24879 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINOf1I1. G-E,P,C'I RICA I, - PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL ,!� /I p�A
BUILDING DIVISION BUILDING PROJECI'IORN'I'IFICAIJOIN - G 4 O J
BUILDING ADDRESS: 111/ - SANITARY NO. APPLICATION SUBMITPAL DATE
'i UNITp LO'1'e
OWNERS NAME: PHONE: CON'IRACIOR'S NAME: LIC NO: NYC CONTROLY
NN A ' /
ARCHITECT/ENG NE[R: LIC NO: ADDRES J D �
CONTACT: Pit ONE. BUILDING PERMIT INFO
QTY. EI,ECT'RIC PERMIT FEE
BLDG ELECT' PLUMB MECH
PERMH'ISSUANCE ❑ 4 o ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p(y.Z I hereby amrm that am licensed under provisionsol'Chapmr9(commencing with
;;dfutfore0ndaffDivision]of the Business ntfosinns and mylicrnuis in ` PANELS
F'0 full force and eRut.
Fa-Z LicenseC Lic.M_ UPT0200AMPS
wQy te Contracmr 201-IIXIO AMPS
ZOARCH,FECI'S DECLARATION OVER IOOIIAMPS SQ.FT.FLOOR AREA E/SQ.FT,
0z"_ I understand m plans shall be used ns public recoNs.
F-W SIGNS ELECTRICAL
Licensed Prfatitomil
c Was:< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
jeOyF I hereby affirm that 1 an exempt from me Contractors Licemse law for the
W 3 fe-m following rensoo.fSution 7031.5.Business and Professions Code:Any city or county TEls11s.METER OR POLE INST.
FLOG which requiresa pe.oil I.emmiu0.alter.improve,demolish,or repair sty structure, -
�W} prior to its ismance,alsmcquinestheapplicamt for such pemduo files signed aatemem MW13R DEVICES
W L4<C that he is licensed pursuant m the Provisions of the Commoner License Law(Chapter
dxLo� 9(commencing with Section]000)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
W_m or that he is excmpnuarefmm andnhe basis far heslleged exemption.Any violationof
FZ> Sceion]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of OUTLETS-SWITCHES-FIXTURES
'R2¢p not more than five hundred dollars(S500). NEW RESIDENTIAL.ELECfR —SQ.FT.
Cf—p
C3 NEW STORIES 'TYPECONSTRUCIGN
will do the%ark,aM the structure isnm intendedoroffered rnrsnle(Sec.I0a4,Business
and Pmfessi.m Cale:The Cnmrvaor'a Licenu law Jas not apply m an owner of
own
progenywh.buildsorimpravestherengaMwhoacessuchwork ornelfm through his
employer,providM thatsucment is vemcntsnrenoUmeofoompffercd thea owner. OCC GROUP RFS.UNITS
builder
will avec ng the
rEmpmvocusin that hediinoneyem or improve
forpenwner
builder will have the burden refocusing that he did not build m improve for pucpnx of
sate')' to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lan the Immfthepro.7(N,nm usinsivelycontrandons idben'M Commonly
License the projut(Sec.oano Business and ywhosians Cale:)the Camrnctor'a
License Law Joersuch Iplytoanownerofpro r(s)whosed puorimt bithehereomond PERMIT ISSUANCE -
%icense aw.f.rsuch projem:withucnmractogs7lic<nsW pursuanuothe Comrvcmr's ALTER Ar FEE SUMMARY
License Law. ( )
❑ 1.ameaempt under Sec. B&P C for his..,.a BACK FLOW PROTECT,DEVICE OUTSIDE PF.FS
N
SrOL
Owner Dme F.CEI N
ON DECLARATION DRAINS-1100R,ROOF,AREA,CONK S TA WORKMAN compENSATIN
❑,ers'Co affirm that lhave acertific:rte atennxnun self-insure,or Lot,C.)which
FIXTURES-PER TRAP 'CEI M
Woflin%Compevatlo a&,this
is per ncen117M copy thereof(Seo.JBW,Iab C.)which - A K E N
colics all employee's undenhis permit. GAS-EA.SYSTEM]INC.40U'TLETS ECEI g
P.licytl 1 NG DTVI IN FEES
Company GAS-EA.SYSI'EMOVER4('A) DTE
C1 Certified copy is hereby famished.
