26987 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
WCHI �GINE�:
PERTINO - - - relcnflr No.
APPLICATION/PERMIT PLUMBING MECHANICAL 26987
IVISION BUILDING PRWECT IDENTIFICATION
BUILDINGS: SANIT'ARYNO. API'IiCAT10NSUBM❑T'ALDAT
UNIT# LOTH?ONEJ CO u CI'OR$NAME: � LIC Gw5 Nil F8:I LIC NO: ADD v
1 W V
CONTACT: PHONE: iaaur'4ti^{`.Y-:vA-rvsx.As:4••.liG'$Y,•.y +^ ,^�•,r,-+ -w,:;n:rBUILDING PERMIT INFO- ::..
EIFT�RI ,PERIAT�LYyµ=i}»:'�'fi:L' 'E:7. ,. ,
y BLDG ELECT PLUMB MLCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL -,IOD DESCRIPTION
OCZ IhdbYaffirmthan l ran licanudunder Provisionsof Chmai Commencing with {A/^'/(✓/O/
WOO Section]0001of Division 3.r be Business and Professions Code,amlmylicanuisin PANELS
�wUF full farce and effect,
<zul License Class Lic.p UP TO 200 AMPS
y<d Data Conuacm MI-I"AMPS
F N Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA EISQ.FT.
j Z y G 1 understand my plans met be used u public records. OVER 1000 AMPS
O L C� SIGNS ELECTRICAL
x'K< Licensed Profession) OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
;Ow V 1 hereby af.Nei 1 am exempt from the Convectors License law for be
J a Q rn following won.(Saxon 7031.3,Business and professiom Code:My dry or money TEW. ER OR POLE INSL
which require a pamin m on.ii,Jur,improve,demolish,or repels any somensre POWER DEVICES
W 2aE prioruiu iuuuRe.Jw Inquiseduappliant(orsuch pemtitufil...igredswement
_TYCO Nm he is licensed pursuant b the Provisions of the Contractor's Li.Law(Chapter
—E: 9(conurcncing with Section 70W)ofOivizion 3ofthe Buslnesatd ProfeadonsCade) SWIMMDIGPOOLELECfRIC VALUATION
w�'an
or dust he massing,therefrom and did basis for the alleged exemption.My violation of OVllb'IS-SWfTCFffS-FD(ti1RF5 ""
-ZY Suction 703 L3 by any applicant far a permiuthe e applicant..Civil penalty of
X=n tmae than five handed dalton(5300). NEWRESIDENT1ALELP,CIR _SQ.FT, STORIES TYPECONSTR CITOI
❑ I.eowrerofNepropeM•ormyemployaswiNwa8cu0uvwkcanpensadon.
�3 will do0xims Coca: he Comisnot inretdedm Lau,
apply TO 6/.Bulinus
and Profesiobu Code:The ves tnnars License law such
not apply to an rmh of
is
ownenywhobaildsorimpove Merton,andwhodressuchwark Nnnuencelfsnughhis OCC.GROUP RES.0 TIS
employas.providedNet such improvemenumenotimendedaof(ertdfa We.If.,
however,the buildingor improvement iswld within one yesrof completion,the owner. TOTAL:
builder will have he burden of proving that he did not Nild or improve for purpax,of Call
veva Yy-: OOD ZONE APN
p)Luownerof the PropenY.em exclusively wnvaaing with licensedconmcunto QTYw-`LanUMBTNG PERMITy*g'r'y ij' PEBt
,;esu A5< 87dfiv,w,e�sas.xrnrn .x\v vY,fiAO K �Y r,.aSO•: •4
comment,the project(SIC.704 4.Business and professions Cade:)The Cwvacur'a pFJyMI'I•ISSUANCE
License law does naupply to an owner of property who builds or improves thereon,and
who contncu for such projects with a Intent licensed pursuant u the Convwtors ALTER,DRAINk VEIN-WATER(FA) leak v ;.',;.,�tiFE_E$UMMARYi"`='U01 ;,=r'.
