26645APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOmID.RIRR:-ELECI'R
BUILDING DIVISION APPLICATION/PERMIT
PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO
26645 /I 4 C
v J
BUILDING ADDRESS: r -
SANITARY NO.
A�/Ir'PLICA
ITMT # LOT #
�TIONSUBMITI'ALDATE
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OWN g AMEe PHONE:
C A NA T LI
NO_.#
ICY//
N/C
❑
CUM 'ROLa
I EG '/ENGINEER: LIC NO:
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CONTACT: PHONE:
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R PERMI
QBTrY._''EE.Y T.
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q.413UILDINC PERMIT INFO
BLDG ELECT FT*
-a -
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1 hembyaffirmthat I am licensed underprovisionsofChapmr9(commencingwith
APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
Seamon 9f1IXq of Diviil1ppn 3 of the Business and Professions Code, and my license is in
full fnrcc unJ of c, `5 Lic. to !
License
Dem Comtxmr
PANELS
UP TO 20D AMPS
'
201- 11100 AMPS
ARCHITECT'S ❑. ARATION
1 undersand my plareshall lwused i s public anemole.
OVER I000 AMPS
SQ. IT. FLOOR AREA
S/SQ. PT.
SIGNS ELECTRICAL
Licensed Ikofessinnal
OWNER BUILDER.
SPECIAL CIRC /MISC.
I a me CoATION
1 u amen from the Conuacor'a License Law for the
TEMP.M OR POLE INST.
ngmby m. (Se and
following Businessadd Profusions Co de: Any city or county
iresa.(Section construct,
which tots is a permit m emawrs, put improve, demolish, or repair any structure
a nnino statement
theinputfine
oslicensed
POWE DfiVICF.S
,be, hor Iulsumat to Cmuer
License Law
thatiscnwith Setion70epo Divisiion the Convusoo's License (Chapter
lore Code)
9(commencingthat
Division 3ofoeed
SWIMMMG POOL ELECTRIC
ygl.ygTl
hisxemith ereion and the exemption. or
or 7031.5 by uhemfemand the permit subjects the exemption. civil penalty
Section by anydredduutfor apemtileubjeco the applicant naacivilpenalty of
��
OUTLETS - SWITCHES -FI%TUBE
than
not more Than five hundred dollars ($SW).
❑ Lmownerofthepropeny,ormyemployeeswith wagesmnheirsolecompensauon.
NEW RESIDENTIAL ELECTS
STORIES
TYPE CONSTRUCTION
will do the work,and lire stmcmre is not intended oroffered foreale(Sec.](W4, Business
and Professions Code: The Connector's License Law does not apply m an owner of
pmperry, who bre Idsmimprovcs Ihemor,mad whodoessuchwork himself uNrm lihis
'
wnempoyees.providedthn mehimprovememsammat intended orofferedforsele. If,
OCC. GROUP
RES. UNITS
TOTAL:
however, the bulltingor improvement is sold within one yearofarmpletion, theowmer-
builder will have the burden of posing It,., he did non build or improve for purpose of
f, QT` -§PLUMBING PERMIT
FEE
❑1l ar owncrol the pmpcny,nnexcluervelycomracling with licemW convect t
Instruct Ilse project (See. 70,14, Business and Pfofcssions Cn.e:J The Connautnr's
MOOD ONE
APN
License Lawdoes not applym an ownerofIrmpeny whoorlds in improves thereoaxnd
PERMIT ISSUANCE
whocontracns forsueh projects with aeon ractor(s) licensed pursuant to the Contractor's
License Luo.
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
❑ 1 am exempt under Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE
Tr—
I. ID I:I"
SANITARY YN
RECEIPT #
Owner Due
DRAINS
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
YN
❑ I hereby affirm that l have a cmificao ofeensennoself-insure,ora cenificam of
Workent Compemmtion Immune ora cenified copy dremar Sec. 3800, Lib C) which
FlXTURFS- PER'TRAP
��
RI3CEIF1'p
PARK FEE Y N
GAS - EA. SYSTEM.I INC. 4 OUTLETS
ciriverstill employee's undenbis peril.
