26103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPull,...s.-fc.,rRICAL PERM[r NO, O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDEN'fiFICA'DUN
BUH.DINGADDRP.SS: - SANITARY NO. APPLICA ZION SIIBMI IT AL DATIL
'
UNITp LOI'M
O NBRS NAML PRONE: CONTRACTOR'S NAME: LIC NO:
M n -72000JL-r,;karhzl NIC CONTROL#
Mt II1'1'ECOU (NEER: LIC NO: ADDRES �J n ❑
z —p /0 z .VN?G ar t
'ON'I'ACT: PHONE: '
QTY. ELECTRIC PERMIT EEL? BUILDING PERMIT INFO
• BLDG ELECT PL'LU�MB MECH
PERMIT ISSUANCE F-1 1a
11.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
pyZ I hereby affirm that l am licensed under provisions ni'Chapter9(commencing with JOB DESC ION
�00 Section 71100)of Division 3 office Business and Professions Code,and my license is in PANELS
CU� full fuse and effect. [�
F7ty License Class I.IC.N UP T02W AMPS r/�
oh y Dae Contactor 201-1(100 AMPS
ZOy� ARCHITECTS DECLARATION OVER 1000 AMPS - SQ.Fr.FLOOR AREA g/SQ.FT.
OZ-0 underhand my plans shell be used as public records.
2SIGNS ELECTRICAL
R�
y Licensed Rnfessionnl
OWNHIUBUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xOaF 1 hereby affirm that I am exempt from the Convactora License Law for the is
u13�m< f.11.wingreu.na(Seenon 7031.5,Baeineesand Profexsinm Cade:Any city.,county TEMP.METER OR POLE MST.
which nemiresa pemllt to e.n.cfrom.their.impmvq demolish,of repair any structure
7.;s-:gprior to its issuance also requires the applicant for such Permit o file a signed statementPOWER DBVIC'FS
y�jp0 th;n he is licersul pumnanno the provisions of the Connector's License Lew(Chapter SWIMMING POOL ELECTRIC
v.a0 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) VALUATION
ykj^,n or that he is amnift therefrom andthe bad,for forfeited exemption.Anyviolation of OUTLETS $WITGBB$-FI%TURES •�
Lira Section 7031.5 hy.nyappliermtfor.pemlitsuhnhtsmP.plicammacivil penaltyof _
� , not more than five hundred dollars(5500). NEW RFSID[:NTiAL ELECfR S
Wm ❑ I,asownerofNepmKny,ormyemployaswithwagesestheirmlecompensation, Q.F17 .TORIES 'I'YPF.CONSTRUCOON
a _ wil l Jo the work,Part the structure is not intended or offered for sale(Sec.7w,Business
and Ponfeasions Code:The Contmcmr's License Law does not apply to an owner of
pmpenywhobuildsor improves there.gand whoddessuchwork himseiforthmughhis
owncmployccs,pmvidedthutwch innawcmems arc not imendctoridmodfmsid,.If, OCC.GROUP RIiS.ONE'I:I
however,the building orimpowement is sold within one yearof completiaa,the owner- TOTAL:
builder will have the burden of proving that he did not build m improve for putpou of
cola). TY. PLUMBING PERMIT'
❑ Las the project
r.Ut(Sec. ny,mn usinsivelyconmcOions Coire)The'Clracmnm Q FEE FLOOD—ZONE AIN
constructthe
does
not(Sec.7(#4,Business and Professions Coda? se'Conrmctore
LicenseLawfocurch Poymawithacofpropeny who
sed ds puorimprn thethereon,end PERMIT ISSUANCE -2r 1 ��
wicersereccs fnrsuchpmjemswiNawntranurts)licenced pursuarumhe Comnct°h ALTER-DRAIN&VENT-WATER(EA
License Law. ) PF:E SUMMARY
❑ 1 stn aempt under Sec -,❑&P C for this rcawn BACK FLOW PROTECT.DEVICE UT.IDIS F LS
SANITARY YN
Owner —DataDRAINS-FLOOR,ROOF,AREA,COND. RECEIPTg
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihercby affirm thetlhave accnificate.f consrnno self-insure,oracenificate of FIXTURES-PERTRAP RIiCE1F1'M
.rken'Compensarion lnallraneeor a readmit copy thm,oDsec.38W,Lab C.)which PARK FEE Y N_
v n all employee,mdcnhis permit. GAS-EA.SYSTEM-I INC.4 0UTLE'1'S RECEIPT M
Policy N BUILDING DIVISION FEES
Com y ificJ copy is hereby famished. GAS-HA.SYSTEM OVER 4 H;A) PLANCHECK FM
C
ific l copy is filed with the city inspection division. GREASEANDUSTR1.WASTE INTERCEPTOR
GRADING IIiE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASETRAP SOILS FEE
COMPENSATION INSURANCE
Olds section need not be completed ifthe permit is furore hundred dollars($100) SEWER-SANITARY-STORM EA.200F71'. ENERGY FEE
or less.)
