26925APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPESNO .
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
BUILDING PROJFCTIGENTIFICAI'ION
PERMIT NO.
26925 vJnJ
BUILDING ADDRESS:
SANITARY NO.
APPLIGTION SUBMD,TA�LjDATE
DWVR� NIT. I LOTp
�T
OWNERS NAM PHONE:
CONTRACTOR'S NA E: �.IC NO:
CIL
N/C
CONTROL
L
--1
ARCHITECT/ENGINHER: LIC NO:
ADD ESS:
-I rra-S 7p
CONTACT: PHONE:"'
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G L -
T 8LE(TRIC PERMIT ,y.,i FEE 4
. ;n= ...,z . ,r ry
r
;Z4, d T .� BUILDING PERMIT INFO
LDGPLUMB MECH
PBRMITISSUANCE �+
LICENSED CONTRACTOR'S DECLARATION
Iherehyaffrm that l am licensed under provisions of Chapter 9(commencing with
gppLIANCES-RESIDENTIAL
LOB DESCRIPTION
Section 7")af Division Sof the Business and Professions Code, and my license is in
falleffect.
PANELS
Lic nse Class
License Class Lick
UPT0200AMPS
I
Dam Contractor
MI - 1000 AMPS 0�
ARCHITECTS DECLARATION
1 understand my plans shall be used as public decimals.
OVER 1000AMPS
SQ. FT. FLOOR AREA
f/SQ. FT.
D
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIALCMCUlT/MISC. i
1 hereby M. that I tort exempt from the Contractors License Law for the
TEMP. METER OR POLE !NST.
following reason. (Section 7031.5, Business and Professions Code: My city or county
which rcquircs a permit m conswcL alta, improve. demolish, m ne,m any suuctu
-
prior toiuissrmere..N. requires Jreapplicam for such pers.mflea simadnarament
POWER DEVICES
that he is licensed puuuanl to the provisions of the Convectors License Law (Chapter
9(commencing with Section 7") of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
- VALUATION
or Out he is exempt thcrafromand the basis for the alleged exempt ion. Myvioletion oj
Section 7031.5 by any applicant for a permit subjects the applicanuo s civil peneley
I V
-SWITCFlES-FiX'TlIRES
not Me than oftheve roday,larmyem).
❑ Lmowna.ndthespeny,ormycmployeeswithwagesastheinole campoxness
NBWRESIDBNTIALELECTR _SQ.FT.
STORIES
TYPE CONSTRUCTION
willdothework, offeradl Burin
st
tote
Cdt: Thiscreisnoe.Lieturne
and Code: The Contracors License law
Law not apply lf an owner of
apply to an
orry whiom
progeny whobuildanrimprnves thereon, end whndua each work M1imeelformroughhie
such
wnever,mees,p vementsamneyestrofomo(Pored for salc.l.
-----o—cc .GROUP
RHS. UNI IS
budder, the building
Ing or imosuement is Ne owor-
deat.Fmem is mold within oneyear or
u
huilder will have the burden of proving Nat he did not build m improve for purpose of
improve for
oY8R�'Yq*-'W' d;,r $f 2'wp i� H
QTY.'hLUMBINGPERMITy. ;',kFEB �'
alyl r i 'F. , a..
❑ hmownerofthepropeny,tem licensedc.nwemrtto
FLOOD ZON
APN
exduuvdyconvacting with
mostruel the project (Tec. 7044, Business and PTnfessions Code:) The Condenses
License Lawdaes not applym an ownerofproperty whobuildsmimpmvesthereon,and
PERMIT ISSUANCE
whacommets forsuch projects with acontrumor(s) licensedpursuanttuthe Contractor's
License Low.
❑ 1 em nempt under Sec. , B & P C for this reewn
ALTER EA
( )
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY Y N
RECEIPTN
Owner Dam
DRAWS-ILOOR, ROOF, ARF .CONU.
WORKMAN COMPENSATION DECLARATION
'❑ Ihertby affirm thmihaveaccnificete ofcrosem mulGinsure, ora cenificamaf
Workers'Compensation Insurance or accnifed copy thereof(Sec. 3800, Lab C.) which
SCHOOLTAK Y N
RECEIPTN
FIXTURES-PERTRAP
/
PARK FEE Y N
covers all employee's under thio permit
PoliryY
OAS-RA.S M-IINC.40UTLETS
CEIPTN
BUI IV SIO FEF"
Company
GAS -EA.-OVER4(EA)
PLANCHECK F EE 0
❑ Cenifed copy is hereby fumished.
Y56A6NDUSAC4111l INTF.RCEPI'OR
GRADING FEE
❑ Cenificd copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
pP
SOILS FEE
S Y -STORM EA.
ENERGY FEE
(Thissection decd nalbecompleted ifthe permit is forane handrail dollan(fl00)
or less)
MLECIB
1 certify that in me pdrfmmanee of the work fmwhichthis permit is issued, l shall
not employ any Peron in any manner sec as to become subject to the Worker'
Compensation laws of California. Dere
Applicant
W YSTE EAT!
PAID
Dae ecei d N
NOTICE TO APPLICANT: If, after making this Cmificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cade, you must
P Q. FT.
TOTAL:
forthwith comply with such provisions or this Permit shall be domed revoked.
BUILDING FEE s, --ti
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
CC
1 hereby affirm met then is a construction lending agency for me perfomsnce of
Its, work for which ton permit is issued (Sac. 3097, Civ. C.)
ELECTRIC PBC O
Lenders Name
Lenders Address
I comfy mat I have Rad this application and stem than the above information s
as i'. u
TYa'i'' tr�MECHANICAL
' 3'k N
a* rk to :: --•
PERMIT F a' E',;
hf;or v'w N .i3dri+'d- i a# ...: 24w
PLUMBING FEE L 0
, PERMIT ISSUANCE
MECHANICAL FEE ��
coven. I agree tocomply with all city aM county ordinances and sum laws otafng to
buildingcommuction, and hereby authorize representatives ofthis city toenter upon the
.hove -mentioned progeny for inspection proposes.
ALTMORADDTOMECH. �
CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless the City of Cupectino against
Iiabilitim,judgmens, toss and expenses which may in any way ace me means, said City
AIR HANDLING UNIT ITO 10,000 CFM)
ire 4 deaf the gof this pe
AIR HANDL! NIT( VER 10,000 CFM)
Si tore of Applica t/Ca tm<mr Doe
RXHA HOOD(W/DU
PAID
TING UNIT (TO I00,IXRI BTX)
HAZARDOUS MATERIALS DISCLOSURE
Date Receipt is
Will the applicant or furore building occupant store or handle hvardous materiel
m defined by the Catoctin. Municipal Code, Chapter 9.12, and me Health and Safety
HEATING UNIT (OVC0. ,000
IOTA
Code, Section 25532(a)7
❑ Yes ❑ No
DDA
VENTILATION TINGLE ID)
vi hichemj
Will theapplicantor(uwrabuildingocupantu<iss
OILER- MP�SHPOR 100 BN)
ISSUANCE
U a�
B IL -CO (OVER 1 ," BTU)
hazerdom air cm m orians es defined by the BaManagemcm
t cl7
❑ Yes ❑ Na
A
SEP: 9 1994
DENTIAL CH. SQ. Ff.
I have read the hazardous materials requiretar 6, of he
Califnnio Health& So Code,Sections25505, 2n ss dthn
if the building dorm currently have amaem, thmonly
I) r IINU
CITY Vr
_
tit of the requir mems which must Fa met ptate o
=
Ocup
ccapancy.
ISSUED BY:
Ownermamhorimdagent - Dare
TO
,"OFFICE