25546 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO x aDING-ELF.CTRI AI, PERMIT NO.
APPLICATION/PERMIT PLUMBING CI IDENNICAL 25546
BUILDING DIVISION IIUILDING 1'ROJF.CI'IDF.N'1'IFICATION
.DING A13DRESS: I' '�(�J�/ SANITARY NO, APPLICATION SUBMITTAL/�LDDATE
Al I5* #k'4 e- a.le- y• IVZ UNI'fN LOT It
WN AME: PHONE: 1��l� ONT9�(JJ'OR:SN LIC NO: N/C CON TROL# �!
ARCIE HCI'/ENGINEER: LICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PGRMIT INFU
QTY. ELECTRIC PERMIT PEP.
BLDG ELECT PLUMB MECIi
PERM IT ISSUANCE �. El 0 11
LICENSED CON TRACTOR'S DECLA RATION APPLIANCES-RESIDENI'[AL TOB DM1SCRTPT'TON
QWz I hereby affirm that l um licensed under provisions of Chapter 9(commencing with
O U lulltforce adion
affect. on J of the Business and Professions Cade,and my license is in PANELS C���^_
< W License Class LIc,N UP TO 200 AMPS — yll
y�y Uma Contmcror 201-FINE AMPS
Z�yZ ARCIUTECTS DECLARATION OVER 1000 AMPS SQ.PI'.FLUOR AREA S/SQ.FT.
OZ-0 L 1 understand my plans shall be used as public records.
�
tzs L a
�+ Licensed Professional��6 SIGNS ELECTRICAL OWNER-exempt from
DECLARATION SPECIAL CIRCUIT/MISC.
yU I hereby affirm that 1 am exempt from the Contractor's ro License Law for the
n13u.r1'ii which
apernatirni]03LA Business andve.dmolih,or Any
city or county TEMP.MET ER POLEINST.
Le"fJ which its Ps v n permit re eonsw0.ulcer,improve,demolish,or repair any structure
2 p�}C) prior to its pursunttotrtrovisinsocant for ffic Co gemmas rile a License
Lo statement POWER DEVICES
�' O 1hmheH licensedpursuantthep.rldomsof the Contractor's LTcenee Low(Chapter
W R' 9(cnmmeneing with Serion]000)of Dlvislon9nl'tha Business end Profesaione Cattle) SWIMMING POOL I?LECTRIC
,o VAI GAT
tKy or that h7031.5 by myafromand the Permit
subjetsmedeaemant to A civil Penalty of OUTLETS-SWITCHES-FIXTURES a.S �[ 1 _•
CZG hotSection than
,d hundre doll rsMO mit subjects to applicantmacmvil Penalty of Y `V
not more than five hundred dollars(5500). NEW RESIDENTIAL ELECTR
C� ❑ othe wrk,andthe aperty,e isnot intended
arm,Busies Q' IES p 'f�YPP,CONSTRUCTION
y 3r�
will dotework,and theshemreiencor's License
Law
rdoes ntapplyIn44,Business �— p E13 IN
and Professions Cale:The Conwcmr's Liceme Isco does ria apply m on owner of IIILLL LL.W// V
pmpcny who huildsmimprovestbcrron,and who Joes such work himaclfnnhrough his '
cmr.thees,p building
or improvement
one
earofidmplefion,the owner-
builder
wn Ir, CC.rGH UP RL+S.UNITS
howeverthebuildmngorden of mem issoldwithinoneyear ori prove for thrower- TOTAL: 11
builder will have the burden of proving that he did not build or improve for purpose of t
sole
at ownemfte progeny,am exclusivelycmnraNns with licensed contractors to QTY: - • PLUMBING PERMIT AI`N
rmmct the pmjem(Sec.]014.Business and Professions Code:)The Contractors
ansa Tawdrwsnotapplytoanownernfpmpenywhobuitdsorimpmvesu,crcon,wd PFIT ISSUANCE
whocontrnetx far such projects with a comractons)licensed pursuant o the Contractees
Lircnw Law. ALL 17R-DRAIN&VENT-WATER BEA) FEE SUMMARY
❑ 1 am exempt under Scc. ,B&P C for this reason BACK FLAW PROTECT.DEVICE SANITARY TY DF. N
Owner Data RECETITN
DRAINS-FLOOR.ROOF,AREA,COND.
.� WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
❑ Ihereby affirm that l have a certificate ofcoment to self-imare.or a certificate ofFI%'KRIS-PER TRAP RECEIPT#
Wmkcrs'Cnmpensation lnsumncemecrnifed copy tercof(SttJab
g00.LCJwhich PARK FEE YN
covers all employee's under this permit GAS-PA.SYSTEM4 INC. OF RECEIPT'M
Policy M BUILDING DIVISION FEES
Company GAS-RA.SYSTEM-OVER 4(LA) PLANCHECK FEE
❑ Cenif nl copy is hereby Famished.
❑ Ccnifial copy ms filed with rhe city inspersion division. GREASEINDUSTRLWASTHINTERCEPTOR GRADING FIA:
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Thissermon needmn be completed lite permit is fortune hundred Jolters(SIM) SEWER-SANITARY-STORM HA.200FT. ENI?ROY FEE
or less.)
I certify that in the performance chile work fur whichthis perrnit is issmad.lshnll WATER HATER W/VENT/F.LECTR
not employ any person in any manner so u to become subject to the Workers PAID
Compensation Laws of Califomia. Date WATER SYSTEMITRPATING Date Receipt#
0z Applicant
Z 0 NOTICE TO APPLICANT:If,after making this Cmifcate of Exemption,you should NEW REM DENTIAL PLMIL SQ.IT. TOTAL:
Imoi become subject to the Workers Compensation provisions of the Labor Cale,you must ^
� > farm.im comply with such provisions nr this permilshall be deemed revoked. BUILDING FEE
aCONSTRUCTION LENDING AGENCY SEISMIC ME
Vz I hereby affirm thatthem is a construction lending agency for the performanceof TOTAL: ELECTRIC FET?
O the work for which this Permit is issued(See.3057,Civ.C.)
Lender's Name
p U Landers Address QTY. MECHANICAL PERMIT FEE PLUMBING PER
I certify that 1 have mad this application and state that the above information is
W correct l agree to comply with all city and county omlinamces and state laws relanngm PERMIT ISSUANCE MECI IANICAL FEE
_ buildingconsauction,and hereby authorize mpmsentrivesof,his eitym mon.pon the CONSTRUCTTONTAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree te save,indemnify and keep hornless the City of Cupcnino egainst
Iiubilitmes,judgmmmts,costsand expenses whichmay in any wayacerueagainmsaid City AIR HAN OILING UNITOG 10,000 CFM)
ar woc ut the ting of this permit 14
AIR HANDLING UNIT(OVER Io,000 CFM)
ae Signut of APP tan Ctummmor pate EXHAUST I IOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00),BTU) Dam Receipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU)
as de road by the Cmpcninm Municipal Code,Chapter 9.12,and the Health recd Safety
Code.Section 25532(a)?
❑Yes C3 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 11X),(1110 BTU) ISSUANCE DATE
Will",upplicanmrluturohuiWingrccupum useeyuipment ordevices whichemit �y w
1� Intimations air contaminants us defined by the Buy Area Air Quality Management BOILER-COMP(OVER 100,000 IFFIL I-ry 'O
District!
❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT. $�/]
I have read the hazardous materials requirements under Chapter 6.95 of the I�
California Health&Safety Code,Sections 25505,25533 and 25534. I understand that C��y 1983
if the building dues not currently have atenant,that it is my responsibility to notify the rd / U
occupant of the requirements which must be met prior to issuance of a Certificate of h LUrrr`
Occupancy. V/y,Ir
///�tt•ivy//
Owner m mhorimd agent Data TOTAL: ISSUED BY: ` 1
OFFICE /