28371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OFCUPERTINO - B HATING-ELECTRICAL - PHRMIT'NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL /�Q
BUILDING PROJECT DENTIFIC,ATION Lo
BUILDING ADD SANITARY P0 1114
UNITM LOTH
OWNERS SANITARY NO. APPLICATIONSUBMITTAL DATE
V2yo
NAME8. PHONE: CO�ANNT�T�R-ACTOR'S NAME: yy7I ��77�� y� LIC NO',
6 FC1i�/Q�Yn4ry'Uh/�� GV � �� 7N/C CONTI1kRCIIITECI EE LICN AUURFSSNJ4c,cFCepr st
CONTACT: PHONE: QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG ELECT PLUM13 MECH
PERMIT ISSUANCE ❑ ❑
LICENSED COST RACI'OR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION
pWZ I hembyaffirm thin l an limmedunderprovisionsof Chapmrt)commend.,with
ts100 Section 7011 Division Sof the Business and Professions Code,and my license is in PANELS � I lww I rC� D AIQ
yWC fullforce and if N�
•-lV /L' /1'
F ZUZ CWJ Licmue Class �/ LispO Q UPl'0200AMPS
m
y6y Due, Coe, 201-IOW AMPS
ZOr`iz ARCHI'I ECTS DIS .ARATION OVER I"AMPS SQ.FI'.FLOOR AREA $/SQ.FI'.
p Z_0 I enderstanJ my plans,hull be card.public records.
Fy ; SIGNS ELECTRICAL
Licensed Professional
OWNER-Bempt from
mtthe Cmd TION SPECIAL CIRCUIT/MISC.
OyE I hereby affirm that 1 um exempt from the Convenor's License ittw for the
W3u-m which followingreason.
Permit
toconstS,Businessend Professions Code:Any city structure
TEMP.METER OR POLE IN5f.
which)equina issuance,permit re carat,.aper,improve,demolish,or repair nay umannae
ce, }� pain,is lcensedP.. ,totha the visios.1tlot e CmaomiunLienseLaJ,(Cement I'f3WISR DEVICES
yj in thin In.monar arinwith Setion70eprovisloom(the Ca Basin is License Law Care)
aao� 9(commencing with Stttion]aq)nfDivisionJofthe Business add Profession,Calc) SWIMMING POOL ELECTRIC VALUATION
yKJ_y or that he is exempt herefrom and the basis for the alleged exemption.Any vialsoonof
OUTLETS-SWITCHES-FIXTURES W
G arta ]tan ye cnyapplicem for spetmit subjects the applicant acivil Penalty of /a dJ
ml mI.a than To Fthc ro rty,ormyempl NEW RESIDENTIAL ELECTR S Ir
HIM ❑ othe wrk,andthe someone
probated forihei(sole cnmpensiiess Q SIY)RIFS TYI'IS CONSTRUC'T'ION
a will do wons ande:The Cuzc la tot intendedprofferedLaw does not
apply to
an owner or
and Professions Code:The ms no ors rid bo Law does not apply m un owner is
propenywhulmyees,prsnrimprovesihereon.somerampact itende himselfonM1ro ale.IL
7n
owu ever,thebuildingmdtbutench improvadwitthinme ear ofcmpletirn,the
sale.IL OCC.OROUP IIHS.UNI'T'S
huilder ,ehav building urian everrinal ofprovini that he within of immolation,purpow a TOTAL:
builder will have the burden of proving that he did not build or improve for puryou of
sale.).
