S 1199 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO RUT,)ING.EI.EC'IRICAI. • PEIIMI'1'NO.
"-BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAI. S 1199
;BUILDING PROJECT IDENTIPICATIUN r` r
UILDIINNG ADDRESS'. - ' ' SANITARY NO. APPLICATION SUBMI'ITAI.DATE
PHONE:., CONTRACT 2S NAME: - LIC NO:
CON ISHE,47
EI:.1 : Ja � Ez�> '
h' ARCHI'IECf/ENGINEER: LIC N1Y ADDRESS: - ❑
CONTACT: ,PHONE'. - -'• I I ILDINOPERMITINFO,
±r
❑ Consultant Pees Paid by Applicant(Initial) BLDG . ELECT P.UMP -MECH
❑ ❑ ❑
LICENSED CONTRACE ORS DECLARATION QPY t+ CLECCRICPCRMIT'It CFEE -
I hereby ft that I l : 1 d p ' .- f Chaffer 9( g +N . . JOB DESCRIPTION
DaZ ems t 7000).fU 3 fthRta JP r.,, Cosecant]mylic se RESIDENTIAL
,� 1 O w oil f e J Bcct. FERMI f ISSUANCE.
'^W^ " ' C SPDW L ITCHCN REMODEL
11UU
License Class I'c# - APPLIANCES RESIDENTIAL y7a u] Dem Com ehr - - ❑ANDITION LIM BIND RE-PI PE
G ARCHI'IPC I'S DECLARATION I I PANELS 0 MULTI UNIT ❑SEERUCTURAL
O0ym
Z Iundcr ndnty p]..,,hall be.,oil as public records MODIFICA'T'ION
UPTO 200 AMPS CINTERIOR [:1 CHIMNEY REPAIR
F Ej Licensed Professional - 201-100EAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IWIlAMPS _ ❑BATIIREMODEWREPAIR CDF.MO1,11'ION
-' I h by fl ff I mat f d C t der L' Law fo the
O funcevinu,reason.(Sell.,,"10315 H sine'. and F f naC d 'A Y payorcnunYSIGNS IiLNCDtICAL - El OTHER '
3 w RFj which respub,'.pcomis ,,corsound,idle p ,dearmlint.is re'sm,an,mrunure -
1- an prior to its lasnonce.also requires theappiicvnr forsuch promiva Ble a signed smmment SPECIAL CIRCUIT'DMISC, _ -
j J I
bat be islicensed p t to the provisions ortheC Incl License L (Chadert)
00 (conammucing withSection 7W)0)dfDivismd 3 ofthe Bruire,,tudP f sCodc)or TEMP.METER OR POLE.INST. COMMERCIAL:
.4L W a eL In.,he's exempt dion, n and the basis fies the alleged everopliA.Any violation of ❑NEW RLDCUADDITION .0 DEMOLITION
iC
m n m applicant Scrum for o permit Subjects the applicano a civil penalty of POWER DEVICES
0 TENANT 0 FOOD SERVICE
not 1.r,owm five Trimmed dollars SOIL). IMPROVPMENI
5pQ ❑Lmowder of the pniperty,lir myemployees with wred for Oci(See 044,Bmmien, SWIMMING IKlO1.PJ.ECTI2IC
qF will doth,aicnv Cosbemet he Costa not s Li cense La due, zale(Soo.1.a..,do,ness
OOTHER
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.and Property
no
Code:The to Contractors License wh Low doer nal apply s on ownar of OUTLETS-SWITCHES'-FIX TURES '
his ,,a wbo builds of sided that
t such b and who does such,inte himself oared for
his own employees,provided That.tach impnrvamente am not intended or offereA for NEW RESIDENTIAL ELLCTR SQ FI'. `
sale If,lmwcver,the building orimprovcarat is sold within one year ofcompletion.Ihc SQ.F'�L(9DIt�Rg(s $/SQ.INE
owmer,hudder will hove the htnden of proving that he did not build or improve for par- " L''1� L�//
pogo f. f _ TOTAL: -
1 f the p pe lt' exclusivelye tra fay with licensed T T I - 1 FEB f
c T tth p j t(S 9044 P dSol C 1 )TI C t I I' sl .. -.I - ( f ' ANS' .