❑ Citified copy is fled with the city inspection division GRFASIyINDUSTRL WASTEINTER R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE'I'RAP SOILS FEE
COMPENSATION INSURANCE
(Thi"ceden need nm hec.mplirld ifflepermit is l nrnnehundreddall.NBUIXq SEWER-SANITARY-STORM HA.201AT. ENERGY PEE -
le"..)
I certify that in part onnenet,of Ilia work for which thispermi(is knod,(shot) WATER I IFAI'RR W/VIRJr/3LECTR
not amploy any person in any mamma so or in tweome suhjoo to the Workcre' PAID
Compensation Lnwsol'California. Data WAI 17R SYSTEMITREA'TING pate � ReceiptB
Zz Applicant
0 NOTICE TO APPLICANT:If.aflennukingthis Certincutc of Exemption,you should NEW RESIDENTIAL PLMB. SQ,1'1'. TOTAL.:
H ti
bw.me subject .the Worker'sComns
peation provisions of the Luh,Code,yoamnat
t
> forthwith comply with such provi........this permit shall hodamted revoked. BUILDING FEE
0. A CONSTRUCTION LENDING AGENCY SEISMIC FEE
Vz l hereby affirm that there isocanstrecion lending agency for the performance of - -
0 the work for which this permit is issued(Sec.3091,Civ.C,) _ TOTAL: ELECTRIC FEE
Lender's Name
OL•✓ Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U d certify Ont I have read @ix application and state toot the above information is
correct. l agree to comply with all city and county ordinances and state laws relining to PERMIT ISSUANCE MECHANICAL FEE
�o V) huildingconatructinn,and hereby authorize representatives of this city in enter upon the CONSTRUCTION TAX
U z above mentioned progeny for inspeomn purposes. ALTER OR ADD TO MECH.
(We) area m save,indemnify and keep harmless the City of Cape n ngam
lishilifies,judgmena,costsand pemseswbichmayinanywayaccrueu stsaEd City AIR HANDLING UNIT(TO 10,000 CFM)
consequence of the tiny fthis pemci 9
/ AIR HANDLING UNIT(OVER IB,BIp CFM)
tgna rent Applican mmmor - Data EXHAUSTHOOD(W/DUCU
PAID
HAZARDOUS MATERIA1 S DISCLOSURE HEATING UNIT(TO 300,00)BTU) Data Receipt p
Will the applicant or future building occupant store orha.dle Botanical material
as defined by the CLpenimo Municipal CMe,Chapter 9.12,and the Health and Safety fI1 ONG UNI'T(OVER 100,000 BTU) TOTAL:
Code,Section 25532(e)T
C3 Yes ❑No VENTILATION PAN(SINGLE RFSID)
( BOILER-COMP(3HP OR 100.010 BTU) ISSUANCE DATE
I Will the uppticantnons as building by the Bay equipment unlit Manavdhgement P p '
-0anmdous eh c.naminan¢as defined by the Bey Arca Air Qualify Management BOILER
District?. ]BLOW BTU) W
District?.
❑Yes 13 No NEW RESIDENT]AL MECH. SQ.FT.
I have read the hazardous materials reqmets
uirenunder Chapter 6.95 of the /s 17 1993
California Hwlth&Safety Cale.Sections 25505,25533 and 25534.1 undersand than
if the building does nor currently have a senator,than if is my responsibility to notify the V�'
senatosenator,
occupant of the requirements which must be met prior to issuance of o Certificate of �fII"111. .rA
Occupancy.
s
/ Owner oraothorised agent Dare TOTAL: ISSUEDBY:
OFFICE