provisions onhis pemnit sM1nll '1 dee d revnkcC BUILDING 11313
ILA—
6. [� CONSTRUCTION LENDING AGIY `-�~u SEISMIC PEIi
I M1cmbyeffirm that is aconswction lending egen f
7, Y ELECTRIC FEE
V Q the woo,foe whichthis permit is issued ROD.Civ.C.)
Lender's Name PLUMBING FEE
V" F^ Lenders Address QTY, MECHANICAL PERMIT FEE
U 1 certify that 1 have read this application and state that the above information is MECHANICAL.FEE
r>" Da coact. l agree to comply with all city and county ordinances and state lows relating to PERMIJISSUANCE
F^ Co� huilding construction,and hereby authorize representatives of this city m enter upon the CONS'I'RUCI'ION TAX
V z ultovo-mctilmoed property for impcetinn popreas. ALTER OR ADD TO MECH.
(We)agree m save,indemnify and keep homJese the City of Colosimo.against
liebilities.judgmems,arsts undexpcnuswhich may in any way acnve egos tsaid City AIR HANDLING UNIT(TO 10,000 CFM)
onseyuenc tithe granting of this'pe/rmiL
AIR HANDLING UNIT(OVER IO.000 CPM)
Signa of Appl cant} ontmctor )out EXHAUST HOOD(W/DUCT) PAID
I IALARDOUS MATERIALS DISCLOSURE 116,VI LNG UNIT(TO 1X,000 BTU) Date Reccipt p
Will the applicant or future building ocoinnt.store or handle baxandous material I OI AL.
us defined by the Cultivation Municipal Cade,Couple,9.12,and the Health anHEATING UNIT(OVER 100,000 111 U)
d Safety
Code.Section 25532(a)1 VENTILATION FAN(SINGLE RMID) �-
❑Yes ❑No
ISSUANCE DAT17
Will theapplicant or future buildingoecupant usecquipmentordevices which emit BOILER-COMP CHIP OR IW,"BTU) pp
hazardous air recoumirome,as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU) P W
District!
❑Yea ❑No NEW RESIDENTIAL MECH SQ.FT. jilt
I have read the hmardous materials mr uircnents under Chapter 6.95 of the
California Health&Solely Cute,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a meant,that it is my responsibility to notify the Ur L
occupant of the reyuircments which must be,met prior to issuance of a Certificate of Uhr2
Cxcapaney. s
Owner or aothanived agent Date TOTAL: ISSUED BY:
OFFICE