26603APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINOR ILOIC.NIP..I.MMICA.
BUILDING DIVISION APPLICATION/PERMIT - 'LUMBLN. MECHANICAL
BUILDING PROJECI'IDEN'TIPICA DUN
PERMIT NO.
26603
HUILDINGADDRr:SS:
SANITARY NO.
APPLICATION SUBMTUAL DAIS
,/1
20/7/ �v��V .UNIT#' LOTH
6—I
OWNERS NAMIi: PHONI?:
<IJ—.&J_7r VA
CO ACfOR'S NA ME: LIC N�J��
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NIC
❑
CONTROL#
ARCHI'I:CT NGINEER: LIC NO:
AD RESS; /I� �_r
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CONT/�/(',f /yy �7 PHONE:
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QTY, ELECTRIC P13RMIT FEE
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
F-1 ❑ ❑
LICENSED CONTRACT'OR'S DECLARA'GO
IherebyafOnn that l um licensed undwpmvisiwso hepm (commen0i21`th
APPLIANCES - RESIDENTIAL
JORDESCRIPTION
o
Semon 7") of Divisinnlof Ne Bwormssand Profess' reC end mylirertu is in
PANELS
full forte anJ fee
.Zoll. Cl s_,.._ Liv.
UP T02W AMPS
p�
a/�
Dam Coalmdor
HHF.CTS DIiCLA TION
I undemwnA my plans shall Mt used os publio recnNs.
201 - IOW AMPS
OVER 1000 AMPS
SQ. IT. Fi00k AREA
ErsQ. m'.
_
SIGNS ELECTRICAL ft
Licensed l4ufeasinnal OWNER -BUILDER DECLARATION
SPECIAL CIRCUMMISC.
I hereby affrm Nut I we exempt from the Contractors License Lew for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
III sLJ' II 11
UT p q�
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TEMP. MEIIER OR POLE MST. (, )
which requires a permit to comtma, alter, improve, demolish, or structureYeir any structure
prior In its Issuance, also requires the applicant for such permitto file a signed stomment
/ IV j
<_4J
POWER DEVICES t
that he is licensed pursuant o the provisions of the Contractors License law (Chapter
9(omormncing with Section 700jo of Division 3 of the Husinees it Professions Code)
(,'
SWIMMING FOOL ELECTRIC
TI
or Dal he is exemptlhernlmm and the basis for lheillcgcd exmasion.Any, violation of
Section 7031 S by any applicant for u permit subjects the applicant to a civil penalty of
pUl'LETS-SWITCHES-FIXTURES
not mom than five hundred d011ars(SSW). ownerrt
❑ I,, of the propey, ormy employees with wagesas their sole compensation,
NEWRESIDF.NTIALELECTR _SQ.FT.
STORIES
TYPE CONSTRUCTION
.
will dothe work, and the structure is not intended oreffered forsale(Sec. 7045, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds nr improves thereon, and who does ouch work himself or through hia
own employees, provided that such improvements we not intended droffemd forsale.If,
OCC. GROUT'
RES. UNITS
TOTAL:
however the buildingor improvement is sold within one year ofcompledon, theowner
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT YEE
sale.).
❑ I, mowner oftheproperty, am exclusively contracting with licensed convactors to
FLOOD ZONE -
APN
onsuucr the project (Sec. 7044, Business and Professions Code:1 The Contractor's
License Law docs not apply m an .wow fpolitay who builds in improves thereon, and
PERMIT ISSUANCE
who contracts for such projects with a emorn or(s) licensed pursuantto the Contractors
Llceoae Law.
pCITft- DRAIN&VIiNT - WATER (FA)
FEE SUMMARY
❑ I am exempt under Sec. , B & PC for this reason
BACK FLOW PROTECT. DEVICE-
ISID: FEES
SANITARY Y N
RECEIPTp
Owner Data
DRAINS-Ff.00R,RIDGE, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N
❑ Thereby ulfrm lhmlhaventtnificate of consent mself-in tere,oracwtifirmcrif.
