27452APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING -ELECTRICAI-
BUILDING DIVISION APPLICATION/PERMIT PLUMRING -MECHANICAL
BIl11.UING PR(JJEC'1'IDNN'TIFICA7TON
PERMITNO.
7 /I C
I SFJ
BUILDINGADDRPSS: a
SANITARY NO.
APPLICA'IIONSUBMMALDA'IE
UNIT# LOT#
OWNERS NAME: PHONE:
CONI RACfOR'S NAME: LIC NO:
N/C
❑
CONTROL#
RCHITECT/ENGINEER� , I�� LIC NO:
'ps
AD RED O /t
CONTACT: _ nv PHONE:
&30 Ivry ak,J_a39f
//aO IAP it i
`Z
QTY . ELECTRIC PERMIT 1'CC
BUILDING PERMIT INFO
BLDG ELE PLUMB MECH
PERMITISSUANCE
�es
VtaAl 5'
W
LICENSED CONTRACTOR'S DECLARATION
Thereby that) (co mmencing with
APPLIANCES - RESIDENTIAL
JOH DESCRIPI'ON
N 4•--a-. 1✓�L1iy. �lly
C,
or Di 3 of
Section 7") or Division Jafthe Business and Profcssiom Code, and my license is in
fthnsedinss and roficsnfChapm,9
PANELS
full forwand cflrc
License Class
TO 200 AMPS
Ike
D��I U
Coca,
Dine Comrumrump, (y
2 - AMPS
2
ARCHITECTS DECLARATION
I understand my plans shall he used as public records.
OVER IUW AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRI L
Licensed Professional -
OWI BUILD ER DECLARATION
SPECIAL CIRN /MISC.
ma License Law the
1 hereby nfl inn thus I am exempt from the Contma,
'TEMP, MC'I'ER OR POL91NSt'.
7031.5, Co ec
Professions Codi Any city
fulNuwhich
wvpfiomme(mit to construct, alter. strurtycture
which rcyuires n permit re mrtwcL aper, improve, demolish, or repair any swment
to its the a statement
fntsuch Permit tothe
POWER DEVICES
visiosocant Lie
licensed pursuntti m
that heCommunes cese La
Thal he is licensed with See.nnt the provisions of the the Bu cm ss License Law (Chapter
9(ealheeisesemthcrefirn7o00)ue Division 3
SWIMMING POOL ELECTRIC
VALUATION
lleedlexeseandlkofyviolaCale)
orthSectmhe 131.5 by any prom andr.pearsfortheullegcdexemption. Anyviolationpion of
Semone subject the eppliamtoocivil penehy of
WS t� 3SO, Oo
V'
OUTLBTS-SWITCURS-FIXTURE
than veanyapplicantforapermit
not morethanrofthe orerty,dollormSSW).
❑ Lthe w thwagesaxiil '(Stec cam, nsaB.aiaory
NEW RESIDENTIAL ELECTR SQ.
STORIES
TYPE CONSTRUCTION
work,
well dothework, and the Business
mud th mraeomerm at ale l,dm M'w
he Contractor's 'censor
dos not apply in an owner
and Prufesvions Cade: The Commnor's License Law does not apply
if is
pmperlywoces, pdsorimpmvesth improvndwhod«s such work h roffiror through his
employees, provided that such impnrwmentnenm imendednrofferetl fnrsale.If
OCC. GROUT'
RIS. UNITS
TOTAL:
h ,ever, the building or inmmvmnent N,old within one yearofcompleam, the owner-
builder will have the bu cen of proving thin he did not build or improve for purpose of
QTY' PLUMBING PERMIT ••E
le.).
❑ 1,mownerofthepmNny,mnexclusivelycontaning with licenseiconwctorsm
FLOODZONH
APN
Linstruct the project (See. 7044, Business and Professions Craft) 'Me Contractor's
icense Lawdoes not apply to an owncrof properly who builds or improves thereon, and
pERMI'I' ISSUANCIi
whocontrur s for such projects with a commernr(s) licensed pursuant to the Commepar's
License law.
ALTER -DRAW & VENT- WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & P C for this reason
BACK FLOW PROTECT.
