27443 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOTIlba.-bills' PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 27443
,BUILDING PROJECTTDENTIFICATION
BUILDING ADDRESS: -11n //n{ ® SANITARY NO. APP.ICATIONNSSUBMITTALDATE
/t73J 3 (� •/C.. VO/vel UNIT# LOT If
PHONE: 1 CONT CTORS NAME: L NO'
r/O Z��'VS ' W t,le G'N �/ Q••s NIC'
CONTROL#
,•ARCHITECT/ENGINEER: 1,117.1,K) ADDRESS:
[,'] U r.,t,P�ffl Q 11 f p5 1'1.1
CONTACT: PHONE: E-&# A a ar«a -x ' 'y.i..:,m Pit #a x.
QTYe �,' HLEGTRICxPERMIT n . -FFE` ` ` aEU1LI7ING PERMIT IN170ft f -
x K�R:$s: '.4_ pits s y l- vv x: x a a DG ELBCT PLUMB MECH
PERMIT ISSUANCE'
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIALorrcr,ONr
Axz Ihereby offinnthat l am licensed under provisions of Chapter9(commencingwith "4i,XI[y""
[170_0 Section 7000)of Division 3 of the Business and Professions Code,and my license is in PANELS
W full Forceeffect.
yW License Clad Lic.# UP T0200AMPS
ior<Pir Date Combat 201-1000 AMPS
ZOnio` ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.IT.
0z_0 I understand my plans shell be used as public records.
p.,❑ W SIGNS ELECTRICAL
Licensed Profeaminal
Ly�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
W O E U L hereby r (St ne"1 an exempt from the Contmclorx License Law for the
W 3 W w following reason(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST,
1iJ v, which require,a perming construct,alto,impmvq demolish,or repair,any s ndarom
co 22 prior in its issuance,also requires the applicant for such permit to file a signed smtement POWER DEVICES
d 0 that he i,licensed pursuanuo the provisions of the Comeremrs Llcensa Law(Chapter
0. 0 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
Wim or than he is exempnherefrom and0e basis for lhealleged exemption.Any violationof OUTf.ETS-SWITCHES FIXTURES
F 6 Section 7031.5 by any applicant Fr a permit subjects the applicant to a civil penalty of
ez C5
not morethan five hundred doilere($500).
a'�� ❑ I,mownerofthepropeny,ormyemployeeswithwa mmtheirsolecompensalion, NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
will dothe work,and the structure isnot intended proffered formle(Sce.7044,Business
and Professions Cede:The Contractor's License Law does not apply to an owner of
pmpeny wbobuildsnrimpmves thereon,undwhodoessuch work himaelforthrougM1 his OCG GROUP RES.UNITS
tun building
ing or improvement
the owner-
builder
nH,
however,thebuildingorimprovementissolde did .,year ofcomieve for thrower- TOTAL:
h ld.). cell have the burden of proving that he did nml build or improve for purpose of
a
v❑)1,asownerofthepmpeity am exclusively commeting with licensed convector t QTY. >y°PLOMBING PERMIT 4 x x w a,-p eFHE}i 1 FLOOD ZONE APR
construct the project(Sea 7044,Business and Professions GuleB The Contractors LLL
License Lawdoesnot apply to an ownerot'pmperty whbuilds orimproves thrown,and PERMIT ISSUANCE
who contracts forsuch projects with a mnvemor(x)Iicensedpromanttothe Contractors
License Law. ALTER-DRAIN&VENT-WATER(EA) .. FEESUMMARY; '
❑ I am exempt under Sec. ,B&P C for this reason BACK PLOW PROTECT,DEVICE 5 O TSIDE FF.ES
SANITARY Y N
Owner Date DRAINS-FLOORROOF, GONDRECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
PI hereby affirm than l have a cervi fume of consent in self-Insure,or a certificate of FIXTURES-PER TRAP RECEIPT#
rke,'Comp.,mdon Nomination certified copy thersof(See.3800,Lab C.)which PARK FEE Y N
o
rsall employ.',under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS � _ RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCI IECK FEE
❑ Cenificd copy is hereby furnished.
❑ Certified copy is filed with theciry inspection division. GREASEpNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE AP SOILS FEE
COMPENSATION INSURANCE
(This section aced not becompleted ifthe permit is forces,hundred dollars($100) SAN TORM EA.20(1 ENERGY FEE
orless.)
I creifythat in the perfndicnce of the work for which this permit is issued,I shall TER HEA oWNFEMCM
not employ any person in any me as to become subject to the Workers' PAID
Compensationlxwsof Califomie. Data so WAT// fiMOREATING Date Receipt#
Z Applicant-
C,
pplicant MESIDENTIAL ELMS. SQ.FIL
O became TO APPLICANT:rs after Compensation
this Cisions of of Exemption,y a TOTAL;
b.nme,ubjealo the Workels Compensation provisions of the Labor Code,you st
forthwith comply wiN such provisions or this permit shall be deem revoked. BUILDING TEE
Remi Q CONSTRUCTION LENDING AGENCY SEISMIC FFE
z Ihereby affmnthat thea is a construction lending agency for the performance of TOTAL: ELECT FEE
O the work for which this permit is issued(Sec.3097,Civ,CJ
H Lenders Name 9;. PLUMBING IEE
k' Lenders Address QTY? E t h1ECHkNICAli PRIMLY{d " PEE •�
I comfy that I have read this application and slate that the clause mforromie "' Wd w'` '' ' ° r
0. cortex.iagree to comply with all city and countyoNinance,and state laws relating m PERMIT ISSUANCE MECHANICALFEE
buildingconstruction,end h ndby anthonzerepmsemadves of tha,ity tp en tr al.the
V ahove-mentioned property for inspection purposes. ALTERORADDTOMECII. CONSTRUCTION TAX
(W c)egr.to sure,indemnify and men broad.,,the City of Caperton against
liabidilics,judg a s,costs andexpenses which maymony I y accrue agaimi,aid City AIR HANDLING UNIT(TO 10,000CFM)
in consequen the granting of it
IML) AIR HANDLING UNIT(OVER 10,000 CFM)
bali o App,,I nU on re EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) ' Dem Receipt#
Wil l the applicant or future building occupant store or handle hazardous materiel HEATING UNIT(OVER 100,000 BTU)
as defined by the Cuperten
ino Municipal Code,Chapter 9.12, d rhe H.Ilh and Safety
Code.Section 25532(,)7
1:1 Yes No
VENTILATION FAN(SINGLE RPSID) P ge It is
❑
Will meupplidenl orfuturebuilding occupant ase equlpmenmrdeviaes which emit BOILER-COMP(3HPOR 100,000BTII) ���
I DATE
azardeas air eomaminams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) ,
",trim? - 3199
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.IrE
„ i have read the hazardous materials requirements under Chapter 6.95 of the CII}'Uh (,"Lit,•r4IIryU
Califomie Health&Safety Code,Sections 25505,25533 and 25534. 1 underslund thatoccupa
ifthebuildingdoesnotcurrentlyhaveast but let pitis myresponsibility tonotify the •r/
octrinl of @e rcyuiremems which must be men prior m issuance of o Cerlficute of
Occupancy.
Owner er authorized agent Data TOTAL: ISSUED By
OFFICE