25628 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
R 1 .- . AL. PERMIT NO.
CITY OF CUPVISION PLUMBING
PROD•MECHANICAL
BUILDING DMSION APPLICATION/PERMIT BUILDING PaaecrlDENTTFICA'noN
BUILDING ADDRESSS�� SANITARY NO. APPLICATIOINSUBMITTIALLD�ATE
LOT ^La Y/
OWN 'NAME: PHONE: CO A OR'S NAME LIC O:
.}� 2� N/ CONTROL#
CHI /EN INEEIR LIC A ❑
6`r G3 �2 SS9Y �jR.lre�t pee hinted
ONTACT: PHONE: If BUILDING PERMIT INFO
QT ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECH
i PERMIT ISSUANCE � ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
yy I hereby affirm that lam licensed underprovisionsof Chapter9(commencing with2DESCRI ON
�i100 force and affect.
facton 3 of the Business and Professions Code,and my license is in PANELS
fail
i FZty License Class Lie.is UP T0200AMP5
m D oo Dom Comrucmr 2(11-1000 AMPS SQ.FT.FLOOR AREA $JSQ.PT.
ZONZ ARCHITECTS DECLARATION OVER I"AMPS
O Z I understand my plans shall be used as public records. r n
F� t�i SIGNS ELECTRICAL. ^� n. r, � �
2 Licensed Professional
y d'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. R
BTU U I hereby aff an that I son exempt from the Contractor's License Law for the 0 ,J
1�3aa following mason.(Semlon7031.5.Business and Professions Code:Any city or county TEMP.SISTER OR POLE INST, l�
l
C'.J which respires a Permit an conswn,niter,improve,demolish,or repair any structure
YN priorto its issuance,alsorequires the applicant for such Permit file a signed statement POWER DEVICES
<p that he is licensed pursuant to the Provisions of rho Contractor's License Law(Chapter DATFM
❑ tionandProSWIMMING POOL ELECTRIC
aL�de 9t that
heneingwit tSecfromandthe Imision3of theedNuaexesstio.Any ism Code) VALUATION
W_$c- orthn h7031.5 by my
mnt for
Perist sbjetsmedexempt,to civil naft,af
CaSection]031.5 by any applicant furapennit subjects me epplicannoacivil penalty of OUTLETS-gWRCHFS-FI%TURES
G more duan five hundred dollars($500).
n❑ I,asownerofthepropcny.ormyemployeeswithwngauNeirsolecampemadon, NBW RESIDENTIALELEtTR _SQ.FT. STORIES TYPE CONSTRUCTION
6'3� win da mewons and the he Con isnot is LMedora w does not apply t owner
of
tint Professions Code:The Connector's License Lew does not apply m an owner of
prepary who buildsorimpmvmthcmon,.hdwhodoessuch work himealforthroughhis OCC.GROUP RES.UNITS
wnemploy«s,pmvidedt Isuchimpmvemm,sareaotinlendedoroffe forule.If,
however the building or improvement is sold within oneyearefcompledon,the owner- TOTAL:
builder will have the burden of pmving that he did not build or improve for purpose of
are.). QTY. PLUMBINGPERMIT FEE
El Lanwnttof the propeny,em exdusivelyconwcting with licenudcontrnnnrs to ------FLOODZONE APN
construct the project(Sec.](144,Business sad Professions Cade:)The Contractor's
License Lawdcasnm apply toahownttofpropady whobuildsorimproves mamma,and PERMIT ISSUANCE
whoconuacnforsuch projects with aconaamegs)licensed puramen mthe Contmnaea EA ALTER-DRAIN&VENT-WATER
License Law. (EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason ETM
BACK FLOW PROTECT.DEVICE D
SANITARY Y N
Owner Dau DRAINS-FLOORROOFAREACOND. RECEIPT#
, , , .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I hereby sffirnthat l have a esmificete f..t to uff-meam.ma cenificau of FIXTURES-PER TRAP RECEIPT#
tithe'Compensation because.oracmified copy mereaf(Sec.3800,Lab C.)which PARK ME Y N
covers all employee'a under this permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT#
Policy X BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4 GIA) PLANCHECK FEE
❑ Codified copy is hereby furnished.
❑ Certilied copy is filed with the city Inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE,
(This section need not becemp[aed ifthe permit is for one hundred dollari($Ban SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I codify that in the perfvanmse of the work for which this permit is issued,l shall WATER HEATER WNENTIELECIR
not employ tiny person in any mother so a to become subject to the Workers' PAID
Compenaationl-awsaf California. Date ATE 9TiSMEATING Date Receipt
O z Applicant
z O NOTICE TO APPLICANT:If,moa,making this Certificate of Exempma,you. IDENT{AL PLMB. SQ.PT. TOTAL:
f+ In become subject to the Worker's Compensation provisions of the Labor Cade,you must
7 forthwith comply with such provisions or this permit"I be deamM revoked. BUILDING FEE
Lr.I Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z 1 hereby affirm that Nese is a construction lending agency for the performance of T ELECTRIC FEF.
L) O the work far which this pamdt is issued(Sec.3097.Civ.C.)
LT. lander'.Name PLUMBING PER �
t" Landes Address QTY, MECHANICAL PERMIT FEE
LVI cedify met I have read this application and state that the above infomntion is MECHANICAL.FEE
a correct.I agree to comply with all city and county ordinances and stale laws relating to PERMIT ISSUANCE
_u Z building construction,and hereby authticarepreaentatives ofthis city[center upon the CONSTRUCTIONTAX
above-mentioned property for inspection puryoses. ALTER OR ADD TO MECH.
(We)agra to save,indemnify and keep harmless the City of CLperm,against
liubilines,judgme t,cosuuhd expense,whi may many way.remeogainat said City AIRHANDLINGUNIT(T010,00CFM)
in cornu he do ofm' it
once O^ _ 10.000X� AIR HANDLING UNIT 10.OCFM)
S' nes am of Applicti Conueno Data J EXHAUST HOOD(WIDUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,010 BTU) Data Receipt#
Will the appllcam or future building occu,.t store or hour[.hazardous mmedal HEATING UNIT(OVER 100.000 BTD) TOTAL:
a defined by the Cupertino th e
Municipal Cade,Chapter 9.12,and me Beside Safety
Code,Saction 25532(x)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will the apPlicamorfutmebuildingaaupsim useacuipmentordeviceewhichemit BOILER-COMP(3HP OR 100,00)BTU)
Jklmandous air conaminenu as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,010 BTU)
mcd?
❑Yes ❑No NEW RESIDLNTIAL M[CH. SQ.Ff. pp
1 have read the haamduus materials mquimments under Chapter 6.95 of the P A B
if the uil Hearth&Safety Code,have
Roper,
per,m 25533 and 25534.1 understand that
if the building dna not ommacurrently have a must
be, met d is my reserse of. m notify me OCT 12
occupant of the reyuircmema which must be at prior m issuonce of a Certifcme of
OccuPtincy.
Own,.,amhorixd agent Data TOTAL: W'PP�DU
OFFICE