26012 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO n .IDBiE.'�F'LhL"i`Rl�n1. PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 26012I v Q
BUILDING PROJECT IFICAI'ION'
BUILDING ADDRESS: " SANI'TARYNO. APPLICAHOONN SUBMITTAL DATE
/lqf,at LOI at
WNF SNAME PHONE: CONTRACTOR'S&61 /T T `^'NA�1E: LIC NO:
1S _L7 /i v ,---j N/C CONTNOLp
5 ARCI11'PEC'I'/EN'GINEER: LIC NO: ADDRESS. ❑
_:G_ZGHQ S�' L fpa3j
CONTACT: PHONE:
Q'I'Y. ELECTRIC PERMI' FEC BUILDING 1'P.RMI'I'INFO
- O Ii1.LCr PLUMB MECH
PERM]P ISSUANCE - El
LICENSED CONTRALTOR'g DECLARATION APPLIANCES-R[SI if
OCZ El—
[herchyaff lm that am licensed unJerprovisionsofChupmr9(commencing with TOB OIiSCRIITION
YI00 Sccumill)(0)of Division 3ofnhe Bueinessand Professions Cede,and my license is in PANG
FFydE fall htfcow:daffc r./ / t S, i
QQ W License Claxs l.ic.p TO W S
m60t Darel�LE-CTS mr 01 INN M
ZOtiE I 'v ' 'ARCIIITI:CI'S DECLARATIO 'e �1 PS SQ.Pf.FLOOR AREA E/SQ.FT.
OZ 66
[understand my plans shell beused aspuMic records.
PytW SI SELE CA. ,
2„U" Licensed Professional ,
4 OWNER.BIRLDER DECLARATION SPE ALCI If
KOa1 hereby affirm Nal 1 toe exempt from the Commemr's License law for the IB p
W a W r'e'p Inswing rcavnm(Section 7031.5,business and Profceslons Code:Any dry unty TEMP.M• IIS' I� r_ I
�O J which requires a permit to smouraa,alter,impot demolish,or repair any mr costeucturc .. _ _
m}2 to its issuance,also requires the applicant for such permit file a signed POWER DEV[ ES
poor t pP panni gnu
p that he is licensed pursuant to the Provisions of the Contractor[License Lew(CTapmr t
2 px,pC 9(commencing with Section 7")of Division J of the Business and Professions Code) SWIMMINGP )LE � RIG✓ I;,l VALUA'D N
W_m or that he is exempuherefrom and the basis for the alleged exemption.Any violation of
>a Section 7031.56 an applicant for a petmitavbjcets the applic.tto a civil OUTLETS-SWITcinis- ' T' S
F�Fx Y Y PP pcnehY of V
not more lbw five hundred dol 1.($50O.
NEW RE$IDI3 bBLE+CTR -SQ,Irl'.
� p ❑ 1,asownerofthepropeny,ormyemployeeswithwage mOcirsolecomp mafion, "TORIES 'rYPh CONSTRUCTION
o, will do the work,and thestructure isnot imendedmroffered fursale(Sce.9044.1ksiness
and Professions Code:The Contractor's License Law does not apply to an owner of
property whobuildsorimpmvestherece,andwhodoessuchwork fiblea fonhroughhis
vntpinyws,prnviduhhat such improvements urenm intendedondferedforsule.
If. OCC GROUP RES.UNITS
however,the building or improvement is sold within one yearofeomplesion,the owner-
builder will have 0e burden of proving that he did not build or imptnve for purpose of
sated.