I certify that in the performunceof the work for whichthis permit is issued,I shall WATER HEATER W/VLIAiLECI'R
no employ any person in any manner so as to become subject to the Workers' PAID
Compereationlawsof Celifomia. Dam WATER SYSIR cerRFATING Dae Rereiptp
O Z Applicant
Z0 NOTICE 9D APPLICANT:If,after making this Certificate of Exemption.ynu should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
r0 become subject to the Worker's Compensation provisions ofthe Labor Code,you must
ai , forthwith comply with such provisions or this pemtilahell be deemerinceked. BUILDING FHE
LkI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherehy affirm that there is ecunsvuainn lending agency for the perf.mmnce of
Or Ne work for which this permit is issued(Sao 3111 Civ.C) TO AL: ELECTRIC FEE
V. tom" Lender's Name
Lender's Address QTY. M1iCIIANICAL PHRMI'I' FEH PLUMPING FBE
L a I campy that I have mad this application and slate that the above information is
correct.I agree to comply with all city and county ordinances and state laws reining to PERMIT ISSUANCE MECHANICAL FF.E
apy building construction,and hereby authorize representetivesofthis city toenter upon Me
above-mentioned a for ins t n u CONSTRUCTION TAX
L) to save,
y pec io p eprrus. ALTER OR ADD TO MECH.
-(We)agree nt nave,indemnify and keep harmless the City of Cuparest against
incoitiequencmen he
tsind expensa hm any way accrue agvnn said City AIR HANDLING UNI'I'(TO 111,01X1 CI'M)
in<nnuquence he and
olt ' t.
�L/vt
_.5 AIR HANDLING UNIT(OVER H%WOCFM)
Si pp c nUCo c � pate EXHAUST HOOD(W/DUCp
PAID f
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT('I'D HALM)BTU) Date Receipt p
Will the applicant or future building occupant store or handle hazardous material
as Ifi in 11 the Capetian Municipal Com.Chapter 9.12,and the I leahh end Surrey HEA1'I NO UNIT(OVER 100,000 BTU)
Cede.Section 25532(a)7
11 Yes ❑No VENTILATION FAN(SINGLE RF.SID) It Isis,
Am Will theapplicum.rfmumbailding oecup:mtuu equipmemmdeviceswhieh emit
BOILER-COMP(31111 OR 1011,1100 BT1p ISSUANCE.DATE
ot�azardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I(IO,(XM BTU)
Dihdc@
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT.
LGhave read the hazardous materials requiraboals under Chapter 6.95 of the - A /
California Heahh&Safety Cndc.Sections 25505,25533 and 255M. I understand that _ f s�
ilding does nor currently have a mount.that it is my fesponsibllity.,Mary the (�
tempera of the requirements which must he met prior m issuance of a Cmificutc of
ncy. /�
orauthurizW egem Date TOTAL: ISSU119i'�- - ,
OFFICErrhnf�V