26671 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF COPERTINO '' PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 26671
NUILDINC PROd E6T IDBN'fIvicFlCATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'MAI.DAII
—1r3-t8— ':ZHP/DOC,S1 HILL LN3 UNIT# IAT# l�/ r1pot-4
OWNERS NAME?: PHONE: CONT R' A LIC NO:
N/C CONTROI.p
3g-11
�ARCHITIiCgENGINEER: LIC NO: ADD S: ❑
V N
CONTACT://�� '�� •1 cPHONE: QTY. ELECTR PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUAN LDG XE
M N
LICElxSED CONTRACTOR'S DECLARATION APPLIAtCE41 RfSIDENTIAL JOB DCS ION
QWz, I hereby afOrmtha lam licensed underprovisions ofassuer9(commeneingwith
0100 Sagion7A)I))a1 Dlvision3of the Bminess end Professions Code.and my licenu is in PANELS
force and err«L
Lie
Fpm License Clus Lic.# UP /a
2 A I-T��
IYV
mQy Date Carlrectnr 201 1 PS
7 Ois
,Z ARCHITECTS DECLARATION V 1 AMPS SQ.PT. OR AREA I� $)SQ.FT.
OZ-0
I undersand my plans shall be used m public records. � � Oala�
F..vl f'; GNS FlECfRIGM.
QY�,� Licensed Professional L.
OWNER-BUILDER DECLARATION PECIALCIRCUIT/MISC.
XOyU I hereby affimt shut I am exempt from the Commcmr's License Lew for the
013 a v following reason.(Section 703 L5.Business and Professions Cade:Any city m county TEMP.METER OR POLE INST.
F a 0,I which requires a permit to concoct,alter,improve,demolish,or repair any l.auu
"id.caY�:� prior to its issuance.also requires the applicant for such perenitto file a signed statement POWER DEVICES
y1 C p0 that he is licensed pursuant to to the provisions ofthe Correctors Licenu law(Chapter
aKo 9(commeacing with Section 7100)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
ty_y or that he is exempt thenfrom and Ne basis for the alleged exemption.Any violation of UTLUS-SWITCHES- 1 �1
F.3a Section 9031.5 by any applicant for a permit subjects the applicanfto a civil penalty of FlXTURBS J
5=0 not more than fvc hundred dollars(8500). W RESIDENTIAL ELELTA S .IT. L
11 ❑ I,uownerofthepropeny,ormyemployeeswithwagesutheirsolecompensa0on, Q SI'OR -S TYPL CONSTRUCT ION
x322 will do the work,and the svncture is not inteultaimoffered forsale(Sec.70aU,Bumax,
and Professions Code:The Contractor's License Law docs not apply ro sn owner of
prnpcny who builds or improves thereon,and who roes such work hareelfor through his
employees,providcJ thatsuchimprovements arc not inteadedoreffem4forsaie.If,
OCC GROUP RES.UNITS
howe eathe building.,improvement is sold within meyeaofarmpletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
Lasowneroldel, party,.neclusivelycontractingwithlicenudcont tonm QTY. PLUMBING PERMIT FEE FLOODZONE APN
eruct the project(Sec.70u4,Business and Professions Code:)The Conuacmrs
Lic se Law doesnm apply torn ownerofpr.peny who builds or improves thereon,andPERMIT ISSUANCE
muan
who s forsuch projects with.coutrachims)licenard pursuant.Ne Convectors
Lieem Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 exempt under Sec. ,B&P C for Nis reawn BACK FLOW PROTECT.DEVICE OUTSIDEPEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ ers'Coyaffirmon Insurance m ifcre ofconscmereof(insure;o,Lab C.)which FIXTURES-PER TRAP RECEIPT#
Wnrken'Compensation Insurance oracenifWcopy Chemof(Sec.3800,iab C.)which PARK FEE YN
covers all emplaya's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RF;CEIPT p
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is filed hereby
the ed. L
❑ Certified copy is fled with the city impaction division. GREASErINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS ME
COMPENSATION INSURANCE
('This section need notbe completed if the permit is forone hundred dollars($ SSE R- ANI �Y �RM ENERGY FEE O
or less.) J _ _
I<enify that in the performance ofthe work for which this pennitisixxmsd sill 'WATER IfEAT,RW ENT�{,€,�T
.t employ any person in any marmer ea as to become xubjmt to Ne Worker '"
Compenvtion"scsof California. Date r e ( WA'ILR ^EA IN PAIDRa
O z nApplicantDae
z O NOTICE TO APPLICANT:If,after mating this Certificate of Exemption,you should NEW RESI P SQ.FT. TOTAL:
F" 50 become subject to the Worker's Compensation provisions ofthe labed
or Ce,you must
forthwith comply with such provisions or this permit shall be deemed revoke
BUILDING FEF. OO
pW,r Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hcuby,affirm that Neu is a c.nawdian lending agency for the performance of
(� C:) the work for which this permit is issued(Sec.3097,Civ.CJ
TOTAL: ELECTRIC FEE
Lenders Name
U.
F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBINGFEE
WI eerily that 1 have read this application and sate that the above information is
F 0. correct l agree to comply with all city and county ordinances and stole laws relating to PERMIT ISSUANCE MECf1ANICAL FLE
DO building construction.and herebynadamiu reprexntatives of this city roemerupon the,
L) Z above-enmlanW properly for inspection papa,.. ALTER OR ADD TO MECH. CONSTRUCTION'TAX
(We)agree to save,indemnity and keep harmless The CityVaC m againstliabilities,] nts,costs undenpcnses which ma ns dCiry AIR I{pNDLING UNIT(TO Ig000 CIM)
it a eco hegranting this it
I HANDLING UNIT(OVER IBM CFM)
Sign ureof Applicam(Comm au Date EXHAUST HOOD(W/DUCT)
PAID
IIAZA RDOUS MA Mir
DISCLOSURE EATING UNIT(TO 100,000 BTU) Dam RaeiptN
Will the applicant or future building Occup.,secure,handle hazardous maerial
s corned by the Cupenino Municipal Core,Chapter 912,and the Health and Surely HEATING UNIT 100,0!10 BTU) TOTAL:
C Section 25532(a)? -
❑Yes 13 No VENTILATION FAN(SINGLE RES][))
Will thenpplicentorfmmu
are building occupaucquipmenmn BOILER-COMP PHP OR 1 Wp00 RTU) ISSUANCE DATErdevicwhich emit
huumlous air cortammanL,as defused by the Bay Area Air Quality Management BOILER-COMP(OVER IM."BTU)
/Dlshirt. fh p A h
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.PT, fi /sQ 6Y
1 have read the hazardous materials xquiremems under Chapter fi 95 of the /f4/ dN
Califrmin llcuhh&Safety Code.Sections 25505,25533 and 25534. I understand that B
if th �'a
e building does not currently have a tenant that it is my responsibility to notify the rI/) 9
0.4
occupanl of tile m
e requireems which must b,met prior to issuance of a Certificate of 011
Occupancy.
Owncral uthoozed agent Dae
l' T L ISSUEU BY:
OFFICE