27223 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO UMUING-MECHA TC,C' PERMIT NO.
APPLICATION/PERMIT PLGI'ROJ-MEDHANIQAL
RUIhDINC DIVISION ,hI1111.21Nf,1'ROJ{aF�yCI'IDF:NTIF'ICA'I'ION
27223
Bul1QO1NG�FSS: �/� Pd�to r/I'l t� UNITpY �/1 J—�II LOTp 9 SANITARY NO. APPLICAT22ON SUBMITTAL DATE
O LRS NAMP s PHONIb CONTRACTOR'S NAME: LIC NO: NIC �COMROL#
fcz� /0�1 cedes _S_-6&VC7cvNER
• ARCHII'HCT4iNGINHEIL LIC O: ADDRESS: ❑
CONI'A(T: PHONE: BUILDING PERMIT INFO
I QTY, ELECTRIC PERMIT PEE
lee CQ er PERMIT ISSUANCE BLDG ELECT PLUMB MF.Cry
LI ENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL rhGl( WDESCRI SPI'11�OOf'N iy�J
Metz Ihereby affirm that l an licensed underprovisionsof Chapmr9(commencing withJOB
w4 C+0 Section it of 3 of the Business end Professions Code,and my license is in PANELS
C W full force and affect.
E-ZW License Class Licit UPT02WAMPS
rn=y Date Contractor 101-1000 AMPS
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
0 Z_G 1 understand my plans shall be used as public records.
SIGNS ELECTRICAL Ps 3 ✓�6 {/,f,-]I,�
Qy f j Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO V 1 hereby affiant that 1 am exempt from the Contractor's License Law her the ��
W 3 m in following mason.(Section 7031.5,Business and professions Cade:Any city or county TEMP.METER OR POLE INST.
t pJ 0 which requires a Permit to construct,alter,improve,demolish.or repair any sanctums
�`W°}� priorto its issuance,also equines Ne applicant for such permino fileesigned summent POWER DEVICES
W�5 D O that he Is licensed pursuan to the Provisions of the Contranors License Law(Chapter SWIMMING POOL ELECTRIC
X9(commencing with Section 7")of Division Sof the Business and Professimu Cale) VALUATION �.
to or that he is exempt herefrom and the basis for me alleged exemption.Any violation of
I-.Z y Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES �1/61
7a
Q t mart than five hundred dollars($500), a
Ail n❑ Lasa iierofrhe m yemp y g pensatian, NEW RESIDENTIALELECIR _SQ.FT.
y3m he p ..arm to admithwa esasrhe(Sce.cam STORIES TYPE CONSTRUCTION
— wan Pr thewons andma suwweianarimenense La doesal Wepply 7t an owner
of
ss
send Professions cafe:The Contractor license Law does not apply to m owntt of
pmperywhars,,roofim�rovesch improvements
mprove woo acessuchenddhimsecedlthroughnice
howownever, bou
Natsuchimis sold within
thinne earofdmof@red theow.IL OCC.GROUP RES.UNITS
however.the ase the hu improvement is hold within one year or improve
omm a for thaownen
hale.). will have the burdrn of in Net he did not build or ins TOTAL:
Prov g prove for purpose of
❑ I,as Owner of the Property,and exclusively contracting with licensed mntracturs to QTY. PLUMBING PERMIT FEF: FLOOD ZONE APN
construct the project(Sec.7094.Business and Professions Cade:)The Contractor's
License Law does not apply in not ownerofpropmy whobuilds or improvesthereon,and PERMIT ISSUANCE
whommourts forsuch projecewirhacommctiabd licensed pursuvtuothe Conownes ALTER EA PEE SUMMARY
License Law. ( 7
OU
❑ 1 am exempt under Sec. ,B&P C fm Nis season BACK FLOW PROTECT.DEVICE TSIDE FEFT—
;4
TARY Y N
Owner Data RECEIPTq
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR.ROOF,AREA,GOND. SCH YN
• covers❑ UnmbyaffirmthntlbavescenificuLinm -PER TRAP
mofcnnsenuaselsmn,ora certifcaaf RECEIPTp
Wmkers'Compcnsamtt
tionlmunoracertifiedmpy mma
eof(S .38W,Lab CJ FIXTURES FET?which PARK YN
all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLET - RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Cl Cenified copy is hereby famished.
❑ Cenified copy is filed with the city inspection division. GREASEgNDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASHTRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleted ifthep<m,il is forane hundred dollms($IW) SEWER-SANITARY-STORM EA.2IXI11I'. ENL'RGY IEE
or less.)
I certify that in the perfammc.fdo.work far which this .it is irmcd,I shall WATER F IFATER W/VENT/F.LECTR
not employ any person Fn my announce so as an become subject to the Worker' PAID
z CAopplpem`tionlewaof Califir is. Date WATER SYSTEM/TRFATING Dam Receipt#
O0 NOTICE TO APPLICANT:If,after making this CartiEcam of Exemption•you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
F7 y becnmc subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this pemdt shall be deemed revoked. BUILDING // —
W M CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I hereby affres thn erfams
there is a construction lending agency for the pnce of
U O the work for which this Permit is issued(Sec.3097,Civ.CJ TOTAL: F.LF,CITtIC FEE `$ s
Ixnders Name PLUMBING FEF,
0 U Lender's Address QTY. MECHANICAL PERMIT FLEE V
13.1 m I c I agr twt 1 have mit this application and me that an above infnmuting is MF.CHANICAI.FEE
building
caner mon,and with
rebysutyand county ordinances and smm lawsrelatingupon
PERMIT ISSUANCE
alouv innentionediorand herebyauthodurcprcarnwiwe of thio city toen¢r upon tha CONSTRUCTION TAX L �"'Q
V above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. tl v i
(We)agree to a sm,indemnify and keep harmless the City of Capitoinn against
Iwbilitics,judgmenu,costsand expenses which mayin my wayinammagsinst said City AIR HANDLING UNIT(TO I0,000 CFM) • i
cquence of the gra ting of this permit. "—�
_ AIR HANDLWG UNIT(OVER I0,000 CFM)
Si,m1mccf Applimm/Contractor •J >aeJ EXHAUST BODO(W/DUCU PAID
I IAZARDOUS MATE.RIAIS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data ft_Pl#
Will the the Coltman
Codecupmrsmreor hurdle Heardommamrisl HEATING UNIT(OV ER 100,0(10 BTU) TOTAL:
as de,Sed by the(htpenino Municipal Coda Chapter 9.12,and the Health and Safety
Cada,Section ayt VENTILATION PAN(SINGLE RISID) g-k H
❑Ye 's ❑No D
Yes
%SSITA CE•DATE
Willthca licmmrfumrebuildin rota BOILER-COMP(3HPOR 100,000 BTU)
PP 8 pmtuuegoipmem mdevices whichhemit
hazarlo
District?us air contaminmts as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) MAR 29 1995
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT.
I have mad the hamrdous materials requiremems under Chapter 6.95 of the CI I Y Ur l.Urt8I INV
Califnmia Health&Safety Code.Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a¢nam,that it is my responsibility to notify the
occupant of the requirements which must In met prior to issuance of a Certificate of
Occupancy.
Owner on uwhmiand ugem Dam TOTAL: ISSUED RY:
OFFICE