28409 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-CLEM RICA(. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. n O �I O
BUILDING PROJEC TIDEN1IFICAT1ON L v 1.1
BUILDING[.DO PSS:��Q �� UNITM LOT
SANITARY NO. A�ON SIIBMI I�DATL
O + R. I^`;Sy./T�y� � PI /►`w RA R' M12
� CND: N/C CON80L
ARCIiI'I'Iai1FC/I'/YRINGGIN`EERR:: LIC NO:'L/ ADU E ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
BLUG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSEDthatIs.
remerl CONTRACTORS DECLARATION pppLIANCCS-RESIDF.NTIAI. IOyppS ON
pyz Ihtteby of Division
3 ofth Business
and Professioit ns
Coder and mmendng with 7`i
ZOO Section7000)of Division3nf the Nosiness end Profemimns Caie,and my license is in PANELS
F!� fail str�' Liernerceend effect. IR 70200 AMPS
Liceve Clam Lic.p
ot
=y Dale Contractor 201-1000 AMPS
zcr1 z ARC)11'1'EM'S DECLARATION OVER 10100 AMPS SQ.PI'.FLOOR AREA $/SQ.FT.
Oz—G I understand myplansslmll be used as public records.
r yr H SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER
cscm lffromDECLARATION SPECIAL CIRCUT/MISC.
W O on 1 ng hereby
Mas affirm thot I am exempt from the Contractor's License 1<w for the
W I!, whichfollowrequires
m0(Section RIs S, .ate,s
int d ve,de r demolish,
Code:Any city orcounty TEMP.MITI?R OR POLE(NST.
ot, which requirev a permit to ennstrun,eller,improve,demolish,or repair any structure
`O>-;E prior to its issuance,also requires lire applicant lir such permit o file a signed statement POWER DEVICES
W 00z that he is licensed pursuanrm the provisions ofthe Comuaram's License Law(Chapter
D.KOLL SWIMMING POOL ELECTRIC
9(cmumememi,with Section 700 f D
E)mivisioss n Jnfthe Business and Professiora Cale) VALUATION
W, or that he isesempttherefrom and the basis for the alleged exemption.Any violation of
za Section 7031.5 by anYapplicant ftirapemdilsubjecu the applicanno acivil penalty of OIITLEI'S-SWITCHES-FI%'TURES 066C=mqin 1
C not more than Five hundred dollars($500). NEW RESIDENTIAL F.1 :CI'R S .IT.
❑ Lasowncndthe Property,nnnycmployece wish wngesasthcirsnlearmpensntimn, Q STORIES 'I'VPE CONS'IRUC'I]ON
6 will do the work,andthe structure is not intended metered formic(SeeWIm,Business
and Professions Code:The Contraz'mr's License Law does not apply to an owner of
pmpeny who buildsmimproom dommmand whosessuch work himmlforthari his OCC GROUP RES.UNITS
employees,provided that such improvements are not intended oroffered formic.IL
however.the buildingmr improvement is sold within me yearofcompletion,the owner- I
builder will have the burden of proving that he did not build or improve for purpose of
atle.).
❑ I,m ownerofdhe property,amesclusivelycoulouning with licensed contractors to QTY. FIX h MPP FEE FLOOp ZONE APN
construct the project(Sec.70]4,Business and Prolamines Cale:)'fhe Conuauta'a
Liaise Lawdessnot apply to on ownerofpropeny who buildsmrimpmvea theram,and PERMIT ISSUANCE
who contracts forsuch projects withacomtroctods)licensed pursuant to the Communities _L A
ALTER (FLA)
License Low. FEE SUMMARY
❑ 1 tan exnnpl under Sec, ,B&P C for this reason BACK FLOW PROTECT.DEVICE r OUTSIDE FEE.
SANITARY YN
Owner Date RP.CIi1P1'
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,GOND, SCHOOL TAX Y N
r ❑ Ibertby affirm thetl heveecenifi<ate oleo xnnm self-insure,me uruficate of IIRFS-PER TRAP =
g
FIXT
Wdrters Compenwtion lnsumncenruunifiedcopy thcremf(Sec.Jg00,Luh CJ which PARK FEE Y N
covers all employee's under this permit, GAS-IiA.SYSTEM.I INC.4 OUTLETS RECIi 'N
Polic,# BUILDING DIV ION :ES
Company
ElCeniOed copy is hereby famished.
