24506 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUI LUIS°-F',ECFRICA I. PERMIT"° 24506
APPLICATION/PERMIT PI.UMRINO-MECHANICAL.
BUILDING DIVISION RUII.D1NG PROJECT']DEN I'IF'ICATION
HE C.AfL11L13S q/Ir (� 1 (is I1 s UNITN hOTp SANITARY NO. APPLICATION S�l1VBM�1`1)TALDA'l l7.
J�CI711�(T'61-r •11 PPHO(N\E: 11-/1` CO A`�1'OR'SN'g { r� •`�
fir} i, N/C CONTROLp
RCHITECI'ARNGINEER: LIC NO; ADDRESS: f ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEC
RLUG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ 0 V 0
LICENSEDCONTRACTOR'S DECLARATION APPUANCHS-RESIDENTIAL JOB DESCRIPTION
Metz I hereby ufftrm Lost sm licensed under,rovisions of Chapter 9(commencing with
6100 Section 1000)of Division J co the Bminess and Professions Code,and my license ism PANELS �]W��.—
W F full tome and effect. r
f<„ZW Licemse Class Iic.N UPT0200AMPS
co<y Date Cemaaor 201-1000 AMPS
Fy% ARCIII'I'17.CP$DEChARA'1'ION SQ.FT.FLOOR AREA $/SQ.FT.
-LOy— lundonwnd my plansshall heated as publiencomeh. OVER IIXNIAMPS
O%—a
W SIGNS ELECTRICAL
�WKQ Licen¢J Professional OWNER-BUILDER DECIARATION SPECIAL CIRCUIT/MISC. �t
XOatJ I hereby affirm that I ant exempt from the Commcmr's License Law for the ", N
6134.v~7. hollowing ream¢(Section 70315,Business and Professions Codi Any city or county TEMP.MITIER OR POLE INST. J J T
��� which requires a Permit to camlrucl,alter,improve,demolish,or repair any someone / ) � !- R
��YSm is issuance.also res the applicant for such uo file a s7. edstatemenl POWER DEVICES v J- u
poor rtyui pp Pcmd gn
K
,,<0 That he is licensed pursuant m the provoslom of the Contractor's License Isom(Chapttt
a L�o4 9(commencing with Section V000)nf Division 3 ofthe Businessland Professions Code) SWIMMING POOL ELECTRIC _ TION
W❑,Z or that he is exempt therefrom and the basisforthe alleged exemption.Any violation of
�%Q Section JB11.5 M1y any upplicam(orapermil subjecxs ere upplicanuoa civil penaltyof OUTLETS-SWITCIfFS-7.'1%TURES
g�anot mom Dan live bmdred dolhas($500).
NEW RESIDENTIAL EI.FCTR SQ.FI'.
❑ I,mownendthe proMrty,ormyemploy,es with wagesastheirsolecompensation, STORIES TYI'Ii CONSTRUCTION
ea i 3'2 will do the work,and lMswcoteis not immndWnroffemi for sale(Sec.]O4a.Business
and Profeasionn Code:The Comractor s License law does not apply to on owner of
properly who builds or improves thereon.and who does such work himself or through his
employees,provideithat such improvcmenttam not intendedoroffered rorsal,.If,
OCC.GROUP RLS.UNITS
however,the huiiding or improvemcm is sold within one year ofcomplction,the owner- TO'I'AI:
builder will have the burden of proving that be did not build or improve for purpose of
'i°1e')'
❑ I,mewner of the prnpery,amexclusively, contracting with licensed canwnors lu QTY. PLUMBING PERMIT FEC ILOOD ZONE AVN
construct the pmjw(Sec.TWA,Business and Professions Cale:)The Cono-ecrors
License"writes maripplytoan ext erufpropeny whobuildscrimpmves thereon,and PERMIT ISSUANCE
who commas fncech projects with a cmaranor(s)livened pursuant to the Contractor's
License I.aw. ALTER-DRAIN&VENT-WATER(LA) FEE SUMMARY
❑ I am exempt under Sm. ,B&P C for this teawn BACK MOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
IIOwner Date DRAINS-FT,QOR.ROOF,AREA,GOND. RECEIPI'p
WORKMAN COMPF,NSATION DECLARATION SCUCOLTA% Y N
❑ I hachyarfiom that l hav,ncerlificamofaurto setn elf-insure,nraomificateof Fl%TURKS-PER TRAP RECEIPT%
Workers Compensation Insurance or u verified copy thereof(Sca 3800,I.ab C)which PARK FEE Y N
cover,all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECBI VT M
Policy 10 BUILDING DIVISION FEES
ComPany, GAS-FA.SYSTEM-OVER 4(HAL PLANCHECK FEE
❑ Comified ropy is hereby furnished.
