25431APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOG11BTM
APPLICATION/PERMIT
B''- ,
PLUMBING - MECHANICAL
PERMITNO.
n C' p O �I
4
BUILDING DIVISION
BUILDING PROJECT IDEMI'IFICAIION
L J J 1
BUILDING ADDRESS:
SANITARY NO.
APIRLICATION SUBBbiriTAL DAT)
Iq0 O
UNIT# I.Of#
.RS NAME:
HONE:
CONTRACTOR'S NAME: LICNO:
N/C
CONTROL#
❑
ARCHITECT/EsGINEER
LIC NO: ADDRESS:
CONTACT: PHONE:y,J.,,
^� •%<a - �<
FGECTRICPERMIT ..'-.
FEE
BUILDING PERMIT INFO
B{,DG SLOT PLU❑MD MUCH
S v
PERMIT ISSUANTIANYNCE
❑l
T
LICENSED CONRACS TORDECLARATION.
APPLIANCES - RESIDENTIAL
/�y/Y�'I
JOB DESCRIPTION
1 hereby affirm that I am licensed under provisions ol'Chapin9 (commencing with
Section 700m) of Division 3 of the Business and limitations Code, and or, license is in
PANF15
full farce and effect.
License Class Lia.#
IIP TO 200 S
1
` J
Dam Convactm
1 -
ARCHITECTS DECLARATION
E 1 AMPS
SQ. FT. FLOIAR ARBA
$/SQ. PT.
I undctsmnd my plans shall be used as public records.
IINSELECTRICA
LicensedProfessional
OWNER -BUILDER DECLARATION
SPECIAL CIR IS .
I hereby affirm that I a emit from the Contractors License Law for the
following ssand Professions Code: Any city or enonlytum
TEMP. METER LE IN�.
'
m consweL alcor, improve, demolish, or stp0i, any seen tum
which ,egoists a to maters 1. abs
orfs a. Permit
e, rds. he of r such s(aummt
POWER DEVIC
s License Law (Chapter
the the CommitmLiease La
that he is licensed pursuant m the) ovi
that hos licensed pursuant to provisions of the Ce
VALUATIONQ
ii Division Busier
9(commeis phe Division Sof lleedramsand Professions Cad e) SWIMMING LELEC1181C
exemlthandSection
rom an
Snhatbels exempt therefromnt for bermitsbs for ets the4exempti to civiny l pletion of
Section 703 by any applicant far u permit subjects the applicant to a civil pe,Wty of
OVIL -SWITCHES-FlXNRES
0 0
D
n
not moreman❑oftheve o "y,otmyedollars p).
❑ I,nsownerof theproperty,ormyemployecs withwegesastheirsole<ompcnsation,
N RESIDENTIAL ELECTR SQ. 4T,
STORIES
I'YPHCONS'FRUCfION
will Jo the work,and the strucmm isnotimendW oroffereJ forsde(Sm. 7044. Business
and Profusions Code: The Contractor's License Lew docs not apply m as owner of
progeny whir builds or improves thereon, and who dues such work himself or through his
OCC. GROUP
RLS. UNI IS
own empluyees,provided that such improvereentsarenot incrdedoroffertd forsale. If,
however. the buildingor improvement is sold within one year ofet mpletion, the owner-
TOTAL:
builder will have the burden of proving that he did trot build or improve for purpose, of
sinal'
❑ with
exclusivelyan
QTY. PLUMBING PERMIT•
FEE
FLOOD ZONE.
APN
uct the ps ijim (Smpeny.am
Professions
de:) he Comment's construct the project
Business and 9ofbssioms Cade) The Cr,ovn.rand
nom whobuildsarimpmvu thereomand
License Law does nm0pplyms
apply
PERMIT ISSUANCE
crowlpeny
fersuclt projects wish actmmcan(s) licensed pursuam m the Convucmr's
with
whers,
AL'll?R- DRAIN &VIiNI'-WATIiR (CA)
FEE SUMMARY -
Low.
License Law.
