28006 (2) t
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUIILDING- ILLCTRL Ah PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECIIANICAL OOOV1^�
IIUII.DING DIVISION BUILDING PROJECT'IDENTIFICATION 0
BUILDING ADDRESS. I SANITARY NO. AP/PPL]CCATION SUBMITTAALL�DATH
LUNITp 0'p
OWNIiNSN
is PI{ONE: _ so CONTRA R'S NAMIi: r /� 3gOxry - l
M J NIC CONTROLp
ANC ITECT/IIJGINE[R: w LIC NO: ADDRESS,/L � ,ter
❑
CON PACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB PT[1 MECH
PERMIT ISSUANCE LLDG
LICENSED CONTRACTORS DECLARATION APPLIANCES-RESIDENTIAL ;r IOti DESCRIPTION
OC] Ihembyafrtm NadlamlicensMuMapmvisioarofaVtu9(commencingwith � � J
WOO Section 7000)of Division 3 of the Business and Professions Cale,and my license is in PANELS /(
�U� full"..nano erre CF /MO//,nfi
FZW Licenwe aass— _ hien UP T02110AMPS
co Date Contractor 201-IOM AMPS
F•,�„Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.IT.
ZOm- Iunderstandan I 1 IlMuscd as Public rcauds. OVER If10p AMPS
OZ—E YPans e+e
re„�F.4 SIGNS ELECTRICAL
6 J Licensed professional
K W OWNFR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOy F T hereby affirm dust I am exempt be.the Comeanofs License Law for the
W'+n,y followingoutum.(ScaBusinessand
ion7031.5. Prnfctumus Code:Any city."county TEMP.METER OR POLE,INST.
F
P.
which requires a permit 1.coretruct,.1.,,improve,demolish,or repay anysmmtart
�t�Y� prior m its issuvnee.h.mquims theapplicend forsuch Permit file.signedstamment POWER DEVICES
WC<p That he is licensed pursunn to the provisions of the Contractors License I.—"o.
n 6o� 9(commencing with Section7")ofDivision 3 ofdhe Businessand Professions ode) SWIMMING POOL ELECTRIC / VALUATION"
W^y .r tum he ix esanpnh=mlromend the oasis lbr Ne allege)eumpdion.Any violas nor /1//���F/
l—Za Section 7031.1 by any applicant for a Pcm+it.subjects the applicant to a civil penal of OUTLETS-SWITCHES-FIXTURES YE' /
dFonot mom Nen five hundred dollars(5500). NEW RESIDENTIAL ELECIR 5 .FT.
❑ I,asownerof lheproperly.ormyemployces with wagesastheirsolecompenmtio Q STORIES TYPE CONSTRUCT ION
y3a� will do the work,and the structure is not intended or offered finitude(Sec.7W.Busines
and Professions Code:The Conlrocmr's License Law does not apply I an owner of /
property whobuildsor improves there.u,and whodces such work himxlfor through his s
wnempinytts,providcdlhm sucM1 impmvemcmxam notimcndedoroffemd forvle.IL OCC.GROUP RES.UNITS
however,the buildingor improvement is sold within one year ofcamp[tin n.IM1cowner- _ TQj:AL: �C�
builder will have the burden of proving that he did not build or improve far puryou of r
sale.).
❑ ],as owner ofthe property.am exclusively contracting with licenmd comracoo I QT PLUMBING P' FEE FLOOD ZONE MIN
consumer she project(Sea 7010 Business and Professions Code:)IM1e Convector's
I,ittnse Luwdcesm.applymanownemfprope.ywh.buildsorimprose,thereon,and P' ISSU
who commas Forsch projens with a conuacmrts)licensed pursuant m the Contmaors
License Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I
.,it e.cmpl unacr Scc. ,B&P C for This re.s m O SDE £ES
BACK FLOW PROTECT'.DEVICE, SANITARY Y N
Owner Dale RECEIPTp
DRAINS-MOOR,ROOF.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ IM1ercby vfrrm Nalhave acmirc.te of comm�uo mlf-insure.oraccnifica¢of RECEIPI'a
FIXTURES-PER TRAP
Wnrkeri Compensation Insurance orucenifial copy thereof($ec.3gW,hvh C.)which PARK FEE YN
RFC
IVISIAPT p
rs all empl�ty'wvsk•nhbtipi��= A GAS-EA.SYSTEM-I INC.40fITLBTS BUILDING DIVISION FEES
Policy r A//LL,�' ��, l(// T
Con+pany� pLisJJ,/ w� GAS-EA.SYSTEM-OVER 4HEA) PIANCHECK FEE
❑ centred torr is Imr=nr r.mianea.