❑ Cenificdl copy is filed within,city inspersion division. GREASGRNDUSTRL WASTE LNTF,RCEPfOR GRADING IEE
Cliff LIFICAT1i 01:EXEMPTION FROM WORKERSGREASE TRAP SOILS 19717.
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is boron,hundred dollars($100) SEWER-SANITARY-STORM EA.20017. ENERGY PER
or less.)
I certify that in the perfomtarce of due work for which this permit is issued,i shall WATER HEATER W/VENT/ELECR
not employ any person in any m as to become subject to the Workeri PAID
Compcnx:nionl.awsof Calilornia. Date so WATER SYS HiMaREATING Date Receipt
� Z Applicant
� NOTICE TO APPLICANT:Hours,making this Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ,Ff. TOTAL,;
pc,, become subject to the Worker's Com,amation Provisions of the Libor Code.you must
a foMwith comply with such provisions or this Permit shall be deemed revoked. BUILDING 87.E
aQ CONSTRUCTION LENDING AGENCY SEISMIC HE
3 z l hereby affirm that is a ennstmeion lending agency for due Performance of
UO the work for wm
which his perit is isomer,(See 3097.Civ.C.) ELECTRIC FEE
L,nder's Name PLUMBING FEE
F Under'a Add., QTY. MECHANICAL PERMIT FEE
ZA
vanity that 1 have lead this application andante that the above information it MECHANICAL FEE
>4 LJa correct I agree to comply with all city and county onirences and state laws relating in PERMIT ISSUANCE
Cj) building coloration,and hereby authonze representatives ofthis city to enter upon the CONSTRUC IONTAX
Uz
ha -mentimcd proprny sec purposm, ALTI7R OR ADD TO MSCI I.
eI -m eve,indemnify harmless the City of Caperton against
'bili ies.j bhan ywayaccrucagalnslsaid City AIR HANDLING UNIT CFO 10.0(CFM)
y� AIR HANDLING UNIT(OVT:R 10.010 CFMJ
Signature of AppllcanUComrnater Date EXIAUS'I'IIOOD(W/DUC`L) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Dae Receipt
Will the applicant or future building occupant store or handle haurdous material HEATING UNIT(OVER 100.001)BTQ) TOTAL
ss defined by the Cuprti
eno Municipal Code,Chapter 9.12 and the health and Safety
Code,Stolon 25532(a)P
❑Yes ❑No VENTILATION FAN(SINGER RESID)
' ISSUANCE DA9'F;
Will the applicant orfutumbuildingoccuprt usecquipmentordevicas which emit BOILER-COMP QHP OR 100,(X0 BTU)
azaraeos air contaminants ss defn,d by Ne Bay Area Air Quality Management BOILER-COMP(OVER 1a),00)BTU)
istria?
❑Yes ❑No NEW RESIDENTIAL MECH.—SQ.FT.
1 have read the hazardous materials ralmoments under Chapter 6.95 of the W
Califnmia health&Safety Calc.Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the NOV 20 1g0
occupant of the requirements which must b,ma prior to violence of a Crnifictte of
Occupancy.
CII 11 '1 _.s'HVV
Owner or amhorizcd at Date 'TOTAL ISSUED BY;
OFFICE ),