26772 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO R ILDINL-F.I.F.f.TR1 AL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL /J �J/J
BUILDING DIVISION BUILDING PROJF.C'1'IDENTIFICATION G I G
BUILDING ADDRESS:
SANITARY NO. APPLICA'iON SUBMIT
TAL DATE
PHONE: assalll6-Ci160 ` WqaFv\ NIT# LOT#
NIC CONTROL-p
RCNITE�/CCN Ik1FR: LIC NO: AD RE55:
CONTACT: PHONE: QTY. ELECTRIC PERMITT FEE
BUILDING PERMIT INFO
G ELF.Cf PLUMB MEC11
o$ /�p(k g!O •yo PERMIT ISSUANCE F-1El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
qy.L IM1ereby affirm that l eon licensed underprovisions of Chapter 9(commerringwith LOB DESCRIPTION
FOO Section 71N#Il.f Division 3of the Burin mesal Profession,Cad,and my license is in PANELS
<YE full font unA vff� S �,J UP TO 280 AMPS
F6DW License C- I:/:s_O.C.—<`Lic.a_y �
rn<y Dve Conte«tor 201-1000 AMPS
Q.FT.Fl.tMR AREA S/SQ.FT.
F-,�-l. ARCHITECTS .0 OVER 1008AMPS ,e
all be used us public records.
Fy , SIGNS ELECTRICAL
y�d'i, Lic d rocssmnal J
OWNER-BUILDER DECLARATION SPECIAL CIRCUI 19C:�
XOaU 1 hereby affirm that I am exempt from the Contractors License Law for the
m34on following reasar(Semlom7031.5.Business and Professions Code:Any city or county TEMP,METER OR P(
1!10Q which requires a permit In coon, 1.gimp improve,demolish.or repair any structure
�roNs prior to its lsssmncc,also requires the applicant f«auchpcmtitto Fie aligned smtemern POWER Df: _
WA'O that he is licensed pursuantto the provision of the C.ntmetor's License Law(Chapter VALUATE
a e.o�C 9(commencing with Section 7")ofDivision 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC I
Wim .,,bar he is exempt the:nrrom and the basis for the alleged exemption Any violation., OUTLETS-SWITCHES-FIXTURES `tea'
FZQ Section 7031.5 by anyapplicantrm
forapeitsubjectsNeapplicanttoacivilpenahyid 1t oe
no,mom than five huadvd dollars($500). VVV
q NEW RESIDENTIAL GLECTR SQ.FT.
pw ❑ I,senwnerofthc property,nrmyempoyccs with wagcsas theirsolerompensanoo, S'T( 1135 TYPE:CONSTRUCTION
a3— willdo the work.and the structure Isnot intended oroffercd forsele(Sec.7044,Business
and Professions Code:The Contractor's Lioomse Law does not apply to an owner of
progeny who bulldsorierproea thereon,and whodras such work himselforthmugh Ms OCC.GROUP RFS.UNITS
own employees,provided that such improvements ere not intendedor offered for sale.IL
however,the building or improvement is sold within one yearofrompletion,theowner- 'TOTAL:
buiWcr will have the burden of proving that he did not build or improve for purpose of
FT.00D
szle.). QTY. FLUSHING PERMIT FEE —ZONE
APN
❑ I.nsownerofthepmpeny,am clusivelyconuactingwithlicenscdcont tanto
comer,the project(Sec.701 Business and Professions Code:)The Contractors
License Luwd«s notupplym unownerof property who builds or improvcsimmon,and PERMIT ISSUANCE
who contracts for such projects with a contramogs)licensed pursuanuathe Contractor's ALTER-DRAIN&VEN'F-WATEREA
License Law. WATER(EA) FEE SUMMARY
❑ I..c.pr under Sec. .B&P C for this re..n BACK FLOW PROTECT.DEVICE OU'IISIDF EES
SANITARY Y N
Owner Dat° DRAINS-I1,00R.ROOF,AREA,COND. RECHIPTtl
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihereby affirm that l have ucenificamol consent to self-insure,oraccnificateof FIXTURES-PER TRAP RLCLIPTa
Workers'Compensation Insurance nen readied copy thereof(Sec.3800.WbCJ which PARKFEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT'p
BUILDING DIVISION FEES
Policy N
mpony GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK ITE
illed copy is hereby fumh it.
❑ Cenilled copy is fled with the city inspection division. GREASE.INDUSTRL WASTE INTERCEPTOR GRADING ME
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed iftbe permit is for one hundred dollars SI00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I certify that in the perfernamen of he work for which this permit is issued.I shall WATER HEATER W/VENT/ELECIA
a.,employ any person to any manner so ns to become subject to the Worker' PAID
Compensation Wwsof Culifomia. Date WATER SYSTEMTREATING Date Receipt#
O Z Applicant
zO NOTICE 10APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIALI'hMB. SQ.FT. 'TOTAL:
!•+ fn become_suhjecno the Worker's Compensation provisions of the Labor Code.you must
Fa' ? forthwith comply with such provisions or this permit shall be doomed revoked. BUILDING FEE /#
a (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz IM1ereby affirm that is a construction lending agency for the per(nrmmce of
O the work for which this permit is issued(See.3199,Civ.CJ TOTAL: IihiSCTRIC FEE
Lender s Name PLUMBING ITE
LL F Lender's Address QTY. MECHANICAL PERMIT' FEE
0 U I county Nat 1 have read this application and now that the above information is MECHANICAL.FEE
>" W correct.l agree m comply with all City and county ordinances and sum laws relating to PERMIT ISSUANCE
I" a. building construction,and hereby authorim representatives ofthis city to enter upon the CONSTRUCTION TAX
U z above-mentioned property for inspection purposes, ALTER OR ADD TO MECi I.
(We)agree to save,indemnify and keep harmless the City of Coleman against
liabit ies,jud nImuand cxpcnscs which may inanyway accmeegainst said Ciry AIR HANDLING UNIT p 0 IgIXI(1 CPM)
he Bmming ofthis pcmtit. Q
AIR HANDLING UNIT(OVER 10,00)CPM)
pplicunVCnntrucmr are EXI IAUST HOLD(W/UUCP)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
W ill the applicant or future building ove.pam s a.or handle haverdous malmild AL:
as defined by the CrIanion Municipal Qnle,Chapter 9.12,and the Ilcalth end Safety HEATING UNIT(OVER 100,"BTU)
Code.Section 25532(u)'t VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
Will theepplicant«forum building«cupanmucquipmem«deviceswhichemit
BOILER-COMP(3HP OR 100,000 BTU) 1SSItA'CE• ATE
hmardous air contsminums as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100.000 BTU)
District, EI JUL 191994
Ycs ❑No NEW RESIDENTIAL M[CII. SQ.FT.
I have read the hassulloe,materials requirements under Chapter 6.95 is the C17Y Ur
California HeaBh&Safety Code.S«tions 25505,25533 and 25534.1 understand that
if the building does not..any have a¢nuns,that it is my responsibility m notify the 6/
occupant of the requirements which must be met prior to issuance of a Cenifcate of
Occupancy.
Owmersramhornedo,em Date TOTAL: ISSUED BY�I� f r
OFFICE