❑ I,as nwneraftheproperty,arm cndusivelyconmdting with licensed coned oto QTY. PLUMBING PERMIT PF,E FLOOR ZONE APN
amebuer the project(Sec.71144,Business and Professions Coda:)Tim Conlr tor',
Licenu Lvwdocs not opplyman owncrofpropcny wh,builds orimproves thcrco ,end PERMIT ISSUANCI
wnoamvectsfa suchpmject,withewntmcmrts)Iiccnard Pursuanumhe Cnn mr'a AL'T'ER-D I -WAI'lift(FA
License law. FEE SUMMARY
❑. 1 am exempt tinder Sec. ,H&P C for this a o BA ROr",CT.GENIC SANITARY Y DF;FEES N
Owner Dom RECEIPT#
IN. -FLOOR,ROO , R1: OND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affrre that l have a moderate ofcomenrto self-insure,ora car rfiremof XTURES- iR 'Rpt✓ RECHIPTp
Workers Compenearlon lnsumncmnuwrifiW copy thcrud(Sw.38W,Lub .)which
PARK FEE Y_N
Coversa
llem Inyce'x wider Otis ,nil. p5-f?A.SYSTII IINC.40 I.GTS BECF.IPTM
Policy N BUILDING DIVISION Finis
CompnnY GAS-EA.SYSTEM-OV (EA) PLANCHECK Fee
mi
emFed copy is hereby formsdam.
❑ Certified copy is filed with the city inspection division. GRHAMONDUSTR ASTE INrrFRCEPI'OR GRADING Felt
CF.RITFICATE OF EXEMPTION FROM WORKERS' GREASE SOILS FEE
COMPENSATION INSURANCE
(This section need not uncompleted tithe permit is forum,hundred dollars($1 SEWS ANTTARY-STORM EA.200FT. ENERGY FEE
or lmaJ
I cenifydeaullperformnnee (the work forwhich thispernit is iamed,lshall WATER HEATER W/VII De EC'IR
not employ my papa,in as arwer ao d to become subject to the Workers PAID
Compensation laws o(C in. an WAI FR SYSTEM/IREATING Date Receipt it
z Applicant
z NOTICE TO APPLICANT:11,alter making this Cenifiewcof Exerneion,you should N17W Rest DENTIAL PLMB. SQ,FI'. TOTAL:
H W) became subject to the Worker's Compensation provisions of the Labor Cale,youmust
� > fadlb ikh comply with such provisions or this Permit shall be deemed revoked. BUILDING Fee
z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembyvffrm that them aco ti on lending agamy for the porionamcenf
V O the work for which this perppniai (Sec.3(19],Civ.C.) TOTAL: ELECTRIC FIJ?
Lendrr's Name PLUMBING ITS
p F Leaders Address QTY. MECHANICAL PERMIT FEE
V I certify that 1 have read this application and state that the above information is
Lia careen. legreemmmply with all airy avd county mdinancea end stem laws relining to PEIiMI'1'ISSUANCI? MECHANICAL FEE
F'
P.
building construction,and hereby authorize representatives ofthiscay menteropnnthe CONSTRUCTION TAX
L) z n
sie-mentioned gen
proy for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify unit keep hatmiess the City of Canadian ag t
liabillies,judgments,cnste an de eswIF hmay invny ny sector,agaime Ciry A IR I IANDLING ON IT(TO 10,000 CFM)
In crmcyuena oft m th'nspcmtit.
11 r AIR HANDLING UNIT(OVER IO,(M CFM)
Signumreof Applicam/Comracmr Date EXHAIIS'T HOOD(W/DUCT) PAID
HAZARDOUS MATERIAES DISCLOSURE HEATING UNIT(10100,00013 FU) Dam NewtonY
Will the applicant or fuwrc building occupant stem or handle hazmdeus mmeamn
as refined bytne Cupedino Municipal Code,Chapter 9.12,end the Health and Safety HEATING UNIT(OVER 100,000 BTU) as TO L:
Cede,Serol 0 Yes 2(u)]2533 13 No VENILATION PAN(SINGLE RESID)
Willtair commandants
Cts as building by the
equip mem Quality Management
BOILER-COMI'(311POR100,IgIDBTU) IS$ AN0LRDA
�hdddom air comaminanu as Refined by the Bay Area Air Quality Management
District? El Yes ❑No BOILER-COMP(OVER 100.000 BTU)
Q(�c
L 18
I have read the hazalloas materials rNmarmNEW RESIDENTIAL MECH.-SQ.11'.ents under Chapter 6.95 of the Ct i y fir sur' 1`e�/�J
California Heald&Safety Code,Sections 25505,M533 and 25534.I endentand that SRV(
if the hui lding does not currently have a tenant,that It is my responsibility to notify the
occupant of the reyuiremenes which must he met prior to issuance of v Part Beate of
Oceuparcy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE