25280 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C PTY OF CUPERTINOt 1 II.11� )�,-61.MA'RICAI. PERMIT NO.
APPLICATION/PERMIT - PLUMBING-MECHANICAL. 25280
BUILDING DIVISION BUILDING PR(1JF.C'IADEN'FIPIC.A'1'[ON
BUILDING ADDRESS: a f ��//�� ' /s P SANITARY NO. APPLICATION SUBMITTAL DATE
y l 'br I V V UNIT# LOTH ##
R. NAME: s, /f P{ _ CONTRACTOR'S NAME: LIC NO:
w lW 1 I,w0.,.1 ' CONTRACTORS
NIC CON TROLp
CNITECI'/INGINECR: - LICNO: A S: - ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE RUIf:DING PERMIT INFO
ftLDG 'L PLUMB MECH
PERMIT ISSUANCE `ILC/N,.
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DFSCRI N
p00 IM170h),I'Dithml 3 rufansedinss and isionsmfCChade,add
mmecense with � -
sWEy]❑ Swwiorce itl of Divisinnlof the Bulinus and Ro(essions Code,enJ my license is in PANELS
<UU fall fmneanudTed.
F6zly License Clave Lic.# UP T0200AMP5
a Dam Comme 201.["AMPS
yz ARCHI'IRCTS DECLARATION
ZOv,� OVER 1000 AMPS ^ IISOLQCI7ARCJ S/SQ.PI'.
07^0 IundcrsmnJ my pions shall he ueetlupublic records. In U \ `I �I 1
SIGNS ELECTRICAL
6 �, Licensed Professional
Eiw< OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
Oa V hereby affirth Se 0taw I am exempt(mow the Contractor's License Law co the ��� x� /�
31+-y
following toco31.5.Busiteanndwe.demolish.
Code:Any city or county TEMP.METER OR POLL'INST. t Z iwg
S >-; which sequins u permit to nam,th t,ulteq improve,demolish,or repair any sainthood _
W rC) that hor esliensed ,rsunquires@revision for such the Co pcnniuofile a Licens Law(Chapter
POWER DEVICES _
<p that he is licensed pursuant to provision al the Comnmror's License f.aw(Chepmr SWIMMING POOL ELECT RIC
p,o,oK 9(commencingwithSection7")ofDivision3ofheBusinesslandProfesaionsCode) VALUKIWp
millet bets exempt wherefromand thebuisforthe alleged exemption.Any violationof OUT LITS-SWITCHES-FIXTURIN 2we
GSection 7031.5 by any applicant for it permit subjects the appliennnooeivil pemtby of
� mno( then fiveh.ndrcd dollarn(5508). NEW RESIDENTIAL ELECTR _SQ.FT. STORIES TYPE.CONSTRUCTION
Lasownerofthepropery,mmyemployeeswithwagesuthci...lecompareadmn,
y do ework,aadthestmcmreisnotimendeJ mroffertd(tarsale(Sec.7o44,Business
w d Professions Cade:The Contractor's License Law dives not apply to an owner of
propcny Man builds or improves thereon,and whudces such work himselforthmughhis
cmployeee,provideJthat such improvetrxnueme not innandedmof&rtdfor sale.If, I OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one yearofcompletion,themwner- T( A
builder will have the hunlen of proving that he did not build or improve fm purpose of
le.).
❑ I,uowner ofthe pmpenY.amexdusivelyconmcwing withlianudcontmaorswa QTY. PLUMBING PERMIT FEE FLOOD ZONE AI'N
smnsuuet the project(See,70M,Business and Professions Code:)The Counselor's `.
Licemaae Law dues not apply as an o,werofpnspcny who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with aconbamogs)licensed pusauanuu the Conlmeamor ACI1iR-DRAIN&VP.NT-WATGR(FA)
License Lew. FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE IDE� b
SANITARY YN
yj Owner Date RECEIPT#
GOND
AREA
ROOF, , .
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOL TAX Y N
❑ Ihcreby aflirm thm lhevea cenifwmofamsem wo self-i ns.rc,oraceni0camof RECEIPT#
Workers'Compensation Insurance or a certified copy whercof(Sec.3800,Lab C.)which FlXTURFS-I'ER TRAP r� PARK FEE Y - N
covers all employ"a under this pernit. GAS-P.A.SYMM-I INC.4 OUTLETS RECEIPT#
'-- Policy BUILDING DIVISION FRES
Cnmpan, GAS-EA.SYS'ITM-OVER 4(EA) PLANCHECK FEE
\� ❑ Cenifiedeopyisheraby Pomished.
❑ Cenifedeopyis filed with the city inspection division. GREASEIINDUSTRL WASTE INTERCEPTOR GRADING FEF.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEC
COMPENSATION INSURANCE
(This sactionnceA out be completed ifthe permit is forenehundred dollar($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I counlythat in the perfmmanceof the work far which this .I,is issued,l ahall WATER HEATER W/VF.NT/ELECI'R
—_ nm employ my person in any mummer so as to become subject to the Workers' PAID
Compensation Lewsof Culifmstiu. Dare WATER SYSTEM/1REATING pate Receipt#
p z Applicant
Z NOTICE TO APPLICANT:If,after making this Ceniftcate of Exemption.you should NIiW RESIDENTIAL PLMB. SQ.Ff. TOTAL:
U) become subject o the Warkels Compensation provisions of the Labor Code,you must
� ? forthwith comply with such provisions orchis pemtiw shall bo mL
deeed invoked. BUILDING FEE
0. ra CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
7 z I hereby affirm that them is a construction lending agency for the perrommnee of
L) the work for which this permit is issued(See.3097.Civ.C.) T ELECTRIC FEE
CT. it Lcndcr's Nmnc a PLUMBING FBE
O U finder's Address QTY. MECHANICAL PERMIT FEL.
asasass
I anify dam 1 have mad this applicmion and sate that the above infmrandon is
�-' Da comet. l agree to comply with all city and county ordinances and state laws relating to PERM IT ISSUANCEMECHANICAL FF.E
building construction,and hereby oulhonze representatives of this city to enter open the CONSTRUCTION TAX
V 2 abo.e-mentioned propcny for inspection pumpman. ALTER OR ADD TO MECIL
(We)ware to save,indemnify and keep husmlen the City of Cupenino agailan
linbilitie 'u ents.c un #peneswhichmayinan ey accrue sins sxidCiry AIR HANDLING UNIT('fD IQOIXICYM7
inam ec dth m'
/ AIR HANDLING UNIT(OVER 10,00)CPM)
Signuwm mCApplicanVConvucmr (� Date EXHAUST HOOD(W/DUCI)
PALO
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT('10 IM."BTU) Dam Receipt#
Will the applicant Min building xcupam stem or handle hazardous mateeW
sea defied by the Cucninpinn Municipal Code,chapter 9.12,enJ the Health and Safety HEATING UNI'!(OVER IIXI,BfI(1 B'I'll) TOTAL:
C:Wr,Section 25532(a)'1
❑Yet, ❑No VENTILATION FAN(SINGLE RESID)
Will the upplicumorl'murcbuilJingmccupem uttequlpmentor dcvitts whichemit
BOILER-COMP Ship OR IIIQWRIITU) A EDATL•
hazardous air confirmation u defined by the Bay Area Air Quality Management BOILER:COMP(OVER 100.000 BTU)
JUL = 6 1993
12 Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have read the hazardous rtwled.[,requinmems under Chapter 6.95 of the 0D Uh wreh I IIV
California health&Safety Code,Section 25503.25533 and 25534. l understand that
if the building does not cuncally have a narrow,that it is my responsibility to notify the
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy. ''\''�\./�.�j�/�\/
Ownnraloolvinaed agent Data TOTAL: ISSUED BY: Vll�1
OFFICE