❑ I am exempt under See. , B & P C for it is reason
BACK Ff/6W PROTECT. DEV ICE
O FEES
TS'IDE
SA WTARY
ITN
1 RIiCE1P1'#
RF,CEIPI'# N
Owner Dom
DRNN -FII f P, B (I D. f"'
WORKMAN COMPENSATION DECLARATION .: _ _
C1Ihertby affirm thatlhavcattnificam of conummulf-insure.macenifieam of
FI%TUIiFS PpRsTRAP'wt\ l p
/I IJ
f^^ f,�
FEE Y N
Workers' Compensation Insurance or acetified copy thereof(Sec. 3800, Lab C.) which
C II
I_ 140
PARK
RECEIPT#
rstal employees under this permit.
GAS-EA.SYS oM-IINC.4`OCIi.LIi'S
'BUILDING DIVISION IgiF_S
Polcyp
Company
GAS- .SYSTEJIOI C4 EA)
P CHECK7<
❑ Certified copy is hereby famished.
GRADING FEE
❑ Certified copy is riled with the city inspection division. GREAS� DUSTRL WASTE IN'1'ERCEPI'OH
. CERTIFICATE OF EXEMPTION FROM WORK ERS'
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
ENERGY IFF,
This section need not he completed HIM permit is for one hundred Jollars($100) SEWER -SANITARY-S'FORM Ii .200
m less.)
I certify that in the performance of the work for which this permit is issued, l shall WATER HEATER W/VENI'/ELECTR
not employ any person in any mannef as a m biome subject to the Workers'
P
Compensation LDwsof Califimia. Date
WATER SYST NVI'REAT[NC
Date Receipt#
Applicant
NOTICE TO APPLICANT: IL after makingthis Cedificateof Exemption, you should
NEW RESIDENTIAL PLM. SQ. FT.
TOTAL:
become subject to the Worker's Compensation provisions ofthe Labor Cade, you must
BUILDING FEE
forthwith comply with such provisions a, this permit sbull or deemed mocked.
S D
SEISMIC FEE r
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform mce of-
TOTAL:
ELECTRIC FEE
,he work for which this permit is issued(See3097, Civ. CJ
lender's Nome
Under's Address
QTY. MECHANICAL PERMIT
FEE
PLUMBING ftiC
I celify mat I have read this application end state that the strove information is
-
MECHANICAL PEE
correct. l agree to comply withal] city and county ordinances and suite laws icladng in
PERMIT ISSUANCE
_
CONSTRUCTION TAX
buildingmnevuction, and hereby nathodm stpresenuiJves of this city teenier upon the
above-mentioned progeny for inspection purposes.
ALTER OR ADD TO MECIL '
(We) agree to save, indemnify and keep harmless the City of Cuputi,o against
'abilities,judgerems. an us ex hich may is any wayaceme Dgvost sod City
AIR HANDLING ON] '1'('1'O IO,IKNI CFM)
uqu<nce of the granting of is perms.
AIR HANDLING UNIT (OVER IO,000 CFM)
PAID
btg PIi Convect r Dat P,XUAUST HOOD (W/DUC )
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100J" BTU)
Data Receipt #
'IUTAL:
Will the applicant or fat re building oer,ant smm or handle hazardous m urn.1 I MATING UNIT (OVER I W,(NIO BI U)
a' defined by the Calendar, Municipal Cale. Chapter 9,12, and me I Iealth and Safety
Core. Section 25532001
❑ Yes ❑ No
VENTILATION FAN (SINGLE RESID)
ISSUANCE UA'I'E
Will theapplicanmrfumre bui]JEngoccupam use auuipmentordevices whichemit
BOILER- COMP(3HPOR 100,tN)OBTU)
P A D
hamtdous air mouremand, as abroad by the Bay Ansa Air Quality Management
BOILER -COMP (OVER 100,000 BTU)
,Di... CO
❑ Yes ❑ No
N17W RESIOI IIAL MECIL SQ. FT.
AUG 9 1993
I have read the hzxaNers marcors requirements under Chapter 6.95 of the
Culitn,nia llcalth & Safety Cor<, Sbctiomx 25505, 25533 end 255)4, l nadeamnd that
if the builJing does nm cumnlly have a mnanL that it'n my respmsibiliry m notify theFr
'CI ti UL ACU m I Wilk)
of the requirements which must Ix: met prim to issuance of a Cbnificate of
Occupancy.
v • tktrf,
P.0 iD BY: c I
Owner or uniformed mixd agent. Data OTAL:
v -HUL: