26176 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOI.D ,-LLNtu FRICAL PERMIT NO,
BUILDING DIVISION APPLICATION)PERMIT PLUMBING-MECHANICAL 26176
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRUM::�ZC/�� . � . ,.2 SANITARY NO. APPLICaATITION`SUBBaMRTALDATF.ZI kA6U IT. LOT# �Lg�
slistOWN. E: PHONE: CO TRACT Sy'Mil nr LIC NO:
NIC CONTROL p
• ARCHI'IECT/ENGINEER: LIC NO: A DRESS: �Jv �•� ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MF,CH
PERMIT ISSUANCE 1� ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
004Z Iherehy affirm p
that I am licensed underprovisionsofChater9(commeming with JOB DESCRIPTION
POO Sudan 7000)af Division Sof the Business and Professions Cafe,sed my license is in PANELS
yw1 till fo eand effect. '_`1
UP T02W AMPS
y6y Ito J.rq-=�CanuaD 201-IOOOAMPS
ZFOti'�, ` , ARCHITECTS DECLARATION OVER IOW AMPS SQ.PI'.BOOR AREA E/SQ.FT.
O Z at G 1 understand my plans shall ba used as public records.
F'y I_ SIGNS ELECTRICAL r
4 Licensed Profesaiorul pI Ip'�� gp�q pp
OWNER BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �, � ', L�.. E L..a' I N
y4�O y U I hereby off,.mar 1 am exempt from me Contractor's License Law for the ^ t
413 y following reason.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
IS which requires a pencil to construct.alter,improve,demolish,or repair any stmeture pUWE0.DEVICES
'7 prior to its issuance,also reqm
uites e applicant for such person trifle a signed statement
41 QO shot he is licensed pursuwl.the provisions of the Cadourmss License Law(Chapter
Lpy,oX 9(commencing with Section 70o0)of Division 3 of the Business and Pmfcaions Code) SWIMMING POOL ELECTRIC TION
Www or that he is exempt therefrom and the basis for me alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURPS
tZQ Section 7031.5 by any applicant forapermit subjects lheapplicaut to a civil pemJry of
G
not more than five hundred dollars($500). NEW RESIDENTIAL EL[CTR _SQ.Pf.
yy�F ❑ Lesnwnerofinepropeny,mmyemployenwilh wagaastheirwlecmnpcnsation, STORIES TYPE CONSTRUCTION
y3� will do the work,and the atmmum isnarimmodedoroffesed fmaals(Sax,70MBuslness
and Pmfessiom Code:The Contructor s License Low does not apply to an owner of
property whnbuilds orimprovesthemon,and whodoes such wark himselfmthroughhis OCC.GROUP RES.UNITS
building
uildin idedthatsuchimptov sold
within
not imendedaroffered tarsale.If.
M1owevewthebuildingnrden of cmentissoldwithinoneyear or impo efor Jeowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
ole.).
❑ I,mowner of the propcny,am exclusively convecting with licemedconlmctonm QTY. PLUMBING PERMIT FEE ROOD ZONE APN
constraint the project(Sec.7010.Business and Professions Code:)The Contractor's PERMIT ISSUANCE
License I ow does nm apply man owner of properly who bas i Ids m i mpmvea thereon,and
who coutrensfmsuch projects with accomactods)licensed pursuant to the Contractor's
License low. W pL3EDRAfN&VENT-WATER(FA) FEE SUMMARY
❑ 1 am exempt uMW Sec. ,B&P C far this mason BACK ROW PROTECT.DEVICE SANITARY Y D N
OwnerDate RECEIPT p
• COND.AREA,,
WORKMAN COMPENSATION DECLARATION DRAINS-MOOR, SCHOOL TAX YN
❑ IWCimitffrmt ,Ins. or ncaneofcopy then sel(inwrt,or Lid,C.)which RVFURPS PER TRAP RECEIPT If
W
sters a'Cmployee's Inlia,msmermit. ed copy merwf(Sw.3800,Lid,C.)which PARK FEE Y N
covers all employee's under Nis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTRM-OVER 4(EM PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Candled copy is filed with the city inspection division. GREASEIINDUST'RL WASTE INTERCEPTOR GRADING HE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forone hundred dollars(11100) SEWER-SANITARY-STORM BA,200FT. ENERGY FEE
or lea.)
I certify that in the performance,ofthe work for which this permit is issued,l shall WATER HEATER W/VENT/ELECTR
act employ any perwn in any manner so as to become subject to the Workers' PAID
Compenammnlowsof Celifomla. Date WATER SYSTEMITREADIR] Date Reseipt#
Qz Applicant
Z
0 NOTICE TO APPLICANT:If.after making this Cedifcate of Exemption,you should NEW RESIDENTIAL MbIB. SQ,PT. TOTAL
aVsubject] become subjeco the Worker's Compensation Provisions of the Labor Code,you must
j forthwith comply with such pwvisiom or this permit shall be deemed revoked. BUILDING FEE
ITa Q CONSTRUCTION LENDING AGENCY SEISMIC FIX
z I hereby affirm that mere is a construction lending agency for the performance of CLECTItIC FEE
O the work for which this pencil is issued(Sec.3097,Civ.C.)
Lender's Nume
�-' 1<aaera Address QTY. - MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that I have read this a plication and state that me above information is MECHANICAL FEE
>" 609. correct.lugree to comply w' a end county ordinance and sw¢lewa relating to PERMIT ISSUANCE
buildioirmutruaion.u ereby an.mpmsenrativesofthisciry memerupon the CONSTRUCTION TAX
L) above-mentioned pm 0y fur' pcaion purlwses. ALTER OR ADD TO MUCH.
(We)agree l mnify end P hmmlea Joe Ciry of CLpersino agdrut
Iiabiiities,judg ms cVe and expect htnayinanyway accrue egeinstsvJ City AIR HANDLING UNIT(TO 10,IXIOCFM)
in conscyuen of runlin8 of a sen.
AIR HANDLING UNIT(OVER 10,000 CFM)
Igna ofA plicanV reran Data EXHAUST FIOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTU) Date Receipt#
Will the saffron,orfumre building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) TOTAL:
I efi.M by the Cupcnin.Municipal Code.Chapter 9.12,unJ the Heplth and Safely
Code,Section 25532(x)? VENTILATION PAN(SINGLE RESID)
I]Yes ❑No
ISSUANCE DATE
Will the applicanwrfuwmbuildingacupanmseequipmentmdeviceswhichemit
BOILER-COMP IMP OR 1 0900
, 0 BTU)
• hmaNnm air croamamems us defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) PAID
District?
❑Yes ❑No NEW RESIDENfIALMECH. SQ.FT, ffra
1 have read the hazardous materials requirettems under Chapter 6.95 of the AR 2911994
91 199
California Health&Safety Code,Sections T5505.25533 and 25534.1 understmtd mat ly /t
if the building does not currently have a tenant.that it is my respno
responsibility to tify the wf
Occasc
......f the requirements which most he met prior to itand.M e a Cenificmof ur' f✓Vr�
Owner or amhodud agent Dole TOTAL: ISSUED BY
OFFICE