❑ CenilieA copy is tiled with the city inspection division. GREASEANDUS1'RL WASTE 1N ERCBPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This uet..need.ot be completed ifthe permit is(osolm hunNddollars(SIM) SEWER-SANITARY-STORM fiA.20014. ENERGY FEE
or les)
I cenify that in the performance of the work far which his permit is issued,l shall WATER HEATER W/VENT/ELCMR
not employ any person in any m as to become subject o Ne Workers' PAID
Coml+ensalion Wws.l Culifomia. Dater WATER SYSTF,M/IREATING Date Receipla
O z Applicant
NOT ICE TO APPLICAN:If.are,making this Cenilicme of Exemption you should NEW REST DENTIAL PLM B. SQ.FT. TOTAL:
y beasmesubjeclto the Worltcrs Compenvtinn provisions of the Labor Coati,you must
a forthwith comply withxuch provisions or this permit shall be desmdi revoked. BUILDING FEE rjI
Q CONSTRUCTION LENDING AGENCY SHISMIC FEE
I hereby vffirso shat shim is a eTropnou++n lending agency for the permorrou e.of
L) O TOTAL: ELECTRIC FEE
Ne work for which this pem+it Noticed fScc.3(19],Cis.CJ
Leader',Name
u' F Lenders nderess QTY. MECHANICAL PERMIT FEE PLUMBING FEE
L) 1 vitrify that 1 have rend his application and sate tum B¢above infonnasion ix MECIIANICAL.FEE
>. IW conch. Iagrtt to comply with all city and county ordinwces and state laws relating to PERMIT ISSUANCE
F' building corelrut'Jinn,imd hereby suNorir<repres=ntmivee oflhis city mender upon the CONSTRUCTION TAX
U z abswe-mentioned propery for inspection purpe.. ALTER OR ADDTO MECI I.
(We)agree to save.indemnify and keep harmless due City of Caperton against
Iiahililics,judgmentx,costs and expenses which may in any way acerae against said City AIR HANDLING UNIT(TO 10.000 CFM)
in consequence of IM1e gre.sing of Nis Permit.
AIR 14pNDLING UNIT(OVER 10.11110 CFM)
Signature of ApplicaMConvacmr Date CXI MUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipsa
Will the applicant or future building occupant sort or h.ndle hursom us material
as defined by the Cureman Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.0(s)BTU) TOTAL:
Code.Section 25572001
❑Yes ❑No VENTILATION hAN(SINGLE RESID)
ISSUANCE DATE
)
Will shcepPliwmorl'umm buildingoccupant useequipmem oNcviceswhich emBOILER-COMP OHP OR 100,
it 000 BTUZ'P ria. r
hnrxrdoes air contaminant.aits dirtied by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0110 BTU)• �nyw//�Damell 11Ycs [I No NEW RESIDENTIAL MECH.—SQ.FT. NA Y
1 have read the hamutIm s materials requirements under Chapter 6.95 or the ?995
Culiforniallcalth&SnfdyCodaSections25505.2551Jand25534. 1u.dm V Cqecarma fy l QF�UNEFirI
if the building does not currently have a tenant,that is is my respm sibility to notify the
occupant of the requirements which must be stn prior to issuance of a Ccmfinme of
ccup
Own,,ncy. '/ .
Ownu . Ih
..... .agOor Date TOTAL: ISSUED BY:
OFFICE