❑ 1,as ownerof thepmpeny,amexdusivdycunvaningwith licensed nmtradorstn QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License lawdoesnnt apply to an ownerafpropeny,whobuilds or improves thereon,and PERMIT ISSUANCE
whoutmrnas for such projecla with ammnmmr(s)licensed pursntmno the Connector's
License Law. pLTER-DRAIN&VENT WATER(EA) PER SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this reason BACK FLOW PROTECT.DEVICE. UT IDL FEES
SANIJ'ARY YN
Owner Date RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION memorial ONDECLARA'1'ION SCHOOL TAX Y N
❑ Ihereby'Compersa nhatnM1ave a rance ori cemepythe od(Sself-insurc,ur Labrelfifican,ofwhich RECEIPi'p
FIXTURES-PER TRAP
Wmrkers'Compensmion lnsurunceoreeenibcJcnpy thereof(Sec.3A(XI,Lab CJ which PARK FEE YN
love.all employee's under this permit. GAS-EA.SYSTEM-[INC.4 OUTLETS RECEIPT'p
Policy# BUILDING DIVISION IEES
Company GAS-EA.SYSTEM-OVER 4(HA) PLANCIIECK FEE
f Cendied copy is hereby famished.
Cenifed copy is filed Militia,city inspection division. GREASFJIINDUSTRL WASTE INTERCEPTOR GRADING IEE
CPRTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not h completed ifthe permit is forms,hundred dollars($100) SEWER-SANITARY-STORM P.A.20t ENERGY RE
or less.)
I cerifynhm inthe performance of the work for which this permit is issued.l shall WATER HEATER W/VEM'/EL.ECLR
not employ tray person in any manner it,as to become subject to the Workers PAID
Cmir,comion Lawsof Califomis. Date WATERSYSTEMTI'REATING Dore Receipt#
0 z Applicant
z0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. OTAL:
ybecome subject o the Workers Compensation provisions of the Labor Code,you mull
forthwith comply with such provisions.,,his pe:min shall be deemed revoked. BUILDING FEE saas
0. Q CONS'I'RU CON LENDING AGENCY SEISMICITE
Z - I hereby affirm that there is a construction,lending agency for the performance of TOTAL: ELECTRIC FEE
U O Ihcworkfofwhichlhispnmitisi„ued(Sw.3097,Civ.CJ
��++ Lender's Name
IJ. t^ Lender's Address QTY. MSCI IANICAL PERMIT FEE PLUMBING FEE
0 U 1 certify than 1 have rend this applicminn and state that the above information is MECHANICAL FEE
>.,
correct.Iagrcc to comply with all ciy and county ordinances and stmclaws relating to PERMIT ISSUANCE
building treadmill. ,and hembyoalt ierepreseniativesofthis city to enteruponlhe CONSTRUCTION TAX
U shave-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)agree m save,indemnify and keep harmless the City of Caperton against
liahilitic,judgments,costs and expenses which may in any way seems against said Cby AIR HANDLING UNIT(TO 10.00(1 CFM)
in consequence of the graining of this permit.
AIR HANDLING UNIT(OVER 10,001)CFM)
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT CIO 100,0(1(1 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material IIGATINU UNIT(OVER 100,INp BTI[)
as defied by the Cupcnino Municipal Cod,Chapter 9.12,and the Health and Safety
Code,Section 25532607
1:1 Yes D(No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Willthee licamorfuwre buildin «cu rase BOILIiR'-COMP(311P OR IIX),OIXt 111 U)
PP B pan Armament ordevic Management
it B
�harardnus air camaminant,s9 definN hY the Bay Area Air Quality Manegemem BOILER-COMPIOVER 100,000 BTU) -• / D
3inrin'1 ✓q
❑Yo No NEW RFSIDENTIAI_MECH. gQ.IN'. A/
1 base read the harnrdoue materials requirements under Chapter 6.95 of the
Califomia I Icallh&Sufcty Code,genions 2SSI15.2553)and 25534. 1 understand that V
ifthe hnilJing Ane nm curzently havca¢na ,What it is myresponsibility no notify the Uh(aVr.�
oacup t of he. tents which est met prior tc issuance of a CenificnI of
Occu Y.
O e a vcd tug I Dec TOTAL: ISSUED BY:
OFFICE