24933 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY.OFCUPERTINO BOMBING-FE.ECTRICA L PERMITNO. n
BUD.DwG DIVISION APPLICATION/PERMIT PEUMBING-MECHANICAL 6 4 9 3 3
BUILDING PROJF.C'I'IDENTIFICATION
Bill ING ADDRESS: SANITARY NO. APPI.ICATION SUBMTITAL DATE
f!/ IOrONIT# LOT#
W ERS NAMC: PHONE: CONTRACTOR'S NAME: a I.ICNO: t
12 N/C CANTROL#
ARCHITECT 1 I.I?R: LIC NO: ADDRISS: ❑
/ � a
CONTACT': PHONE:
' QTY. ELECTRIC PERMIT ll?E BUILDING PERMIT INFO
BLDG EI.ECT PI.UMB MECIi
PERMIT ISSUANCE ❑ ❑ X11
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. TOB DESCRIPTION
L-)"
El
0,04zP00 Ihereby 7")of Divthat Iision 3 offfhnsedinss and irofesol@doter and mmecense with
�rs00❑ full Section7")of Division3df the Business and Professions Code,and my license is in PAWLS
full force u-dc=t. N� I
FZu] Licen: loss Lic.# `�� UP T02o0AMPS
r�6y Ua Contractor 201-1000 AMPS
20a ARCIII I ECTS UECLARA'1'ION OVER Itgq AMPS SQ.IT.R,OOR AREA S/SQ,FT.
OZ_❑ I understand my piens shall be used as public records.
PII
, E
$$ F'.41 Electives]I'mfcssinnal SIGNS ELECTRICAL. 1114 N
S�dQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. ` P T E R
OaU I hereby athum ra
affirm at 1 exempt from the Comcmrs License Law for the
3 E y following mason.(Section]0J 1.5,Business and Professions Cole:Any city or county 'TEMP.METER OR POLE INST.
Fp'JOg which requires a Permit to compact.alter,improve,demolish,or repair any s[.cmre
2 ,N� to its issuance,also re 'ren the applicant for such Ho lila a signedstatement POWER DEVICES
LL1'1 prior qw PP Penni
00 That he is licensed punuau
notne provisions of the Cnmracmrs License law(Chapter
aKe� 9(commencing with Section]WO)of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
y(—,y or that he is exempt herefrom add the basis for the alleged exemption.Any violation of OIITLLTS-SWITCIIES-FIX'T'URES
FZQ Section 7031.5 by any applicmn for a per.fu subjects Ilia applicant to a civilpenalty of
f2n not more than five hundred delta.(SIM). NEW RFSIDENTIALI3LECIR SQ.FT.
q F-o Cl 1.aovanerofthe property,ormyemployees with wagesavheirsolecompensation, STORIES TYPE CONSTRUCTION
will do the work,eadthe sdunure is nm ideanded.a iffered for wile(Sea]0J4,Business
and Professions Cede:The Contractors I.icense Iwwv does nm apply to an owner of
property whobuildsorimproveOhetwn,ants whodoes such work himselforthrough his OCC.GROUP UNITS
own employ es,provided that such improvemntsar
eenot imendedmoffered forsale.If,
however,the building orimprovement is sold within one year of completion,thoowner- TOTAL:
builder will have be buNrn of proving that he did not build or improve lit purpose of
sale.).
❑ L mownerolthe property,con exclusivelycontracting with licereaed contracmrsm QTY. PLUMBING PERMIT FEE I'Ll ZONE APN
nnstrucl Ilia project(Sec.7044,Business and Rofessions Cmla:)The Contractor's PERMIT ISSUANCE:
License Lawdoes not apply to an owderof property whobuilds at improves themed,and
whocontmcts forsuch Projects with a conations)licensed pmstrant to the Contractor's
License Low. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 nm exempt under Sec. fi&P C far This reason BACK FLAW PROI ECT.DEV ICE TS I.FF.F.3
SANITARY Y N
Owner Data RECI!IPI'#
DRAINS-ILOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DIiCLARATION SCHOOL TAX YN
❑ no , O
RECi1PTp
WorkeWCompensation
Insurance
oraceifiedcopy,hred(Sew.JgOp,Eim C.)which PI%TURIS-PERI RAP
PARK FET: YN
n all employee'.under thia Permit. RECEB'f it
r GAS-IiA.SYSTHM-I INC.40UTLE1'S
Pol cy N BUIIAING DIVISION PIKS
Company GAS-EA.SYSTEM-OVER 4(EA) PI.ANCI IIiCK FEE
❑ Codified copy is hereby famished.
