26376 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINON IIAING-F.I.ECPRICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL. 26376
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BUILDING DIVISION BUILDINGPROJECI'IDENTIFICATION G
BUILDING ADDRESS: Q` 1 SANITARY NO. "PLICATION SUBMITTAL D 'lti
UNIT# LOT 1_7�
OWNERS NAME. PI NHcc:<< CONTRACTOR'S NAME:
C -fes LIC NO: Nln�/C
V ZY-T Gt,�a..1"1 + WCJ r 2• L-Ip G'�{ C(JN'I'ftOL#
RCIIITIiC17ENGINF.HR: LC NO: ADDRESS:
E To SG o No S
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MECII
IE ,5^0 _ PERMIT ISSUANCE 11 130
LICENSED CONTRACTOR'S UEC RATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
M«Z Ihamm,alfirmtltntlum licensed underpmvisiansafChapter9(commencing with
8100 Section 700BOODivision 3ofibe Bunsaida,vand ProfessioCodemad my liana is in PANELS
<u�
Franram<ana
QZm <t 4235 c Z UP T0200 AMPS
NQ6 Ilalc_.S jrZ 1ECI Contractor -N 401-IIXq AMPS
F y'L ARCI II'18GI"S UECIARATION SP PI.Il0(lR AREA SISQ,11.
ZON— OVER[BOX)
O Z_❑ 1 understand my plans shall be used as public records. f<
r_Fad SIGNS ELECTRIC L 11\1 5� Licensed Professional
IIQ OWNER-BUILDER DECLARATION SPECIAL CIRCUI TSC T,�
Ouyu I hereby talon that 1 am exempt from the Contractors Licanso Law for the V ITL��
tai Oto following rtasse.(Section 0031.5,Business and Professions Code:Any city or county TEMP.METER OR POI-1: rl'.
RO G which requires a permit in construct,Weer.improve,demolish,or repair any smuctum .a
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prior o i¢issuanec.alsomquims the applicantfor such Permitto file a signed statement POWER DEVICESDATE
J
tX that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter SWIMMING POOL G—
mqX e 9(ammmcncivgwitM1 Sadan7W01of Division 3nOheBmmess end Pro(eseiOnsCMy SWITCHES
ETS- - VN.0 ON
WMoo or that he is exempttherefrom and the basis for the alleged exemption.Any violation of d O D�
FN
la Section 7031.5 by any applicant for a Permit subjects e spite..,..civil pcnahy of OUT_ FIXTURES
not mom than five hundred dollars(5500).
ftp NEW RESIDENTIAL ELECfR SQ.FT. STORIES l'YPF:CONSTRUCUON
IiCIiIIFpo [I olhewncmfthim,amny,or m ma
Small,((Sec.
compensation,
will Pr N<worea ande The daardeld intendede Lawdue, ot.,Iaadono ser of
and Professions Cade The Comructor's License Law does not uPPIY to an owner of
property who builds or improves thereon,and who does such work himialfor flrough his
employms.providca thatsuchimprovements are not intended oroffered forsale.If.
OCC.GROUP RFS.UNITS
h,amegthe buildingor improvement is sold within one yearofcnmpletion,the owner- TOTAL:
builder will have the tnodm of proving that he did not build or improve for purpose of
sale). QTY. PLUMBING PERMIT FEE
C] I,uaawnn of the pmpmy,am exclusivdymmrading wird licenxd canwn0rsm Iq.000 ZONE ANN
construct the project(Sec.704,1,Business and Professions Cale:)The Contractor's
License Lawdoesnor apply roan owncrofpropeny who builds orimproves therms,and PERMIT ISSUANCE
whocommns forsuch projects with u wmracmns)licensed pamaam mthe Commmors
License Law. ALTER-DRAIN&VENT-WATER IBM 17iE SUMMARY
❑ [am exempt under Sec. .B&P C for Nis teason BACK FLOW PROTECT.DEVICE O Il IDE EEGs
SANITARY Y N
• Owner Doc DRAINS-FLOOR,ROOF,AREA,COND. ftECE1P1'p
WORKMAN COMPENSATIONrctteDECLAif-ins ON SCIIOOL'1'A% Y N
❑ ers'CoI hereby af0rmoJim lhave
rance or.mimevc ,thad.of(Saure,0r Lab C.)c which
FIXTURES-PER TRAP RECEIPI'p
Workers' Insutianlnsurencea it. copy Nereof(Sec.Jg00.LabCJwhich PARK FEE Y N
covers II c plo c k I Ibis r. RECEIPOp
Pn��ISf`'�"' GAS-EA.SYSTEM-I INC.40UTLETS BUILDING DIVISION MES
Palmy p 1 33 'l1 SCJ
El Certified
TpTF — �NCu0. CE 'JND GAS-F.A.SYSTEM-OVER4(EA) PLANCIIECK FEF.