Wwmri Compenmltoo lrourance Ora ceriftedcmpy theuof(Sec. 3800. Lab C.) which
FIX'T'URES - PER TRAP
RBCHIPTN
PARK FEE Y N
covers all employee's under this permit.
Poliy p
GAS - EA. SYSTEM -I INC. 4 OUTLETS
RECE:IP `#
BUILDING DIVISION FEES
Company
❑ Carolled copy is hereby famished.
Rrl Certified copy is filed with thecity inspection division.
T
GAS - EA. SYSTEM OVER 4IPA)
PLANCHECK ITE
GREASFONDUSTRI. WASTE INTERCEPTOR
GRADING FEE ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
GRFASETRAP
SOILS FEE
COMPENSATION INSURANCE
SEWER- SANITARY- STORM PA. 20017.
ENERGY FEE -
(This section need not be completed ifthe permit is foronehunlral dollars I$I W)
orless.)
WATER HFATER WNENTIELECTR
I certify that in me performance of the work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Workers
PAID
WATER SYSTEM/IREATING
Comperfstionlawsof California. Date
pate Ruciptp '
Applicant
NOTICE TO APPLICANT If, after making this Ceni ficate of Exemption, you should
NEW RESIDENTIAL PLMB. SQ, FL
TOTAL:
become subject m the Workers Compensation provisions of the Labor Code, you most
forthwith comply with such Provisions or this permit shall be deemed residual.
BUILDING TEF.
SEISMIC FE17
CONSTRUCTION LENDING AGENCY
1 hereby affirm thn there is a construction lending agency far the performance of
the work for which this permit is issued (Sec, 3097, Civ. C.)
ELECTRIC FEE
Lender's Nome
Lenders Address
QTY. MECHANICAL PERMIT FEF.
PLUMBING FEE
1 certify that 1 have mad this application and state that the above interactive is
t. Ing ematmpdy with ell cityandanntyw inamces and state laws relmingm
PERMIT ISSUANCE
MECHANICAL FEE
buildingco hnmian, and harebysuthiurmoves of this citymrnmrupon the
abovement 'reit proper for inspection purposes. inxs.
ALTER OR ADU TO M[CH.
CONSTRUCTIONTAX
(We) gine In sav indemnify an p hamtless the City of Cuperroo against
liahilitics,j dgmcnts,a sued expense ich may in any way ucaeallmnst said City
AIR HANDLING UNI 'I'(TO I0jw0 CFM)
n.qu race d he g orating of this it.
ATR HANDLING UNIT (OVER BLOM CFM)
sign at JmTrApplican ontmcmr t Dare
EXHAUST HOOD(W/DUC)
PAID
HEATING UNIT (To IOQWO BTU)
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt It
HEATING UNIT (OVER I00.0W BTU)
TAL:
Willthc applicant or fumm building occupant smmor handle hazardous nmterial
as defined Fyffe Cupcnino Municipal Calc, Chapter 9.12, and the Health and Safer,
VENTILATION PAN (SINGLE RESID)
Code, Samlon a)1 -
11Y,t, No
Ycs
BOILER - COMP (31IP OR 100,000 BTU)
ISSUANCE PATHWill
the nppl icam or future huilAing Occupant use eyulpmem or dev Ices wM1ich emit
BOILER-COME(OVER 100,000 BTU)
hazardous air contaminant defined,NTIby the Bay Area Air Quality Management
District
❑Yes o
f D
PAID p'7
NEW RESIDGAh MECH.—SQ.IT,
1 ha c mad the limardeas metriials requiremems under Chapter 6.95 of the
���
Califomi Health & S !cry Code, S tions 25505, 25533 and 25534. 1 undersmod that
ifthebuil ingdoesn t emrtnlly ]rules moral, that it is my responsibility to noddy the
Occo m f the qu emrnts wbir must be met prior to issuance of a Cenificme of
28
7 (�
C%/'�. ` 19,,94
ISSUI:DBY:
Owner nr uthndzul eBcmDust,
TOTAL:
OFFICE