25183 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C[JPERTINO NG-ELE - PERMITNO,
BUILDINGDIVISION APPLICATION/PERMIT PLUMBING"
-MECHANICAL /�5 ag /11�
BUILDING.PR(1361C1'IDRNT'IF'ICAIION G J 1 a 3
I 0ADDRESS: SANITARY NO. /A/PP�LICCAAIION SUBMITTAL DATE
NIS 5
'�✓ �I��YMFT# LOT# VJ l
I?: PHONE:
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N/C CONTROL#
fI1TEC1'/INGINEER: LIC NO: DQRRSSjz
CONTACT: PHONE: ala ❑
QTY, ELECTRIC PERMiT FEE BUILDING PERMIT INFO
Z Q BL ELECT U MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION 11APPLIANCES-RESIDENTIAL
❑0Z, Ihereby.fGrmthm l amlicensedin,,and isioelic Chapter and license
with LOB DESCRIPTIOyyy
ts100 Section fOr 70001 of Division 3 of the Businev and Professions Code,end my license is in PANEL
F��jj- full fu¢a and effect / 11"
FZw Lt...Class Lic.0 UP TO 200 AMPS
m=y Dam Convector 201-I"AMPS
ZOvvss ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA g/SQ.Ff.
ON F 0 1 understand my plans shall be used as public records.
�+y
SIGNS ELECTRICAL
yea 1.1c."..Prnfcssnonal
S' OWNER-BUILDER DECLARATION SPECIALCIRCunivilSC.
01 0 d F
hereby Offer Nm at I aexempt from the Convectors License Law for the
Ow¢ fellow ing reagin r.(Section 7031.5,Business and Infins.n.Code:Any city ur county TEMP.METER OR POLE MST.
ti J which requires a pe.it m con," ,.,an,improve,demolish,or report any structure
foeQ� For ortonsissuance,also requites the applicant(orsuch permit file a signed statement POWER DEVICES
00z that he is licensed ptm uam m the provisions of the Commulnex License law(Chapter
XeLL 9(commercial with Said..T(100)of Division 3 ofthe Business and Professimu Cade) SWIMMW PO 1q, N
W—Z.rte or that he is exempt therefrom and the basis forthe alleged exemption.Any violation of VpIAp/c9t1y�
Sa
Section]031.5 by eny.p,licam I.,. .it subjects theapplicanno a civil Penalty of OUTLETS-SWI HES t-FIXTURES ��
nm more than five hundred dollars($500).
y3tCFm ❑ Lasownerofthepm mr,,ormyemploymswith wegaes theinolecompense0on, NEW RFSID ELECTR �t tt Sa,jp, I I STORIES TYPE CONSTRUCf10
— willAn the work,and the structure is not imendedoroffered forsale(Sec.]0a4,Business
and Pmfessions Code:The Contractor's License law does not apply to on owner of
pmpanywhobaddsorimproves Narmn.and windier,such workhimselforthough his �jIL
own employees,prnvidnithatsuch improvements are
Is.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyear of ecmpledon.the owner- '
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
sale.).
❑ 1.asownerofthepropeny,amexclusivelycontractingwithlicedsedcontnctoram QTY. PLUMBING PERMIT FEE FLOODZONE "N
mLamn the project(Sec.7W,Business and Professions Code:)The Cmdoserne.
License Law does not applym an ewnerofpropeny who builds or improves thereon,end PERMIT ISSUANCE
wM10 contmeta for such pmjecta with a contrmt ul licensed pursuant m the Castleman,
License law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this mason
BACK FLOW PROTECT.DEVICE. )UTSIDIR FEES
OwnerDom SANITARY VN_
adIftwooliss— WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
I hereby uffinn thu'�heveacenificem ofconsem to self-insure.ora rcnifiam of SCHOOL TAX YN_
mkers'Cmr,' nitlsomer-ir ttniftedcnpythanif(See.380),1ab C.)which FIXTURES TRAP R[CEIPI'#
.\.. covers all employ u6A666r p's it PARK FEE Y_N__
Policy# GAS-EA.SYSTEM.]INC.4 OU METS RECEIPT#
Cam any BUILDING DIVISION F[LS
Conifi opy ie hereb furnished. GAS-EA.SYSTEM-OVER4EA7
❑ CcrY dco Y PfANCHECK FEE
py is filed with the city inspection division. GREASE/INDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS ECF:
COMPENSATION INSURANCE
(This aectionnecd not be completed lithe Permit is for one hundred dollers(SI00) SEWER-SANITARY-STORM EA.200FU ENERGY FEE
Inst
I certify that in the partormarceofthe work for which this permit is i...idjshell WATER HEATER W/VENT/ELECTR
not employ any person in any manner w m ro become eubion ro the Workers' PAID
z Compensationlawsof Califrmia. Date WATER SYS'IT;MMEATING
Applicant Dam Receiptp
z NOTICE TO APPLICANT:If,eller making this Condition of Exemption,you should NEW RESIDENTIAL PIAB. SQ.FT.
C� (� become subject m the Workers Compensation provisions of the Labor Code, TOTAL:
L� fnMwith comply with You nun
� 7 p Y wi provisions or this permit dtall be deemed revoked.
_ BUILDING FEE �•
GI-I CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is a construction lending agency for the performance of
V O the work for which this permit is issued(Sec.309],Civ.C.) ELECTRIC FEE
0 U Lender's Name
Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
1 ccnify that 1 have mad 1Ns application end sate that the above mformedon is
correct.l agree to comply with all city and county anointment;and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
Vj building construction,and hereby uuthon7a reprerentativesofthis city to enter upon the
L.) Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
(We)ague m save,indemnify and keep harmless the City of Cupenioo against
liabilities,jud nts,conts en xpecaes which may in any wey eccmia,ainsl avid City AIR HANDLING UNI3'(1.0 RJDI0 CFM)
is onsequ h Bmn' (this petmit.
AIR HANDLING UNIT(OVER IgauB CFM)
Sig. a of cont/Codown, D EXHAUST HOLD(W/DUCD
P/ PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW.000 BTU) Date Receiptp
Will the applicant or future building occupant store or handle haaardous material
as defined bytheCupenina Municipal Code,Chapter 9.12,add the Health and Safety HEATING UNIT(OVER IW,"BTU) T AL.
Code,Section 25532(.)]
❑Yes 11 No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100,"BTU) ISSUANCE DATE
Will air imicam curs as de Wing by the
Ana Air rJeviceawhichemit P A ID
areNous air mntarNnenta as defined by the BaY Arte Air Quality Management BOILER-
smict] COMP(OVER 100,000 BTII)
❑ad ❑No NEW RESIDENTIAL MECH. SQ.FT. fl((((AI ®9' 1993
1 have read the Safety
o e.mations requirements under Chapter understand
of the Y/lj(I
California Health&Safay Cade,Sections 25505,2553)and 25534. 1 understand that ! y
if the building does not currently have a tenant,that it is my nsponsibility to notify the 1� uf,
eecupant Of the requinmcros which must Iso met prior to issuance of a Certificate of V�I.r
to I fly
Owner or auton
heed agent Date TOTAL: ISSUED BY'I—=N-