27941APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
B NG -R
)TNC. P (N0. MECHANICAL
:IIUILIIINC PROJECT IUENTIFICATIUN
PERMIT NO.
27941
BUILDING ADDRESS:
SANITARY NO.
APPLICATIONSUBMITTALDATE
UNIT
LOT#
OWNERS AMC: PHO B:
CONTRACTOR'S
F
NAME: LICNO:
,ylL
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e
N/C
CONTROL#
ARCIIIT.CUENGINEER: LIC NO:
1
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11
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CONTACT: PHONE
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4 ELFCI'RIG PERMIT.
1 PERMIT ISSUANCE
FEE
3�a (%
•J
,
.i BUILDING PERMIT INFO-
B E PLUMB MCCFI
LICENSED CONTRACTOR'S DECLARATION
1 bereby iffil that I am licensed underprovisions of Chaprer9 (cummencingwi[h
Section?WO)of Division 3 ofshe Business and Professions Code, and my license is in
nse Cie.effect.
j License Class
gPpLIANCBS -RESIDENTIAL
PANELSfall
UPT0200AMPS
��Vj•
LOB DESCRIPTION
N��( 1
// ) „f /
Data
Date Contract a!
201 - 1000 AMPS
1LLJ CJ..
ARCHITECTS
ARCHITECTS DECLARATION
I undersand an, M a y plans shall be uspublic %amrds.
OVER 1000 AADS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
�i Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUHOMISC.
1 Jimmy affirm Nat 1 am exempt from the Connector's Licenu Law for the
fallowing Mason. (Section 7031.5, Business and Professions Cade: Any city or county
TPRi OR POLE INST.
which rcyuiess a permit to consbuct, alter, improve, demolish, m repair say mucturo
prior to its issuance, also requires We applicant forsuch Permit o file asigned statement
PER DHVICES
that he is licensed pursuant to the provisions of the Connector's License Law (Chapter
9 (commencingwith Sectim17fak).f hvision3ofthe Businessand ProfessionsCade)
SWIMMING POOLELECTRIC
VALUATION
or that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 4o a civil penalty of
OUTLETS - SWITCHES - FIXTURES
a VO
O O
not mom than five hundred dollars ($500).
❑ I,asawnerofihepmpM,ormyemployttswithwagesatheirsolec=Mmation,
_
NHW RESIDENTIAL ELECFR SQ PT.
STORIES
TYPE CONSTRUCTION
will do the work, undtheslrvcmtvirmu nterom motteted fonsde (Sec. 7044, Biomass
and Pmfenions Code: The Coatrecwla License Law does out apply W an Is of
propenywhabuildsorimproves thcrcan,and whodoessuchwork himulfortJroughhis
own amp ay
1 tts, provided thasmch ins
earrrdedoraffcredforowner-
OCC GROUP
RFS. UNITS
demsarone
tis mid
h weer will avec a or improvement of pmatishat he id oneyem or improve
builder will have the burden of proving that he did not build or improve for purpose of
of
sate.).
❑ I.mownerofthepmpeny.amexelusivelymnnectingwiNlicmudcmr roto
Q Y'
PLUMBING PER
FEE
FLOODZONE
APN
comruct the project (Sec. 7044, Business and Professions Code:) The Canttachar
License Law doeanotapply tarso ownerofpropeny whobuildsorimprovesthemon,and
PERMITI55
,�kOQ
whocmtnetsforsuchprojmtswithacont emr(s)Iicenud pursuaamothe Contractor's
License Law.
it (')
FEE SUMMARY
❑ I nen acmpt under Sec. B & P C for this as.
BACK FLOW PROTECT. DEVICE
OUTSIDE HER
SANITARY Y N
RECHIPI,#
Owner Date
WORKMAN COMPENSATION,
DECLARATION
❑ thereby of tin that l have a certificate ofconcent to ulbinsurc, ora cenifleme of
Wmken' Compensation Insurance ora certified copy somaxod(Sm. 380), Lab C.) which
DRAINS - FLOORkOOpAREA,
, ..