GAS-PA.SYSTEM-OVER 4(FA) PLANCHECK PER❑
❑ CenifieJ espy is filed with the city inapenion division. GREASEDNDUSTRL WASTE,INTERCEPTOR GRADING FEE
CERTIFICATE OF L'XF.MPI'[ON FROM WORKERSGREASET'RAP SOILS FEE
COMPENSATION INSURANCE
('I'hi.sseclirn need not be completed tithe permit is formic hundred dollars($1000 SEWER-SANITARY-STORM EA.201 ENERGY FEE
s.)
I certify titan I.the performance of the work far which this permit la issued,lshall WATER HEATER W/VF-NT/F,LT:CfR
not employ any person in any manner so m to became subject to the Worker' PAID
Compensotlonlawsof Califomia. Date WATER SY.STEM/IREATING D RecciptX
C' z Applicant
z 0. NOTICRT'OAPPLICANT:If,nflcr tanking this Ccnifcam of Cxcmpdinn,you shrulJ NEW Rf3SIDPNTIAL PLMB. SQ,TT. TOTAL.
Oil become subject to the Worker's Compensation provisions ofthe Labor Code,you must
> forthwith comply with such provisions.,,his pnortalull be deemed revoked. BUILDIN - a—
[� CONSTRUCTION LENDING AGENCY SEISMIC PER
1 hereby affirm that hem is a construction lending agency for the performance of
UO the work for which this Fermi l is issued(Sec.3097,Civ.C.) :� ELECTRIC FIAT
(Iy Lender's Numa PLUMBING FEL'
O U Lender's AAJrcm QTY. MECHANICAL PERMIT FEE
1 certify that I have read this application and state that the above information is
acorrect.lagra tocomplywith all city aMemody.o ioeacesand matf.wsachamg to PERMIT ISSUANCE MECHANICAL FEE
In building construction,and hereby outhoriu representatives ofthisclty,to enter upon the CONSTRUCTION TA
V 7 above-mentioned pmpeny for inspection purpous. ALTER OR ADD TO MECH.
( c)care m save,'ndenmify and keep harmless the City of C nlnm goinsl
liabili ,judgments, andopensesw ' tmay inn ywoy accrue g t. id City AIR HANDLING UNIT(TO 10,I1g)CFM)
in cc se to sof the dig fdhis pe
AIR HANDLING UNIT(OVER IO,II(p CFM)
.igmtuncplmanC (rector Dade EXHAUST HOLD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT On IW,WII OTU) Dole cccipl0
Will the applicant or future building occupant store or handle hazardous mamiial
as defined bythe Calamine Municipal Code,Chapter 9.12,art the Health and Safety HEATING UNIT(OVER UAL"BTI) TOTAL:
Code,Section 255J2(a)7
ElYea El No VENTILATION FAN SINGLE RPSID)
❑
BOILER-COMP(3HPOR 10.0110 BTU) ISSUANCED E
Will thcapplicom nrfuturchuilJing occupant useeyuipmem nrdevices which emit i
haz rdrus air contaminants us defined by the Bay Area A"Quality Management 0 UistrictT BOILER-COMP(OVER 100,1110 BTU) pis
❑Yes ❑No NEW RPSIUCNfIAL MECH.—SQ.FT. e'i Y QJ
1 have mad the IncoSafety
em,Code,
Sections 550uiremema anon Charter understand
of the JUL
awl
Califomia(leallhsSafety Code,Sections25505,t it isend25534. Iundersotit that V(�i R3l✓ 99
iFthehulloing Jrcsnot ments wick atenant,thus it is myrsuance of
Ienotify oho h
occupant rl'the requirements which muss be met prior m issuance of a Certificate of (� r Vr
(kcupancy.
I
Owner or authorized agent Dore TOTAL: I ISSUED BY:
OFFICE