25644 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOILDI. .
.- .F. RI AL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL A
BUILDING DIVISION - BUILDINGPROJEC'I'IDETFIRICA'I �I4 ION (•
BUILDINGADDRESS:, SANI3'ARYNO. APPLICATKINSUHMITTALDA'I'F:
S S LOT C G .
OW ERSN ME:
PHONE: C ACfOR'SN LIC Nl1
^p` Al NIC CON'1'ROLX
RCIII"fECI'/HNGINF.F.R: LIC NO: RISS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
ry1.DG .E PLU MEC
PERMIT ISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION APPLIANCE'S-RESIDENTIAL IW DESCRIPTION
0yg Iherebynffiren do"l em licmemanderprovisionsof Chepler9(commencing with
�00 Section]fl(10)of Division 3.17me Business vnd Professions Cade,end my licease is in PANELS /
y V cdl full force andLicense
Class
effect. UP TO 200 AM I'S 5 --
GGC4, Licenx Clues Lic.p
HadDale C.nwmor 201-1000 AMPS
1-'v Z ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $/SQ.El'.
z0
o,— I understand my plans shall be used as public records. OVER 1000 AMPS
SIGNS ELECTRICAL
3tt
2
q'yy License)Prnfcssi0nal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. I�'V� M•a
V l LOq
°k1O y 1 hereby affirm that I am exempt from the Contractor's License Law for the LV L,Q \yI/\
W3Oy following reason.(Section]031.5,Business end professions Code:Any city or county P.METER OR L
1"'LL O Q which acquires a permit to constmm,alter,improve,demolish,or repair icy structure
KMG2 prion.its issuance,slso rectina the applicant forsuch pemtitto file aligned stmcmem POWER DGVICI-
p that he Is licensed Pollicino to the provisions of the Contractor's License Law(chapter
m o�' 9(cammcncing with Seed...70u0).f Diviri.... heBmincas and Profcsxinns Coda) SWI OL LE RIC' 1 VALUATION
yYj_,y or lhm he is nanpuherefrom end the basis for the alleged aemption.Any violation of OU'I'
F-Z¢ n❑ I,asowneroftheproL TCHES 1 'URES 2\�
Section 7031.5 by any applicant for a permit subjects the applicant a civil penally of
�T0 I more than five hundred dollars($500) .
[J ir2pm peny,ormyemployeeswi0�wagesustheirsolec=Nnsation. NEW RESItLELECIR SQ IT. STORIES' 'TYPE CONSTRUCTION
a willdo the work,and thesuvmude is not imeadedoroffered for sale(Sec.]044,Business
and Professions Code.I'he Contractors License Law does not apply to an owner of
property who builds or improves thereon,end who does such work himself or @rough his
wnemr,the
ng rimpralthat such impmvemwithis notyearo oompl tion,rsed fine xle,IL
OCC.GROUP RES.UNITS
M1owevegthebuildingurden of gmem issolde didnot year or improve for the owner- L:
builder will have the burden of proving that he did not buil)or improve for purpox of
❑ I,asownerofthe n ycon gwi QTY. =PLUMBING PERMIT 'PGE FLOOD ZONE APN
pec. y,L,Business
ofesi Otde:) heCmmersto
Licenseconsumer the project(Sec.oano Business vnd Professions Code:)The Commerce's PERMIT ISSUANCE
whoco Law does sec applytoar.wner.fprogeny whobuildsorimproves thereon,and
who corrects By such projects with a conva<mr(s)licensed pursuant to the Contractors
License
Law. ALTER-DRAIN&VENT-WATER(G) TBE SUMMARY
❑
Iran exempt under See. ,B&P C for this reason BACK FLOW PROTECT.DEVICE 'S E FEr:S
SANITARY YN
Owner Dale RECFIPTX
DRAINS-FLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION ofou DECLARATION SCHOOLTAX Y N
❑ Ihereby'Compef thmlhave
rance or certificate copymencof(to insux,or Lob C.)an,ofwhich FIXTURES-PERTRAP RF.CEIPI'#
Worteea'Compensation Insurance or ecenified copy thereof(Sec.3800,lab CJ which PARK IT.EIt Y zN
covers all employee's under this permit. GAS-FA.SYSTEM-1 INC.4011TI.HT$ RECEIPY#
Policy# BfhDINkDIVAPN FEES
Company GAS-EA.SYS9'EM-OVER 4 HLA) PLANCIIEC e 6
❑ Cenifird copy is hereby famished. IL
❑ Certified copy is fled with the city inspection division. GREASEANDUORL WASH.INTERCEPTOR GRAIN '41
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILIF
COMPENSATION INSURANCE
(pok,ecumrsed not be completed iflhe pcmdt is furore hundred doll ars($100 SEWER-SANITARY-STORM EA.200F1'. FEE `
or less.)