FTXTURES-PER TRAP
`y-��'
2
SCHOOLTAX Y_N
RECEIPFN
PARK FEE Y N
coven all employees under this permit.
Policy N
GAS - HA. SYSTEM -I INC. 4 OUTLETS
RECEIPT p
BUILDING DIVISION FEES
Company
❑ Certifiedcopy is hereby furnished.
GAS - CA. SYSTEM -OVER 4(EA)
PLANCHECK FEE
❑ Certified mpy is filed with the city inspection division.
GREASFANDUSTRL WASTE. INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASETRAP
SOILS FEE
ENERGY FEE
(This section need not be completed tithe permit is Forane hundred dollars ($100)
or less.)
SEWER -SANITARY- ST' ORM EA. 200FT.
I certify that in the peftormnce of the work for which this permit is issued, L shall WATER HEATER W/VP.NT/F.LECfR
not employ my penin in any manner so as to become subject to the Workers'
Compensatlon Lawsof California. Date
Applicant
WATER SYSTEMRRBATING
PAID
Date Receipt#
NOTICE TO APPLICANT: If, after making this Ceniftcateof minptioa-you should
become subject to the Workm's Compensation provision of the Labor Code, you must
NEW RESIDENTIAL PCMB, SQ, FT.
TOTAL:
forthwith comply with such provisions or this permit shill be deemed revoked.
BUILDING FEE
l/
CONSTRUCTION LENDING AGENCY
SEISMIC FEE ,
(hereby affirm that Neu is a construction leading agency for the performance of
the work for which this permit is issued (Sm. 309'1, Civ. C.)
TOTAL:
ELECTRIC FEE de
Lendels Name
Lender's Address
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
1 certify Ohm 1 have mad this application and nate that Ne above informed.. is
rtect. legman comply with all city and mutnymdinances and stab laws relating a
PERMIT ISSUANCE
p
!/
MECHANICAL
---rV
building construction, and hereby andmaiu roprtunanvao(Niscity m enterupon the
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH.
'
CONSTRUCTION TAX
(We) ague to save, indemnify and keep harmless the City of C,mino against
liahilities,judgmenm, costs andexpenses wIt hmayia any wryuccrueagaia.naald City
_
AIR HANDLING UNIT (TO I0A0(l CFM)
asequence of the grunting of this pc it,
AIR HANDLING UNIT (OVER 10,000 CFM)
'
PAID
Signature of Applicant/ carr Date - l EXHAUST HOOD(W/DUCT)
SOS
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT ('TO IIX1,000 BTU)
Date Receipt #
Will the applicant or furore building occupant store or handle hi ardour material
as defined by the Caperton Municipal Code, Chapter 9.12. and the Health and Safety
HEATING UNIT (OVER 100,000 BTU)
_ TOTAL: a�
li�
e
-✓
Coda Section 25332(u)?
❑Yes 13 No
VENTILATION FAN (SING LE RFSID)
ISSiUAWAFFE _-XT7f/_
Will theappliemttorfuu buildingaccupmtuucuipmenrnrdevica whichetsdt BOILER- COMP (311P OR IW," BTU)
Jumbos air contaminants as defined by the Bay Area Air Quality Management
District? 13
13 Yes [I No
BOILER - COMP (OVER Ht BTU)
NEW RESIDENTIAL MECfI. SQ. FT.
17 1995
1 have read the moments materials requirements under Chapter 6.95 of the
Celitbmiu Druid, & Safety Cade, Sections 25505,25533 and 25534. 1 undersand that
I^ T�/ /�L s1Lt]-f s�,�1/�
CIT,, su ..1/UuI_fT iNW
if the building does not currently have a tenant, that it is my responsibility to notify the
mmpunt of the ro,flumnears which must be met print to ismanro of n Cenificale of
Occupancy. -
ISSUF.DBY:
Ownermeothmisedagere Date TOTAL:
7,r
OFFICE