27218 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING ELEUrRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL 27218% q Q
BUILDING PROJECTIDENTIFICATION G I 1 0
BUILDING ADDRESS: �//� SANITARY NO. APPLICATIONSUBMHTALDATE
373 1 a eL / UNIT# / I&4 LOT If / Ii� s
OWN��'I{{S Nr PHONE: CONTRACTOR'S NAME LIC NO: NIC CONTROL# J
iTaTiOrr a)r'Jej >/O�f jS 000 Otvn le h
• ARCHITECT/ENGINEER: LICNO: ADDRESS: ❑
CONTACT Cline
///')t PHONE: Q'IY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
a=.P�. �--+dd lar7p7'�Q� BLDG ELECT PLUMY MECH
PERMIT ISSUANCE: -�( KvLj4( IhQ(
LICENSED C NTRACT1MS DF,CLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pfYz Iherebyaffirst char l am limmedmiler pownumnrof Choptere,(commencing with
P400 Section]IXIB)of Division 3 of the Bulinus and Professions Cale,and my license is in PANELS
U Section land effect v`
_Za Licensc Class Lic.# UPT02MAMPS
m 5roDate Contractor 201-I(#0 AMPS
v, ARClIITELTS DECLARATION OVER IM)AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
zc�vco n I understand my plans shall be used as public records.
w fv{{ SIGNS ELECTRICAL.
�yy 3 LiLicensedProfessional
0. d',EQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
C
pxx, a F 1 hereby affirm that I um exempt from the Cammcmrs License Law for the
W3k s following reason,(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. y
F LL which requires u permit to construct,alter,improve,demolish,or repair any svucntre
prim to its issuance,also requires the applicant for such Permit o file aligned statement POWER DEVICES
W �p that he is licensed pursuanuo the provisions ofine Contractor's License Law(Chapter
a4o�' 9(commencing with Section 7W0)of Division 3 ofthe Businessland Professions Code) SWIMMING POOL ELECTRIC VALUATION
�C
or that heir 1.5 by mhcrtfromand the basis to the the
exemption. civil Plation of /9y 6D3,
F orthatSectioe is
sLempt thmfourantfore basis f rtje all to plimal exemption. civil penally of OUTLETS-SWITCHES-Fl%TURES 01
not mom than five hundred dollars($500). J
propny,ormyemployeeswiNwagesmNeirsulecompensation. NEWRMIDENTIALELECF. —SQ.FT.w ❑ I,unwnerofthe Q STORIES TYPECONSTRUCTION
a will dothework,and the swcmreisnot imendedoruffered foraale(Sec.7044,Business
and Professions Cade:The Convacbrs License Law does not apply to an owner of
property whobuildsorimpmves themon,and whodom such workhimxlforthrough his
ownemploynex,provided that such impmvementimre not inuendedvroffered for sale.If. J OCC.GROUP RFS.UNITS
however,the buddingsa improvement is sold within one yearofcomplefion,meowner- TOTAL: /70a
builder will have the burden of proving that he did not build or improve for purpose of
side.).
❑ I,in ownerufthe popery,am exclusively contracting wit licensed comotexam to QTY. PLUMBING PERMIT 17EE FLOOD ZONE APN
construct the project(See 70al Business and professions Cede)Tha Contractor's
Licerne Law do matipplytnanownerofprapery whobuilds Or imuouromhereogand PERMIT ISSUANCE
whocomusels forsuch projects with acomracmr(s)licensed pursuant to the Convectors ALTER (FA)
License law. FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y E N
Owner Date RF.CEIPI'#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATIONDECLARATION SCHOOL TAX Y N
❑ [hembem'Co a nsatlhnt Lhaven oraceateied nU ereof(Sm .38 o,UbCfcataof FIXTURES-PER TRAP RECEIPT#
Workers'Campensationlnsuranttrmit. ifed copy thereof(S¢.3BIXI,lab CJ which PARK ILII Y N
coven all employee's under this pennik GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE �—
❑ Cecifedcopyisherebyfumished.
❑ Cenifed ropy it fled with the city ivpection Division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not hacumpleted ifche permit is for onehvndred dollars(SIM) SEWER-SANITARY-STORM PA.200hT. ENERGY HE
or leas.)
I cenif dou home perfomance of to work fm which this permit is issued,Ishalf WATER HEATER W/VENT/ELECTR
not employ any,person in my mummer to as m become subject m to Workers' PAID
Compensatioalawsof Califomia. Date WATER SYSTEMITREATING Data Receipt#
Q Z Appliesat
Z 0 NOTICE TO APPLICANT:IL eller making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,PT. TOTAL:
rA become subject to the Workers Compcnmrion provisions of the labor Code,you must /
forthwith comply with such provisions or this Permit shall be deemed revoked. BUILDING FEE �O
Lkl (] CONSTRUCTION LENDING AGENCY SEISMIC FEE a `r_
I hereby affirm that there it a construction lending agency for me perfomunce of ��sa,�ss FLECRtIC FGE
U O
the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: /X a Q 0 t
Lk. Pander's Nome
O F lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING ILO
0 QST
U I eerily ohm I have read this application and state that me above information is MF.CIIANICAI.HE
r1'a 6Wi <orrtct.Iagreemrnmply with all city enJ county ordinances and stem laws rtleting to PERMIT ISSUANCE174,
'.' building construction.and hereby authoris representatives oftbis city menter upon the CONSTRUCTION TAX
U Z move-memionedproperty for inspectionpuryosm. ALTERORADDTOMECII. Sq
(We)agree m save,indemnify and keep hefmlas me City of Colman,against
IiaM1ilities,judgmems,corn and expenses which may in any way uceme against said City ALR HANDLING UNIT(TO 10,001)CFM) 1
carom ace of t4ting of this pemmir.
N If'yh� AIR HANDLING UNIT(OVER 10,001)CFM)
Signnmre of Applicu.VC tmclor V "I Dare EXHAUST HOOD(W/DUC11 PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT TO IW,t00 B'TU) Date Receipt#
Will the applicatorPo amici al Code.Chapter 9.12,
or and to Hath
HEATING UNIT(OVER 100,000 BTI) TOTAL:
a<definedby the 32m)tnn Municipal Cade,Chapter 9.12,and the Health end Safety
Cade,Seco El Yet, a)'t VENTILATION FAN(SINGLE RFSID)
❑Yes ❑Na
ISSUANCE DATE
Willteapplicenmrlumrebuildingoccupnnmseequipmenmr devices whichemit BOILER-COMP DHP OR I00,0fi0 BTU)
•havudnus air contaminants as defined by the Buy Arca Air Quality Management BOILER-COMP(OVER 100,010 BTU) p
6
DisrricR
❑Yea ❑No MiW RESIDENTIAL.MECN. SQ.FT. PA
1 have read the hmudous materials requirements under Chapter 6.95 of the Am
California Health&Safety Code,Sections 25505,25533 and 8tan
534. 1 understand that C
if the building does not currently have aroom.that if is my responsibility to notify the LT. sY
occupant of the requirements which must be met prior to issuance of of a Certificate of CRY U/•
Occupancy.
• NO
Osommauthonaed agent Data TOTAL: QeQ ISSUEDBY:
OFFICE