e L d t apply t s f property h hands improves thereon, d QTY ' PLUMBING PERMIT;• .r l PCE-
who carriers for such products with a cont tar(.) caysedpursuantn the Contra ct I�'� y
Ur
Lice d.L PERMIT ISSUANCE VV7•CMIIN
OI am exempt under Sec tl&PCforT eretson V -
ALTER-DRAIN&VENT-WATER FA) VALUATION
Dam
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE _
I hereby affirm under penalty of perfory one of rhe following declamdonc - -
❑ Ihavc and will meimaihe Cerlificute of Colscnluself-insumfor Wnrker'hCompem - DRAINS-FLOOR,ROOF,ARBA, ). 1 - S'T'ORIES' 'TY PE CONS'FRUC[ON
'kation,as provided for by Section 3900 of the Labor Code,k;,the performance of the
work for which this pemtir is issued, I>IKI URES-PIR TRAP '
❑'I have and will maintain Worker's Co madmairion Tasman m required by Suction
3900ofthe Labor Code,for the perfonnmme of the work for which this pcmld si+'rued - GAS-EA.SYS'ILM-1 INC.4OUILIrIS OCC.GROUP APN
My Worker,Compensation Inodunrec.rrior and Policy rimmbenlre: . -
Carrier: - Policy No.: GAS-EA.SYSTLM-OVERrI(EA) -
CERTIFICATE OF EXEMPTION FROM WORKERS'. '
COMPENSATION INSURANCE GIHASFJINDUSTRI.WASTE,INTERCEPTOR - -
(This section nein bot he cnmplweduthe noon is for one hundred dod...($Ilk) BUILDING DIVISION hEI:S
Orissa) t GREASETRAP PLANCHECK FFP,
I comity thatsit thepefirmounoe of Oto wok for wh lch this Permit is issued l shal l SEWER-SAN ITA BY-STORM P.A.20d FT.
nal mph y yp t a,in n :o as to M1 subject at the Workers Cnmpen- ENERGY PER -
sound Law,urCl'forn DateWATER HEATER WIVLN'I ItlhBC'IR
Appl't m s - - . - - - GRADING FEE' -
. y NOTICE TO APPLICANT II after making this Certificate or Exemption,you should WATER SYSTEMaREATING -
(ti.� become subject In the W kc,,Cp I Pm,smrs idf tire Luber Code,you must - SOILS FEE
fanhwlh comply with hp : Ih p 'I:h'll M1CJ d ' kr': _ WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RLSIUIiN'1'IAL PLMB. SQ.PI'. PAID
'Z. Thereby affirm Thathconditioned' lending agency fnhc perfor nonce of ;iota - R solar#
�'� the woo:for which this permit is issued(See 3099,Civ.C.)
U I.code,s Name
nd 'Add
Fa1 Iit,that Ihave lid 11 his application d stube Full the above a Formation � te', i - � BUILDING FEE
ti consII agice us comply withll cityad county ordinances and:rne laws elating IQTIY's-; 0 MFC)HANICALPBRIAl -t' s FEE'
U Z mild gu+mtrttio.and herenor
byumz ,a
p nttives s fthr lily I,,enlermry,the t '.t to SEISMIC FEF.
neeve-mentioned property for inspection purposes, I PERMIT ISSUANCE
'(We)agree to save,Indmnnify and keep harmless the Cily ol'Cuperlinm against EIEC'I'kIC FE
Iiabilities,judginent,costs and expenses which may in any way ammo against said City' ALTER OR ADDTO MECH. i
nneequence of lhegmnling of ibis permit. PLUMBING
APPLE ANT UNDERSTANDS AND WILL COMPLY WITH ALL ANON-POINT AIR HANDLING UNIT I'(TO 10,000 CPM) -
SOI�( T ULATIONS. I - MECHANICALFEE
1/ .c t'3 AIRIIANULINGUNI'1'(OVEI214000CFM) - -
...///""" �` CONS'I'ItIIC'I'ION T %'s
,Ignamre 4Applicanl/Cwturcmr - ate EXHAUST HOOD(W/DUCT)
/ HAZARDOUS MATERIALS DISCLOSURE -' - HOUSING MITIC TION PPE
Width.applicant lir found hoildiagnwupml sure or handle hozmdo.s material []EATING UNIT(TO 100,000 PTU)
as defined by the Cmp9rlino Municipal Code,Chapter 9.12,and the He.IIh odd Safety
- Code,Section 25532(.)9 - HEATING UNIT(OVER 100,000 B'IU - -
❑Y --, ❑No VLNPILATION FAIN(SINGLE RESIDE PAID
Will thea Ilea I future huilJ m, Pum lie Doc Receipt#
ppequ' I ryes res which BOILER COMP(3HP OR 1()(),ONIO HTII1
Lt hazardous air cam ninanl. a ddined by thotloy Arca A r Quality Monagemem' a, f
Dimond?
❑Yet, CNo BOILER-COMP(OVER I00,000FITU) -
-Throe mod the hazardous nmlrndls myuiremenls under Chapter fi.95 of the CTJi- IV L
AIR CONUI'1'IONGk ISSUA EDATE
panda Health&Safety Code,Sections 25505,25533 and 255341 ondosmnd deu disc NEW RESIDENTIAL MECH. SQ.FE
building
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building does not conently have a tenant.Thal it is my responsibility to notify the occupant _
afthe requirements which must he net print to issumbe of a Certificate of Crematory.
Owner.,milhowed agentDale TOTAL: ISSt1ED nY:__-
, OFFICE o