❑ Cmified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CER TIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOII.S FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM F.A.2001ef. ENERGY FEE
a,less.)
I eadifyflaw in the perfornowee ofma work for which this permit is issued.I shall WATER HEATER W/VF.NT/ELECfR
not employ any .on in any..be,so as.become subject m the Worked' PAID
Compensation Laws of Califnmia. Dam WATER SYSTEMR HEATING
Z '
Date ReveiptN
zO NOTICE TO APPLICANT:ILaficr..kin this Ccrtificam of Exam on
Code,you
should NEW RESIDENTIAL PLMB. SQ.FI'. TOTAL:
t-+ (/] hwovithc.,Iy,ito the Worker's Compensation Provision of tneamed ,.k.d.umuv
[�^ � forthwith mmPly with such provisions or this Flermit shell be Accmcd revoked. W � /� BUILDING IEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC IEE
Vz Ihereby affirm thatthem is a construction lending agency for the performance of
O the work far which this permit Is issued(Soo 3097,Civ.C.) O ELECTRIC FEE
Lcndd,Name 1
c U [,.dors Address QTY. MEC(IANICAU PERMIT FEE
PLUMBING HE
U I racily Nat 1 have read this application and statement the above information is
r�" W comet.lugreemmmply will,ulldly andmuntyonlinuncesund state laws mlmiagm PERMIT ISSUANCE MECHANICALFEE
building construction,and hereby auNorire representatives ofthi.s city to enter upon the CONSTRUCTION TAX
U z above-mentioned Properly for impaction purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupenino against
Iiabili'es,judgments.costs and expenses wh' h may in anyway accrue agenew said City AIRHANDLINGUND(TO10,000CF14)
rte of,he granting of Nis palmi
AIR HANDLING UNIT(OVER 110.000 CIM)
Signtelmol Applic ontract Data I:XHA UST HOOU(W/DUCT) PAID
HAZARDOUS MATF.RIAI.S DISCLOSURE HEATING UNIT(T'0100.00f)BTU) Date Receipta
Will the ii,dicam or future handing nce...a,oom or handle hazardous widened ]RATING UNIT(DYER IIXI,(IIX,BTU)
as defined by,he Cupenino Municipal Code,Chapter 9.12,and,he lisehfety
b end Sat
Coda Section 25512(a)'!
11 Yea CI No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will the appltcamorfuturebuildingoccup ral usecquipmentordeviceswhich emit
BOILER-COMP(311P OR 100,000 BTU)
hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
District, ❑ 13PAID
Yee No NEW RIiSIDENTIAI,MECH. SQ.FT.
1 have read the hazardous materials requirements under Chapter 6.95 of the APR
C.Iifomin llealth&Svfery Cndc,Sectlrn,s 25505,25537 and 255:14. Iuodammndthnl APR w aa�
if the building does not currently have o tenant.that it is my responsibility to notify the 1JY
occupant of the requirements which must be met print to issuance of a Certificate of (`�� y..,
Davaprnay. CII T " C�;;,:,,,
OwnermiuthoriziaJ.'e t Data TOTAL: ISSUED BY
OFFICE
Water- Sewer- Gas Line Installation and Repairs
6 Electronic Leak Detection and Pipe Locating
A .1 Miscellaneous Repairs
D. Cummings Plumbing
Lic.4292558
' 14311 Buckner Dr. 923-4221
San Jose, CA 95127 res. 259-2586
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