License law. - -
❑ 1 em aempt under Sec. B d:P C far Nis rtnost BACK FLOW PROTECT.DEVICE SID
SANITARY Y N
Owner Dau RECEIPT N
WORKMAN COMPENSATION DECLARATION DRAMS-FLOOR.ROOF,AREA,CONO. SCHOOLTAX Y N
jj9g�qI hareby affirm Net l have a certlfcme of concent to uhf-insert,ono codficam of FrMURES-PER TRAP /
RECEIPT*
rMit Canpenuuwlmunn....mEM Copy Nertof(Ser.3800,IabC)which PARK FEE 1' N
Vr1JF coven Jl.ployazuMerthispermic GAS-EA.SYSTEM-IMC.40UT1-E3S RECEIIT#
PolicyM BULLRING DIVISION FEES
Company GAS-EA.SYSTEM-OVER d(EA) PLANCHECK FEE
❑ Comficd copy is hcrtby famished.
❑ Cenifed copy is filed with Ne city inspection divialon. GREASEBNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FTE
COMPENSATION INSURANCE
(This section need not be Completed ifthe,permit u furore hundredmHn(SIM) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I Oddly that in the Perfomwtce of the work for which this permit is issued,I&hall WATER HEATER W/VENT/ELECTR
not employ any parent in any manner so u u become subject to the Worked PAID
Compmxuim Laws of Cdifomia Dein WATER SYSTEMIMEATING Date Receipt N
O z Applicant
z 0 NOTICE TO APPLICANT:IL aftermhing this Cenifnd.of Exemption.yoummld NEW RESIDENTLU-PLMB. SQ.PT. TOTAL;
y become subject to the Workers Compensation Provisions of the Labor Cuda,you must
foidwith comply with such provisions or this pvmit shall be themed Invoked. BUILDING FEE
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of AL ELECTRIC FEE
V O the work for which thus permit is issued(SIC.3097,Civ.C.)
Lendce.Name a.' cyey.'.2 }' ou—s¢y+ "f'- -1, 'C:'^�- PLUMBING FEE
Lenders Address _,MECHAMCAL PERMITr;::•t.l;-{FEE
I ratify Net I have cad this application and area tut the above Nformatlon is -'µ—Y MECHANICAL FEE
correct.IapeeucamplY with all city andcowryordinances ere zuu laws rtlatini to PERMIT ISSUANCE - . ,rc
_ � building consvuttion.and hereby auNorixrepmrnuuva of Nisciry m muccupon the
CONSTRUCTIONTAX
U Z above-mhndoned property far inspection putpous. ALTER OR ADD TO MECH.
(We)agree to save,indhmnify and keep hersid.Ne City of Colombo,agai.
liabilaica.judgmers u dexpenseswN wayucrmagainstuid Ciry AIR HANDLING UNIT CTO M.000 CFM)
xomequrn tin6 of this
7 �s AIR HANDLING UNIT(OVER 10,000 CFM)
Signaure of ApplicanUComncur Dau s!- EXHAUST HOOD MIDUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,OIXI BTU) Dow Receipt
Will the appliesm or future building occupant sum or handle harnd0us nwcrid TOTAL:
as defined by the Cupertino Municipal Cale,Chapa9.12.and Ne Health and Safety HEATING UNIT(OVER 100,000 BTU)
Cede.genion 23532(4)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the applicanwrfmure buildingoccupant use mordevices whichamit BOILER-COMP(3HPOR Io0,00D BTU)
Areipme
hexallous air conuminanu u defined by the Be,Aree Air Queliry Menegenmt BOILER-COMP(OVER 100.000 BTU) ��
Drum"?
' ❑Yes ❑Na NEW RESIDENTIAL MECH. SQ.FT.
f
I have rad the hazardous matiInquiwrnits und/er/Chapter 7p
Ne
CaliforniaHealth Safety Code, ons 23503,23533 and sI understand N
if h,building Eos not currently haveI, its my responsibility u notify the
orcup NIn rioissuance of.CCdifme of
Ocupcy // �/'
Owneduda8ent
Due TOTAL: ISSUED BY:
OFFICE