❑ Certified copy is herebyfiled.inte famished.
,.EL Certified copy is file)with the city inspection division. GRFASFJINDUSTRL WASTE INTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF.TRAP SOILS RAE
COMPENSATION INSURANCE
OUnk&ection need not be completed ifthe vendit is!afore hundred dollar,S 100) SEWER-SANITARY-STORM EA.200Ie1'. ENERGY FEE
or less.)
I certify that in the performance offle work for which this Permit is issued,I shall WATER HEATER W/VFNTIELECIR
not employ any person in any manner so as to become subject to the Worhas" PAID
Compcnsaimal.awsof Califomia. Dae WATER SYS'TEMITREATING Date Receipt
0 C) Applicant
Z � NOTICE TO APPLICANT:If,after making his Certificate of Exemption,you should NEW RE SI DENTIAL PLMB. SQ.FT. 9'OTAL:
W) become subject to the Worker's ComPemafion provisions of rhe Labor Code.you matt
a >
f,;ohwiih comply with such Provisions or this Permit shall he deemed idevoked. BUILDING FEE 7,00
Q CONSTRUCTION LENDING AGENCY SEISMICFEE s�
1 hertby affirm that there is a construction lensing agency for the performance of
,7 � TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
Lgnder's Name PLUMBING FEE
L4 F Lerh,ra Address QTY. MECHANICAL PERMIT FEE
U I certify that I have read this application and state that the above information is MECHANICAL FEE
come,.I agree to comply with all city and county ordinances and&rate laws misting to PERMIT ISSUANCE
F-' buildingconstrvction.and hereby authorire mpreantatives ofthisciry roenter upon the CONSTRUCTION TAX
U z aWve-mentioned propcny for inspection purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupeniim against
liabilities,judgments,costs and expenses which may in any way accrue against said City AIR HANDLING UNI'I'('1010,001 CPM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.001 CFM)
Signature of ApplicuMContracmr Date EXHAUST HOOD(W)UC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 1011.01)BTU) Date Receipt#
Willrhe applicant err future building occupard store or handle harardous mmeriW
as refined bythc Catania Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW.000 BTU) TOTAL: 1
Cale,Section 25532(al'I VENTILATION FAN(SINGLE-RESID)
CI Yea ❑No
ISSUANCE DATE
BOILER-COMP(3HPOR IM."BTIJ)
Will rain conundrums
s a defined by dre ay Am Amen Quality
,Y9 YJ
hazadaus air comuminants as defined by Ne Bay Area Air Quality Management BOILER-COMP()VER I010,000 BTU)
Diwricfl
El Yes ❑No NEW RESIDENTIAL MECII. SQ.FT, PLAY 18`a 1.'I[�(�/�
794
1 have mead the havardous metrial,rev doma<nm under Chapter 6.95 of the
California Health&Safety Cale,Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a mount.that'it is my responsibility to notify the CI1Y Or wrrnnnU
occupant of the requirements which must Yz met prior to issuance of a CeniOwm of
Occupancy. _I `.
Owner or amhorired agent Dare TOTAL: ISSUED BY: V '
OFFICE