IDE FEES
SANITARY V N_
RECIiBsp4
Owner Date
DRAINS-F100RROOFAREA, ND.
,,
WORKMAN COMPENSATION DECLARATION
SCt100L TAX Y N
❑ Ihereby ofirm that l have a arlifiate ofcoment to self -insure, or a certificate ofFlXTURIiS-PER'IRAP
Workers Compensminn lm�u0mt ncyeeorucenlfied copy thereof (Sec. JflW, Lab CJ which
RECEIVI'q
PARK FET? YN
GAS-PA.SYSTNM-11 O LETS
covers all employeeand't
at.k(�
Policy p #
RECEIPTM
BUILDING DIVISION FEES
Company �I
GAS - EA. SYSTEM -O 4 P )
PEANCHEiCK FEE
erpy is hereby fumished.
GREASIVINDUSTRL ASTI: '1ERCE1'l'OR
GRADING ME
❑ CCenlfW
enified copy is filed with opacity inspectiondivision.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM P.A. 200MM
ENERGY FEE
C17m,wetion need not Is, completed ifthe neuron is foram hundred douse($TOB)
or less.)
WATER HEATER W/VF.NT/BLECTR
I cenifylhat imheperf(mamafthe workforwhich thispemtil is issued,) shall
not employ, any person in any manner so arm become [object m the Workers'
PAID
WATER SYSTEM(FRFATING
Compenemionl.awsof Cnlifomm. Date
Da¢ Receipt If
Applicant
NOTICE TO APPLICANT: If. after making this Cetifnate of Exemption.yot should
NEW RESIDENTIAL PIMP. SQ. E'.
TOTAL: -
hecome subject m the Worker's Compensation provisions of the Labor Code, you must
hmbwith comply with such provisions or this permit shall be deemed revoked.
BUILDING FEE
SEISMIC FEE "O
CONSTRUCTION LENDING AGENCY
Iherebyufrrnn thauhere iso construction lendingagency for Ne performance o!
work for which this panni, is issued (Sec. 3097, Civ. CJ
Lender's Name
'TOTAL:
ELECTRIC HE
Lender:Address
QT1',MEC) 1ANICAL PERMITFl?E'
PLO MBIN0 FEE
I certify that 1 have need Nis application and state that the above information is
cancer. I agree m comply with all city and county ordinances and state laws rchningm
PERMIT ISSUANCE
M[ ICAL FEE
building c m,malion, and hereby authorize representatives of this city m enter upon the
adene-awminncd property for inspection purposes.
ALTERORADDTOMECH. G).V
CONES UC4 T X
(We) agree to save, indemnify and keep harmless the City of Capstan against
Iiubilities.judgmems.cost andcs,..a which may in any way accrueagainet said City
AIR HANDLING UNIT ,"C )
consequence of the gmnting of Otis permit.
•r ry
AIR HANDLING UNIT (O 10, CPM
Signal of Appli,am/Cmationer Dote
EXHAUST HOOD(W/D ) I
PAID
BT
HEATING UNIT (TO 1It I
HAZARDOUS MATERIALS DISCLOSURE
Dam Rcesipt #
Will the applicant or future building occupant pore or imine. Inzndoua material
as defined[ bythe Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
HEATING UNIT (OVER ,0110 U)
TOTAL:
Cade, Section 25532my?
11 Ye �a
VENTILATION FAN (SINGLE RFSIO)
�"No
buffing occupantuse
Will tai(
BOILHR - COMP (SHE OR 100,00) BTU)
ISSUANCE DATE
BOILER -COMP (OVER 100.000 BTU)
Auipmem ualityo Management
contaminants
havrict? air contaminenla ss define) by the Buy Ares All Quality Management
ants as
District?
❑Yes Ubho
NEW RESIDENTIAL MECH. SQ, FT.
I have read the hazardous materia, requirements under Chapter 6.95 of the
California Health & Safety Cale, Sections 25505, 25533 and 25534. I understand that
if the buibling docs not currently have a,.nano, that a is my responsibility to analytic
occupnm of the requirements which mull he mel prior to issuance of oanile I of
Occupancy.
TOTAL:
Owner or authorized em Dam
ISSUED BY:
UI.1-Ict