24697 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOI 1 )N,-EL. TRLA P17RM13'NO.
APPLICATIONIPERMIT PLUMBING-MECHANICAL /I
BUILDING DIVISION BUILDING PROJECT 1 DEN'rIF-ICAT /J4ION G
697
BUILDING ADDRESS. 1y - SANITARY NO, APPLICATION SUBMITTAL DATE
Icaf
`0Lt_ � r fZ� UNIT# LOT# II�1 Z
O ERS NAME: 1IN[w I�a PIi�NG:4'� _7 91.
CONTRACTOR'S NAME' "LICN :t NIC CONTROLpitt •I
'C'OHJGINEEK: LIC N�'01111 ADDR S: -
CONTACT: PHONE;.
?AAA SUV 4n4 J '�1�O QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG FLF.Cf PLUMB MECH
PERMIT ISSUANCE a/ 11 X
LICENSEDCONTRACfOR'SDECLARATION APPLIANCES-RESIDENT JOB DESCRIPTION
pceZ I hereby affirm that l am licensed underpmvision+ofChapter9(commencing with
J400 Section 7")of Division 3 ofthe Business and Pmfeisions Code,and my license ism PANEI �5
Fy,�F fullfmreeandeffea,
Gp„Z tsl License Clvx LiC.#
m<y Dam Cturnacmr 1- M
FyZARCIIITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.FT.
O Z0—_G a
I undersand my plaaashall be used as public records. F. I PS
(;2255 SIO EL CI'ItIC 1 ��I ��
C yU Licensed Rofessionnl OWNER.BUILDER DECLARATION SPEC LCIRCUIT IS 1 1
'Oa 1 hereby affirm that I am exempt from the Contractors License Law for the '
W 3 et tia following reason.(Section 7031.5,Business and Profession Code:Any city m cowry TEMP.METER OR INST.
(: tri which requires a Permit m consumer.oiler.improve,demolish,or repair any structure POWER DEVICES
}�
Prior its issuance.also requires the applicant for such permit to File a signed statement
HOC) that to is licensed pursuant to the provisions of the Contmotors License[aw(CTapter SWIMMING POOLE CTRIC VAL ATI N
aim � 9(commencing with Section 1000)of Division 3 ofthe Business and Professions Code) jj��
WMo, or that he is exempt therefrom and the basis for the alleged exemption.Anyviolationaf �\ A
�Za Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty m IITLETS-SW CITES-FIXTURES b
C not mom than five hundred dollars($500). NEW RE F:NTIAI. Q'ELECfR S FT.
p0 Elpe
I,esowneroftheprony,ormyemployeeswithge
wasustheirsolecompensation, ,w STORIES TYPECONSfRUCfION
a will dome work,and the swctureis not itnendedoroffered f«sale(SaJDia,Business
and Professions Code:The Commctnr s License Law does not apply m on owner of �. ll
propeny who buildsorimprovesthereogand whodoes such workhimselforthmugh his OCC.GROUP RES.UNITS
can nnployces,provided mat such improvememe are not intended err offered for vie.IL
however,the buildingor improvement is sold within one yearofcompletion,the owner. .ro
builder will have the burden of proving that he did not build or improve for purpose of
vl0')' QTY. PLUMBING PERMIT IEE I E(-gQD E APN
❑ Iuct the project
(See,704 ,Business
and
Prolesingwim de:) o Comctorsu N
iconmt ow project(Sec.7044,Business and,whosioma Code)The Contractor's
Licrnu Lawd«snm apply toanown<mfprolmrty whobuildsmimprovq therwn.end PIiRMIT ISSUANCE I
whocnmmets forsuch projects with acontactms)licensed pursuant to the Contractor's ALTER TP.RE
License Law. FEE SUMMARY
❑ I ern exempt under Sec. B&P C for this mason BACK FLOW PRO1 ECT.DE EUNITARY O Y D FE N
Owner Data RECEIn#
_ WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA,CON X YElaN
❑ I hereby affirm mat l have a cenificme ofcomerum sff-imine,oro certificate of PIKTURFS-PER TRAP RECEIPT#
Workma'Comperemion Insurance es a certified copy thereof(Sec.3800,Lab C.)which PARK FEE YC
all em to ce's under mil peom* R[ EI
coven #
P Y GAS-EA.SYSTEM-I INC.4 OUTLET
Policy p BUILDING DIVISPIN FEES
Company GAS-FA.SYSTEM-OVER 4(F.A) PLANCHECK HE
❑ Certified copy is hereby famished.
❑ Cenifiad copy is filed with the city inspection division. GREASWINDUSTRL WASTE INTERCF OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section read not b,completed ifthe permit is foeone hundred dollars($100) SEWER-SANITARY-STOR FA.2IF T. ENERGY IR In Sc Ittt,
or less.)
I cmify that in the performance of the work for which this permit is issued,l shill WATER HEATER W/V /ELEM
not employ any permit in any manner so v to became subject to the WorkersPAI
z Coarpernvtionlawsof Califomia. Date WATER SY TING Date Receipt#
zO
Applicant D NOTICE TO APPLICANT:If,after making this Cmificam of Exemption.you should NEW RESIDE IAL PLMB. SQ.Ff. IfTOTAL:
.I. become subject to the Worker's Compensation Provisions of the Labor Code,you most
�i forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
LTa (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I heteby affirm that hem is a conswction lending agency forme perr.cc of
U O the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I et nify that I have read this application and sant Nat the above Informed.is [PAID
CHANICAL
corral.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
sJj building construction,and hereby aulhoize,representatives of this citymeater upon the U above-mentioned progeny for inspection purposes. ALTER OR ADD TO MECH.
(We)agree th save,indemnify and keep humless me Cty of Cpnino instliabbilifict.ju^d°gm°rnd�,coxa and expenses which may many wayacemeagainst mid City AIR HANDLING UNIT(TO 10.00 CFM)in
rr,2l tag�,� 241/CS.LAIR HANDLING UNIT(OVER 10,000CFM)
Amount,of pb t/Contreme /�1$ E)HAUSTIIOOD(W/DUC)
HAZARDOUS MATERIALS DISCLOSURE I[EATING UNIT(TO 100,0010 BTU) D e
Will the applicant or future building occupant store or handle hmaedous material TO A
as defined by mVENTILATION FAN e Cupertino M unicipul Code,Chapter 9.12,and the l health and Safety HEATINGUNFANER 100,"(SINGGLELEftMID)
BTU)
Code,Seen..25532(x)+
❑Yes sallo ISSUANCINPATE
Wil l the applicant or future building occupant use equipment ordevices whichemit BOILER-COW U3HP OR I O1,000 BTU)
heradous Dir contaminants as defined by me Be,Arca Air Quality Management BOIL M-COW(OVER 100,00()BTU)
Wool,
11 yet �No NEW RESIDENTIAL MECH. SQ.FT.
I have real the hazardous materials requirements under Chapter 6.95 of the, t
California Health&Safety Code,Sections 25505.25533 an 25534. 1 undrntand that 7f}q
if the building does not currently have a tenant,that it is my responsibility to notify the =� IP
«cupastt of me requirements which must be met prime to issuance of a Certificate of Occupancy.
Ownerteramhodzedagent Date / ISSUED BY�
OFFICE r, VJ1 GhIIIVV