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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPE
BUILDING DIVISION APPLICATION/PERMIT PLUMBING • MECHANICAL
t:r>�,p.ag• BUILDING PROdgCg IDBNTIFlCATION ;:.,.
I kM r "°
25185 J1OJ
BUILDING ADDRESS:
27-1-9 - /�J aM1If/ saUNIT# LOT43
SANITARY NO,
APPLICATION SUBMITTAL DRIB
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SHAME:
06"
PHONE:
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.. .!,�.L'"BIBLDINC PER MIT INFO
BLDG ELECT UMtl MECH
❑-
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hemby aff ran that I am licensed under pmsui... of Chapin 9 ( commencing wi N
APPLIANL'ES-RESIDENTIAL
POB DESCRIPTION
Vv v
Section 7").fITDivizion3of the Business end Professions Code, and mY licrnuis in
full torte and eR meg,
Liana Lic.x J
PANELS
UP TO 2W AMPS
Date = Cantamm
ARCHITECTS OEC 10
public reNs.
I undersand my plans shall be used u m
201.1000 AMPS
SQ. FT. FLOOR AREA
6/5O.FT.
OVER
SIGNS FIE 1 I
'
Liomeed Pm(easional
OWNER -BUILDER DECLARATION
SPECIAL C SC. •, '• I
1 he chY all= that 1 are exempt tram the Contsmarz License law for the
following rmmn.(Section ]0315. Business and Professions Code: Any riry or county
TEW. METFROR POLE INST.
which requires a pcmut a mmaucL alter. improve,
iiuusna,elmi hamfthemh Pcroutu mrile rcpav any ewcturt
om'.
POWER DEVI t
that heu licensed Institution athe ovisimin of the Cm Lomax Law (Chapm
9mwith Section ]W)of Division 3of the Business and Pnifeuiom Code)
«Nat he iauemPtNaefmm anti the buieforthe alleged exemption. MYvioladm of
Section 7031.5 by any applicant far a peorm ubjans the applicant toe civil penalty of
SWIM GPOOL FIECIAIC
��ss VALUATE
OUTLETS - SWITCHES - FIXTURES
me more Nan five hundred dollars (5500).
❑ hssowncroftheproperry.ormyemploy«swish wagexutheirmlecompewtim,
N RESIDENIUL ELECRt _SQ.
STORE
TYPE CONSTRUCTION
will dothewmk, moth sale(Sec.]014, Budsues
he Comiatatintendedar awon s
and Profeuims Code: The Canuacare Liana law does not apply a an owns of
propem who builds or improves Nermn, and who das inch wank himul f m through hie
ow thatsmh liswidwiva We. I-
OCC GROUP
RES. UNITS
.pp
tto
cr,lacbuilrovided
metintmded io .,for
however. Nc building m den of arxnt is roM within meyW ofimpiniedm, Ne owner-
builder will have the burdrn of proving Net he did net build or improve for puryou of
ale.).
❑ I,ssawncrafNe lusivel ama«tin Nliwaedmnaanwsa
peer .amuc y gwi
Lien a the project Mly mo Business orb ProfessionshoiCode:? The Co ,arz
LiemuLawdasnotapplytoanownern Property whobus'unsimprove aro
v:F.c:✓.IN611s6a, {{ yy
QTY 'PLUMBBiG PERMIT ntx1{;`i?FEE,""�-
..c: -.
Fl- p2ONE
APN
PERMIT ISSUANCE
whomnnaw. fmouch projects with econwctm(sIliamed Pursuant to da Conaands
Como
uanataw.
ALTER k VENT (FA)FEE
,
SUMNIARY-
.4....a^• '
-
❑ Ian exempt under Sec. , B R P C fm Nis roan
TACK FLOW PROTECT. DEVICE
1
SANITARY Y N
Owner Dau
DRAWS - FLOOR. ROOF. AREA. COND.
