26763 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BtI,Wllrux IILMMIC,A PERMITNO.
APPLICATION/PERMIT
PLUMBING- -MRCIIANIC'AL 26763
BUILDING DIVISION BUILDING PRO.IECT 1DIENTIF'ICAT'ION
BUILDI DRESS: SANITARY NO, APPLICA'EON SUBMITTAL DATE
1 S �{!➢ F� LOT#
OWNERS PHONE: NT5,4CIOR'S NAM' LIC NO:
NIC CONTROL N
\HCIi I'I'F:C'1'/ INhE LIC NO
'ONT'AC'T: PHONE: ECRaC r PBMFEE
BUILDING PERMIT INFO
L a YNCE 1 X ' M1 35. DG EEC (ECH-
O� PP.RMIT ISSUANCB
LICENSED CONTRAC'TOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DUSCRP1'ION
y= Iheabyiffirm that Ism liavedunderprovisiomofacpter9(commencing with
O Secume 000)uf Division inf the Business and Professions Code an td rBy license is in PAANELSUP TO 00AMP5
ty WV full force and eBect. ;6 3
`ura+�� license C s Lic.p
y Q VN Dwe Contractor { 201-1000 AMPS
7.O.ices�' CHITEGTS UN RAl'ION OVER I"AMPS SQ.FT.FLOOR AREA $/SQ.1'I.
b 2`- underswnJ my pla nM1all he used us public records. `tea
E^F-W SIGNS ELP-G'1'RICAL SJ
KKa �n Licensed Professional
d'6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XO a V I hereby strum shat 1 am exempt from the Contractors License law for the
W'�+WOEi fallowingreasoa.(Section 9031.5,Business and Podasim,Code:Anycityur county TIME,METER OR POLE INST.
oIwhich armims a permit m construct,alter,improve,demolish,or repair any structure
t[vrv]],�� pricrm its issuance,nim regnires the applicant for such Permitto file a sighed moundent POWER DEVICES
ty C a0 pm that he is licensed Formation the provisions of the Comfacmrs License Law(Chepmr
E
4ax e9(commencing with Section 7")of Division 3 of the Business and Profusions Code) SWIMMING POOL ELECTRIC VAI ON
W_to of that he is exempnherefmmnnd the bans for the alleged exemption.Any violation of
�QSection 2031.5 by any applicant for a permit subjects the applicam ton civil penalty UTLHTS-SWITCHES-FIXTURPS �� �% Q�'1
not more than five hundred dollars($500). L�.7
04 ❑ I,asownerofthepmperry,ormyempioyecs withwagesestMireolecompensedon. NEWRESIDENTIALELECTR _SQ.IT. r n T IF.STTMNIKI CTION
willdothe work,and the stmetureisnotimmrded oroffered formle(See.2044,Business I'1� i�
and Professions Code:The Conuacmrs License Law does not apply to en owner of
property who builds or improves thereon,and who daessuch work himulfor through his l)
onseareployes,providedtbat such improvememsnfe not intended mothered fora e.If, U .UNI
however,the building orimprovetnent is sold within one yearofcompletion,ihemmor- T
builder will have the burden of proving that he did not build or improve for purpose of
le.). , r
❑ I,asownerofthepmpeny,amexclusivelycomractingwiNlicensedconwctonto gTaY;' ? ` PLUMBING PERMIT
construct the project(Sea.2014,Business and Professions Coll Ihe Contrecmr'e PERMIT ISSUANCE
License taw does not apply to s a owner o f propmy who builds or improves thereon,end
who contracts for such projects with a contraetor(s)licensed pursuemuothe Comraomr's ALTL'R-
Llcause Law. DRAIN&VENT-WATER(GA) It [ZEE SUMMARY
❑ 1 um exempt under Sea ,B ce P C for this reason BACK FLOW PROTECT,DEVICE SANITARY �Y N
Owner Data RECEIPT#
GRAINS-FLOOR,BOOP.AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ Thereby off,batt have acenifiaa a(consenno sel4insurc.ora anifiam of ftE EIPTM
covers
ompensudon&,thisceofucenified urpy thereof(Sw.38(O,Leb CJ whluh IOXTURES-PER TRAP PARK ITB Y
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS F. T
Pnlicyp BUY1DIAiii0bTQ.%ZNPGFS '
Company T OAS-EA.SYSTEM-OVER4(EA) PLANCIIECK FF
ClCeniOed copy is heahy famished.
milled copy is filed with the city inspection division. GREASP./INDUSTRI,WASTE INTERCEPTOR GRADING iF
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEF
COMPMSATION INSURANCE
(Thu section readmit he completed ifthe Permit is for one hundred dealum(S 100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or Iai
I certify that in the perfrmunce of the work for which this permit is issued,Ishe] WATER HEATER W/VENTELECTR
not employ any person in any manner so as to become subject to the Workers PAID
Compensauonlawsof Gdifomia. Dam WATER SYSTEM/TREATING Uate Recti tM
O z Applicant
O NOTICE TO APPLICANT:If,after makingthis Certificate of Exemption,
ynu should NEW RGSIUI3NTIALPLMB. SQ,FT. TTAI:
rrsZ (q become subject o the Workers Compensation provisions of the Labor Code.you must
forthwith comply with such provisions or this permitshall he deemed revoked. BUILDING ME may
Q CONSTRUCTION LENDING AGENCY SEISMIC HE
1 hereby affirm thatthern is a construction lending agency for the performance of
U C) the work for which this permit is issued(Sec.3092,Civ.CJ LiTAL)iai
lender's Nome
F tender'.,Addms QTY. MECHANICAL P-RMI'P FEE PLUMBING"I.
CJ 1 certify that I have read this application and into that the above information is
correct,l agree to comply with ill city and county ordinenas ad auto laws relating to PERMITISSUANCE MECHANICAL ME
building,hn.struction,and hereby authorize representatives all[his city msituational the CONSTRUCTION TAX
U Z abave-mentioned property for inspection patinas. LTER OR ADD TO MECH.
e)agree m save,indemnify and keep hurmless the Ciry of Cupeninn against
liabifi es,jud rat costs, xpenses which may in anyway acerueagainat said City AIR HANDLING UNIT(T'010,000 CFM)
incon a eoR tin his it.
7 0 AIR HANDLING UNIT(OVER low CEM)
ej uture of huanvO or /,Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt p
Will t a applicant or future building nern unt,lore or handle hazardous material
as defined by the Cupert Municipal Code,Chapter 9.12,end the Health and Safe,, HEATING UNIT(OVER 100,o0I)BTU) "TO
Cole,Section 25512(a?
❑Yes VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
Wlllthe applicamorfuwabulldiogoecupumuueyulpmemorileviceswhich emit BOILER-COME(311P OR 100,100 BTU)
hazardous air coram unites as defined by the Bay Area Air Quality Management BOILER-COME(OVER 100,000 BTU)
District? C��sa
❑Yes r NEW RESIDENTIAL.MECH. SQ.FT. %A D
I have read thha
The hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25513 and 25534. 1 undersmnd that JUII 2 g
if the building do•' currently It mnan6lhal it is myrnponsibilitymnosily the 1994
srcupan oft requi menu whi the Puerto issuance of o Cemfiate of
Occupant t v/,
r or amboJagart !Dam U ISSUED B
OFFIC