25371 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOIcrRLECTR PERMITNO.
APPLICATION/PERMIT PLUMBING-.MECHANICAL 25371.
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS J /�� / _ /1 SANITARY NO. APPLICATION SUBMITTAL DATE V�TO AUVZMg1-Z/'n— �/'-. UNIT# LOT at V-1 Yi
OWNERS NAME: L PHONE: NTRACI'OH'�'(ME: /I� LIC N(
N IL 4OB- br-I'1 k#.J ! S VCd N/C CONTROL It
RCHITECT/ENGINEER: LTC NOr 1T, DRESS: MIZ
r�I Q
t J`t�J2 6r L $
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�k�/ t� c a� sa. BLDG ECf P MECH
R�sl}HA R9, (-t0� a6,T1700 PERMIT ISSUANCE !
LICENSED CONTRACTOR'S DECLARATION gPPL1ANCE5-RESIDENTIAL 10 DLSCRIPI'IUN
owy I hereby affirm that l am licensedrom
under pvisionfmme
Chapter9(concing with
�00 Section]000)of Division 3 of Nc Business and Professions Code.and my license is in PANELS /'�
y.�FF full force and effect. fff JJJ���� it/1
NZW License Cl-s Lic.#,IF� UP T02 AMPS
6 p. Date Commnor Ems' OV-I"AMPS h t]O , S/SQ.FT.
ZOyy CHITECTS DEC A A ON OVER 1000 AMPS (.,yk
O!—p IugdawiwrYl�Phow sh4" useQ as publi�pcor SIGNS ELECTRICAL
�3 �1
P:n Jw.l hiccn eaTi,Doul A/ '!`J V
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. t n ;
Xce. 1 hereby affirm that I am exempt from The Comranors License Law for the
I+131s-,F<it following reason.(Section 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST. I
F�-0y J which requires a permit to conswn,other,improve,demolish,or repand,any structure N I l
cau, poor W its lssandrea,also"cancer The applicant fofsuch permit to file a signed stemadent POWER DEVICES
fy C O0 that he is licensed pursuant to the provisions of the Conuecmr's License Law(Chapter SWIMMING POOL ELECTRIC
9(commencing with Section 7")of Division 3 ofthe Business and Pmfessioru Code) VALUATION
a W_y (ir that he is exempt therefrom and the basis for the alleged exemption.Any violation of,
F'Za Scaion]U31.5 by day dpplicum forapermit subjects the applicannoecivil penahy of OUTLETS-SWITCHES-FIXTURES
not mono than five hundred SD dollars F1500). S'1'OHIIiS 'I'YYE CONSTRUCTION NEW RESIDENTIALELE-M _SQ.FT.
C F-o ❑ I,asowncrof lhepropcny.ormyempinyxswiN wagesu Neirsolecompensadnn,
y3°. will dothewons Coale:
oaswdure ixnoes License
offeredsnot apply
9044,Business
and Professions Codc:'ILc Contractors Licenu Lew does not apply to m owner of
pmpmywhobuitdsorimpmresdarean.andwhodesetsuch work himselforduough Ns OCG GROUP RES.UNITS
ownemployws,M)Yidedthat.suchimpmvemenm=mtinten&doroffemd fondle.If,
however,the buildingor improvement is sold within one year ofcompletion,theowner- A.
builder will have the burden of proving that he did not build or improve for purpose of 1t
sale.). PLUMBING PERMIT FEE QTY.
❑ Las owner nl'Ibe properly,wn cxdusivdy andrnding wiN license)rontmctun to FLOOD LONE ANN
construct the project(Sec.9044,Business and Professions Ccdep'Die Contractors �.