RECEIPT
SCHOOL TAX YRECEIPT# N_
WORKMAN COMPENSATION DECLARATION
bY .afElrn NdtlhaVtettrllECda Of[my:rlt to Self-111¢a2.maar4RW[aI
ssdon Wmuaemaanified copythercof(Sec.3glD.lab CJwhich
covin all employee's under this permit.
polity• x
FIXTURES PER TRAP
PARK FEE Y N
RECEIPT
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
BUILDING DIVISION FEES
Company
GAS - EA. SYSTEM-0VER 4 (EA)
PLANCHECK FEE
❑ Cadgedcopy is hereby fumBhed.
GREASFANDUSTRL WASTE INTERCEPTOR
GRADING FEE
❑ Cerified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASETRAP
SOILS FEE
COMPENSATIONINSURANCE
SEWER - SANITARY - STORM EA. 200FE
ENERGY FEE
Mus section mad not he completed if the pmnin is for me hundrN dollars (5Hill)
or leu.)
WATER HEATER WNENT/ELECTR
1certify Net in the perfomunce of the work for whit thi¢ cmtitis issued. label
not employ any P in an r so uD she Workai
PAID)
WATER SYSTEM[TRFATING
Cmnpsman Lvs/D'Uif Due
Date Receipt#
Appliant V
NEW RESIDENTIAL PCMB. SQ. FT.
TOT
N P AN gWs CeroflcneofEumpuon. You Nould
mesTO
e&Cmp
became subjecty it Wohers Csm. or d. p�o tshalofdilator Code,ya mut
forthwith 4romp1Y with such povieiam m Nis pemdt Nall be domed revoked.
BUILDING FEE
SEISMIC FEE \
CONSTRUCTION LENDING AGENCY
I hcrebY aff that there is a construction lending agency fm Ne pnfonnana of
the ware for which Nis peanut is issued (Sec. 3097. Civ. C.)
ELECTRIC FEE
Lenders Name.•,y,.:,�i'!¢.*+rl
y;;
-r-.,''.''"MECHAM(:AI: PERMIT uq.,..ilFEB�.
PLUMBING FEE
Lenders Address
n latim is
1 ttnity that 1 hue read this city and county
01 ore sed sane Net an above laws
wo counryordinaneamd ease lewsrelatinga
coldni I agree semi.
PERMIT ISSUANCE a
MECHANICAL FEE
and thyinboti
building ca turcol im, eco hoebyae tion p r p seenudves of Nis riry a enttt upon Ne
ebov prapmy, for inspection purposes.
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(Wendoned
(We) agree to ave, indemnify and keep hamins the City of Cupmino against
liabilitic 'udgm .ttsu WcapmmwNch may inmyway accrues sins sad City
AIR HANDLING UNIT (TO 10.000 CFM)
to. granting of '
/.
(f
AIRHANDLMGUNR(OVER IO."CFM)
Ino a ApPM— mmctm I Date
EXHAUST HOOD(W/DUCO
PAID
HEATING UNIT (TO 100,000 BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dau Rcaipta
HEATING UNIT (OVER IOp,OpO BTU)
OTAL:
Will the applicant in future building occupant store m handle haardous materiel
u defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 255324)?
❑ Yes ❑ No
Will the applicantorfutum buildingeccupmt uscequipmemmdevicawhich emit
\
VENTILATION FAN (SINGLE RESID)
BOILER- COMP PHP OR IM.000 BTU)
ISSUANCE EFATE
4�
BOILER -COW (OVER 1W.” BTU)
uw, sit cimiaminms u defined by the A. Bey AAt, Quality Mmaeanent
❑ Ycs ❑ No
, Q
• V /1
NEW RESIDENTIAL MECH. SQ. FT.
I have read the harsrdas materiels requirements undn Chapter 6.95 of the
C(j t e7 X993
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understand in.,
if the building does not currently have a tenant, that it is my mspomibility to notify the
occupant of the requirements which must be met prim a iguana of a Cenifiau of
Kll
Occupancy.
ISSUED BY:
Owner m authorized ¢gent Dau
TOTAL:
(A -Hut