Policy #
RECEIPT #
BUILDING DIVISION FEES
Company
GAS - PA. SYSTEM -OVER 4 (EA)
PLANCIIECK FEB.❑
Cenifed copy is hereby Doctrinal.
GREASEDNDUSTRI. WASTE INTERCEPTOR
GRADING FEE
❑ Cenifed copy is Bled with the city inspection division.
CERTIFICATE OF MUMPTION FROM WORKERS
GREASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA, 200 FT.
ENERGYFF.E
U losseeionnecd embe completed ifthe permit is for one hundred dollars SIDB)
or lasi.)
WATER HEATER W/VENT/ELECIR
I minify that in the Performance of the woA for which this permit is issued, l shall
non employ any person in any manner so as to become subject to the Workers'
PAID
Compcnsalim Lawsof Califmaio Dela
Applicant
WATER SYSTEMOREATINO
Dam Receipt#
NOTICE TO APPLICANT:If, after making this Cenifi<ate of Exemption, you should
became subject to the Workers Compensation provisions of the lobar Code, you must
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL:
forthwith comply with such provisions or this permit shall be teemed invoked,
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I botchy affirm that them is a construction lending agency for the Performance of
the wnrk far which this pcmtil is issued (Sec. 3097, Civ. CJ
Lender theme
7t TOA
ELECTRIC FEE
Lantern Address
1
Y �, r MC'GIIANICAI,rPE IT
j S m A"
FEE
PLUMIfING FEE O
I. I ago that I have reit this aty anal tou county
nem than an above m s existing o
cording city anal countyoNinsacuind skolawsmining
to comply wrshy
PER
PERMIT ISSUANCE
I
MECHANICAL PCI3
cram ri
building ennsnedproadd herchyaudtion p rpses. ivesafthiacirymemttupon the
a
above-mentionedpropertysum.y for inspersion purposes.
ALTER OR ADD TO MECH.
CONSTRUCTIONTAX
(We) agree m save Indemnify and keep harmless the City of nt
lieilitex.jodgmena.otsand expense wldeM1 may oony, wry acme against said City
AIR HANDLING UNIT (TO I0,000 CPM)
in consequence of the granting of this permit.
AIR HANDLING UNIT (OVER 10 CFM)
Sigramneof Applicianna7mactin Dam
M- AUST HOOD (W/DU
PAID
HEATING UNIT( 7foo.otm RTC)
HAZARDOUS MA'I 17RIALS DISCLOSURE
Duro Roceipr tl
Will the applicant or future building occupant store or handle hesordous material
as defined by the Cupenim Code, Chapter 9.12, and the Health and Safety
HEATING ON (OVER Hall BTU)
TOT ;
Zen
Code, Section 25532(x)? ✓}
❑ Yes g0 NO
a Iti
VENI'lLA ON PAN (SINGLE RFSIDI
Will the applicantor future building occupnm use equipment or devices which emit
baerad.ae air cnmamiam; trade cd by the Bay Area Air Quarry Management
Dim -et?
BOIL F-COMP(JHPOR 100,(100 flTU)
(+ISSUANCE ATE
3 01994
BU .ER.COMP (OVER 100,000 BTU)
f-
0 Yr.
AU#.
NEW RESIDENTIALMECH. SQ. IT.
I have read the humorous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.25533 and 25534. I undersand that
C� 1 i UE uVi -r%111,4V
if lhebuilding does Ice eptly haveamnant,that it is my responsibility no notify the
cecupnm of the r nv t rs he ten it... to issuuncj,pf Can' mute of
Occupu (�l{—
ISSUED BY:
.bvdmc au o zcA agate Da
TOTAL:
OFFICE