24699 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOI I. I G-ELb. TRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT IsLUMBING MECHANICAL. /� C(� (J
-JUALVING PROJECT IDENTIPICATTON 4 v J J
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
/I UNIT# LOT#
OW iRSNAMF.: PHONE: CONTR OR'S NAME: LIC NO:
.� NIC CONTROL#
'R 'I'E GINEER: LICNO: ADD ISS:
� s #
"ka
10 'ACV: PHONE: v BUILDING PERMIT INFO
` eo-^_^tt# S/a 960 sale QTY. ELECTRIC PERMIT FL'E
_ BLDG ELECT PLUMB MECH
PERMIT ISSUANCE 14 11 13 El
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
a'Z Iharebyafr,.that l am licenuJ underpmvixionsof Chepter9(commencingwith
0R40❑ Sectio 7000)of Division 3 of the Business and Professions Code.and my license is in PANELS G �i�r)d��
IVU fu 11 force and effect. pVrf'["�/,C��!-''�V\�1
pa-zw License Class Lic.p TO PS e
sat D ate ComraeuD t-%� 11-1
CZ- ARCHITECT'S DLCL ATION I ANTS
SQ.FT.FLOOR AREA 3/SQ.FP.
O2�❑ 1 understand my plans shell he used as public records. 010L G
at IGNS ELE IC L
Licensed Professional �OO
241xK 6 OWNER-BUILDER DECLARATION SPECIAL R /MSC.
xa6F I hereby affirm that I am exempt from the Connector.License Law for the
[r1 yQ following oamm.(Section]031.5,Business and Professions Code:Any city or coumy TEMP.M R OR POLE I _
LLJ m..I whichrequiresapenmirtoconstrucLaltee id" avgdemolish,or repairah"drucmm
�qf Prior to it.issuance,Was perfumes Ne opplichum forauch prmtit to file asignedsutmumt POWER D VTC•
0.a 0 that he u liwruM punuatua Ne pmvisiore of the Convenors License 1<w(Chapter
X� 9(commencing with Smtion]Il(Il)of Division afthe Business and Professions Code) SWI POOR.ELECTRIC /� VALUATION �^
or that he is exempuherefrom and the basis for the alleged exemption.Any tvilpeatianof OUTLETS-SWI'Toms-FIXTURES �^
TyQ Sectimra than by hundred
lours S50nnit subjecm the applicant toecivil penalty of
W GFSnot mom than fivehundrtd dollars($SW). NEW RESIDENTIAL FlECIit _SQ.FT.
❑ I,uowneo(thepropeny,ormyemplamswithwagesaiMiraalecompensalion, SfORIGS TYPE CONSTRUCTION
will do the wark,and the structure is not imendedoroffered for&We(Sec.70,P%Busbass
and Professions Cade:The Contmchues License Lew does not apply to an owner of
property who build,.,improves thercon,and who does such work himselfur through his
own employes,provided that suchimprovernerai snot imendedorofferedforsale.If. I/ OCA.GROUP RES.UNITSl
however,she building orimpsovement is sold within one yesrofc rapleuon,Ne owner
builder will have the burden of proving that he did not build or improve for purpose of
sale.). Jp
EI awncrofthe pmpeny,and"clusivelycommoing with licensed contractors m QTY. PLUMBOG ~T LJ PE FLOODZONF. APN
consumer the project(Sec,7D44,Business and Professions Code:)The Contractors V
License Lawdo msta ply roan ownernfproperry whobuildsorimproverflummon,end PERMIT ISSUA CE
whocotmcufmsachpmjccuwithaconmector(s)licensMPur mttothe Contmctora ALTER Law. l FEE SUMMARY
❑ 1 tun exempt under Sec. B&I'C for this reason DIS
BACK FLOW PROIECf.DEVICE SANITARY Y N-
}I Owner Date DRAINS-FLOORRODEAREA, "Chin#
. , , .
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN_
Ihembyaffirmthotlhaveaceni0cote ofcanxnttoxl6insum,oracenificateof IHXTURFS-PER TRAP RF.CF.ln#
N]orkeri Compensation Insurance nrucenifedcopythemof(Sec.38W,Lab CJwhich PARKME Y_N_
.4.. ;jcovem sell employee'sundcnhis permit. GAS-FA.SYSTEM-1 INC.4OUTLETS RECEIPT#
< Pnlicyp BUILDING DIVISION FEES
Pe^Y GAS-EA.SYSTEM-OVER O(G) PLANCHECK FEF
't entified copy is he famished.
Certified copy is fl with theciiy inspection division. ORRASIVINDUSIRL WASTE INTERCEPTOR GRADINGME
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIASHTRAP SOILS FEE
COMPENSATION INSURANCE
(This sectimnr ulna be completed ifthe permit is for one hundred Bogus($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or
lees.) .
I . Icenifythat inthe Pcdormancenfthe work forwhi•hthis cmyAs'sued,lshall WATER HEATER W/VF.NT/ELECTR
nm employ any person in y manner so as m b t wakens' PAID
z Compensmionl�WyyiC lif�ma Dz��" WA'I'ERSYSTEM/fRFATING Date Receipt#
APPlicant jr6GF�4lK!{ /�{i Qr
ZOO NOTICE.TO APPLICANT:If,uf¢rmnking this Ceniaan,of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
F-I U) become subject to the Worker's Cadillac nsa[am provisionsofthe Labor Code,you..it
ice forthwith comply with such provisions or[his pennii shall be deemed revoked. BUILDING FEE
aQ CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that there is a construction lending agency for the peffeammnee of
V Q the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: FLE.CfRIC FEE
0 sr Lenders Name r r PLUMBING FEE
� [C-�• Lenders Name QTY. MECHANICAL PERMIT PGI.
I certify that 1 have mad this application end stair Nat Ne oMve anticorrosion is
0. correct.lagree w comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FRE
V) building construction.and hereby iuthnrire representatives ofthis city to enter upon the CONSTRUCTION TAX
T•) 7 above-memioned property for imirclion purposes. ALTERORADDTOMECH.
F7 (We)agree to save,indemnify and keep harmless the City of Carman,against
liebilitiee,judgmenu,cons andeapenses whichmay in any way accomagainst said City AIR HANDLING UNIT(TO I0JI00 CFM)
in cmxcqueoce etaningaf this Perrot.
AIR HANDLING UNIT(OVER 10.000 CFM)
gna[urc of ApplicvnU nmmcmr Dam EXHAUST HOOD(W/DUCI}
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00)BTU) Dare Receipt#
Will the applicant ofuture building occupant Hort or barrage hamrdeas material HEATING UNIT(OVER 100,00M BTU) T A
as dented by the Cupertino Municipal Code,Chapter 9.12,and the Health end Sit cry
Code.Secti 125532(a)
❑ 'I Yu 13 No VENTILATION PAN(SINGLE RESID)
Will theepplicantorfuturtbuildingoccupantux<quiprnemordeviceowhichemit
BOILER-COMP PHP OR 10n.000 BTU) ISSUANCE DATE
Ihaaa dous mr cotaminare,as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) p
Dli•tnn]
13 Yes ❑No PAID
D
NEW RESIDENTIAL MECH. SQ.PT. pA
I I have mail the haunams materials mquiremema under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25573 and 25594. 1 understand that JAN 2 -1993
if the building does not currently have L tenant,that it ix my responsibility to notify the
Ococcupant of the requirements which must he met prior m issuance of o Cenificum of
cupancy.
CuT tyrCUf'tnunv� ILA
Owner or authodaed agent Dem TOTAL: ISSUED Itee
OFFICE.