I eertifydnt m da perfarmance ofthe work for which this permit is issued,Ishalt WATER HEATER W/VENTR.LECfR
not employ any person in icy manner so as to become subject to the Workers' PAID ®�
Compenswion Luws of Califomiu. Dom WATERSYSTEMITREATING Dem Rce
Q Z Applicant
z C) NOTICE TO APPLICANT:If,after making this Certificate of Excmption,youshould NEW RESIDENTIAL PLMR. SQ.FT. TOTAL:
(q become subject to the Workers Compensation provisions ofthe labor Code.you must
forthwith comply othhsuch provisions an this permit shall be deemed revoked. BUILDING FEE �#
W z CONSTRUCTION LENDING AGENCY SEISMIC 19ili
^a Ibcrebyaffirmthal theme is a consauctiun leadingegency birdie perfmmunceof
L.3 the work for which this pemtit is issued(See3097,Civ.C.) TO ELECTRIC IEP.
Lenders Name
OLenders Address QTY. MECIIANICALPERMIT FEB PLUMBING FEE
L) 1 codify that I have read this application and state that the above information is MECHANICAL FEF.
>' T17 cortect. l agree to comply with all city and county oNinancesind state laws relating to PERMIT ISSUANCP.
L) ziJ building rationalism,and hereby authorize representatives ofthis city m enter upon the CONSTRUCTION TA%
above naentione u us. ALTER OR ADD TO MECH.
ug Jemnif a los the City a(Cupcnino ageimt
cmc against xid Cid AIR HANDLING UNIT(TO 10.0t CFM)
a,se8 ng of 's permit.
AIR HANDLING UNIT(OVER I O."CPM)
Signemxu D a EXHAUST HOOD(W/DUC)
PAID
H ARDOUSMATERIAM DISCLOSURE HEATING UNIT(TO I00,00OB'I'U) Date Receipt#
Will the applica l or future building comptmt store or handle hazardous matenal HEATING UNIT(OVER 10411(10I3TIp TOTAL:
as defined by the Caperton.Municipal Coda,Chapter 9.12,rod the Health and Safety
Code,Seeder,
Yes 11 No 25532(a)'!
❑ VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Will the epplicwtor(murehuildingoccupanlusem
equipmenrdevices whichemit I BOILER-COMP(3HP OR ID9,IXp BTU)
betatrons gk
air contaminates us defined by the Bay Arca Air Quality Management BOILER-COME(OVER IBO,WO BTU) ry e
District'!
❑Yes 11 No NEW RESIDENTIAL MECH.—SQ,FI'.
I have read the hazardous materials abhu amens ander Chapter 6.95 of the (MAY 0 6 1994
California Health&Safety Cade,Sections 25505,25533 and 25534. I understand that
if the building does not currently have a terent,that it is my responsibility to notify the y�/ +,C 1 #
occupant of the requir menta which muss he met prior m issmnce of a Certificate of C�I l v1 Qurth I
Oiamplrcy.
Owner or eudhonzed agrnl Data OT ISSUED BY:
OFFICE