License Lawdcesaot apply town owncrofpm,erty who builds or improves Hereon,and PERMIT ISSUANCE
whoccntmcts branch projectswiN a conuectorts)licensed pursuanuo Ne Contractors ALTER-DRAIN&VFM-WA'IFJe EA
License Law. ( ) FE£SUMMARY
❑ I am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE f
SANITARY Y N
owner Date DRAINS-FLOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
'�❑ I hereby affirm that l have.certificate m emsent to aelf-insure,ora certificate of FIXTUHPS-YF,R TRAP �� RECEIPI'#
Vorkers'Cnmpenmtion lnsumnre oracenificd copy thenooflSec.38t]O.Lab C.)which PARK FEE YN
nvcls.11 employee's under This permit. GAS-FA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy IT BUILDING DIVISION FEES
Company GAS-LA.SYSTEM-OVEN 4(FA) PLANCIIECK FEE
CI Coddled copy is hereby Familial.
❑ Certified copy is Bled with the city inspection division. GREASIONDUSTRL WASTE INTERCEPTOR GRADING FEE �+
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF,ASETRAP SOILS FEE O ��
COMPENSATION INSURANCE
(This section need not ho completed ifthe permit is frronchundrel dollars(SIM) SEWER-SANITARY-STORM EA.200IT. ENERGY Iq?li
or lust
-� I certify That in the performanemf Ne work for which this Permit is issued,l shall WATER HEATER W/VENT/ELECR
nut employ any person in any manner so as to have.subject or the Workers' PAID
Compcnsetionlawsof Califomia. Doo WATER SYSTEM/CREATING Date Receipt#
p Z Applicant
Z � NOTICE TO APPLICANT:If.afher making this Cenificdteof Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
� .�. becomesubjecunthe Wmker'x Compensation pmvisimsofthe Labor Code,you must
fn dhwith comply wohsuch provisions.,,his permifshall be deemedrevoked. BUILDING IFF O '—slI
(� CONSTRUCTION LENDING AGENCY SEISMIC FEE
D" Ihereby affirm that there is a construction lending agency for The performume of
U O the work for which This ELECTRIC FFE
pemdt is issued(Sec.309],Civ.C.)
Lenders Name
v^ TY. MEC IANICALPERMIT FEE PLUMBING ItiE
QU I
l<nd certify That I hav<mad this application and stale Nat the above information is
>" L1a cored lagnocmmmply withrill city and county oNinwcesand state lows mldsing to PERMIT ISSUANCE .7 MF.Cf1ANICAI.FEF.
f^ p" building construction,and hereby audience representatives of Nis city to enter upon the
above-mentioned n for inspection ACT ER OR ADD TO MECI I. CONS9RUC'TIUN'TAX
(We) pmpe y peer purposes.
( gree nt save,indemnify and keep my
the City of Cupcnino againstCty
liebilities,judgments,costs and expenmawhich may in my way eccrve�#d ndi City AIR HANDLING UNIT(TO 10.(gO CFM)
uence of the granting of this permit. (�/]
AIR HANDLING UNIT(OVER 10,11110 CFM))
tureof Applicant/Contracmr MarcEXtIAUST IIt]OD(W/DUCI'1
SignaPAID
I IALARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 000.100 BTU) Onto Receipt#
Will the applicant or future building occupant store or handle bmandous mwerial 11G'1'ING UNIT(OVER 10POS)BTU) TOT
as defined by the Cupemino Municipal Code,Chapter 9.12,and Ne Health and Safdy
Cale,Section 25532(u1't VENTILATION FAN(SINGLIi HFSID)
11 Yes ❑No
ISSUANCE.DATE
Will heapplicantorfumrebuileing occupant uuequipmemordevicn whichemit BOILER-CQMP(3HPOR 100.000BTU)
xauudous dr contaminants as defirsed by the Bay Arca Air Quality Management BOILER-COMP(OVER 100,000 BTU) f� p
A
ice] ❑Ycs ❑No NEW RESIDENTIAL MECIL SQ.FT. •
1 have read the humadous mncrials requirements under Chapter 695 of the
California Health&Safely Code,Sections 25505,25533 and 25534. 1 understand that SEP F!08
m �
if the building docs not currently have a teas.that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificam of
OccuWn Y a rr
V I
\' I1h 111YV
Owner or authorized dgnn Date TOTAL: ISSUED BY: VV
OFFICE