27438 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMBING" u-'IEM- 'LuI RICAL PEMITNO.
MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT IU11U1NGPROJKC1IDENTIFICATION
27438
B II IL/y1 poU��INGADDHE55: SANITARY NO. APSUBMITTAL
A91i
mUNIT# LOT or
OWNERS NAME,: PHONE: CON7RACI'OR'S NAME: LIC NO: NIC CONROLa
L So
JL
RCHI I EC'UhNGINELIC NOt
0Q lyl cz_
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PLUMB MECH
� PERMIT'ISSUANCE El 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
awz Ihcrcb,.Ir,.thatlamliccnudunJcrprovisiona of Chapmr9(c.mmcncingwith R�/l Ca.ir [, h:M n'C � Y�Q�
WCC Seclion)000)of Division 3ofthc Business and Profession:Cale,and cry license is in PANELS 1f-
qW .. full hnca.mdrfl y,�) c�/f 2 �(
F'd License Cl.sa�L Lic.p ��� > 1'� UP TO 200 AMPS �tt yl-e U
m?ti Dme Conmacmr 201-1000 AMPS SQ.FT.FLOOR AR S/SQ.FT.
709E ARCHITECTS DECLARATION OVER 1000 AMPS
I enders and my plans shall be.sed as public records.
FyF-m SIGNS ELECTRICAL
QyY Licensed Pmfcssimid
y�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�xs�'Oy V 1 hereby affirm that 1 am exempt front the Conttucm,License Law for the
1y3 ay folkmingremon.(Scaion]03 t.5,Business and Professions Cale:Anycityorcoutny TEMP.METER OR POLIS INST.
F C< which ims a perark to construct.alter,improve,demolish,or mpurr any structure,
E p�Y: pHe1.re requmormcaaR.rtquires theapplicam ficamch perniuo file.6,rard tatement POWER DEVICES
'sip that he is licensed pursuanno the pmvisinvs of the Commcmr's Li¢nu Law fOmpmr SWIMMING POOL ELECTRIC vaday{y 9(commencmg with Smion]09)0)of Oivisinn 3ofthc Business and Professions Code) VALUATION
y am or that he is exempttherefrom and the basis for the alleged exemption.Any violationof O(rfLE s.SWITCHES-FIXTURES / Q O
�KQSection 7031.S by unyupplieam for.peronlobje,l, he applicant a civil penahy of
not more than rive bundmd dollars($51kp.
Fop NEW RESIDENTIALELECIR _SQ.FT. ORIES TYPE CONSTRUCT ION
of ❑ L..s ownernft ,hcsmucam,iva ,cleashadm hw niforges sale(See.
compcosminn,
d will dothewons and c: he Com is tot ire kende Law does of apply
to an,Business
and Professions Code:The Como-mals License Law dors not apply r.an owner of
properly who buildsmimproves Merton,and whodoessuch work himulforthruughhis
OCC.GROUP RES.UNITS
own employees,buiprovided that such improvements ld whheart yearo ompleered ficusaletheow. rL
buwevep the buildingnrimprovement ishathwithinone yea,or improve
omm,for tbeowner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpnu of
sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
❑ 1,muwnerofthepropeny,amexclusivelycontraingwithlicenudconm.a.rsto
construct the project(Sac.7044,Business and Professions Code:)The Contractor's
Licenulrwdt snotapplytoanownerofpmpenywhobuildsorirep-veaN eon.and PERMIT ISSUANCE
who contract for such projects with a conv.cwgs)licensed purua
snuothe Commuccon's
License Law. ALTER-DRAIN&V ENT-WATER(EA) FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason OUTSIDEFEES
BACK PLOW PROTECT.DEVICE
SANITARY V N
Owner Date DRAINS-FLOOR,ROOF,ARBA,COND. RECEIPI'0
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Iherebyaffi,m thmlbeve acmificam of conunuo self-insurt.mattr0ficme mf FIXTURES-PER TRAP 1-1 RECEIPT#
Workers'Compensation lnsurarme.,.ce.ifiescopy thermf(Sce.3800.Lab C.)which PAR E Y N
overs all employesOirdertNsygrplk� GAS-G.SYSTEM-1 INC.4 OUTLETS RECEIPT'M
Pull]icyk •J..11 �r L BUILDING DIVISION PEGS
Company GAS-EA.SYSTEM-OVIiR4 P PIANCI CK FEE
❑ Cenifedco,isherebyfumishcd.
❑ Cenilied espy is fled with the city inspection division. GREASEIINDUS L WASTE INTERCEPTOR GRADIN FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FE
COMPENSATION INSURANCE
(This section need not be completed ifthe Permit is forone summit dollaia(S HIO) SEWER.SANITA Y-STORM EA.200Fr. ;NIiRGY FAE
or Icss.)
I certify that in the performatteeof the work for which thi s permit is issued,l shall WATER HEATER /VRNTpiLE ,�1
not employ any pe,,.a in any manner ,,.s to became subject to the Workers' AID ' Is
Coni'mittionlnwsof Califomla. Dam WATER SYSTLmfr ATING ^Dam Receipt It
ZZ Applicant
0 NOTICE TO APPLICANT:If,after making this Certificate of Esempti......should NEW RESIDENTIAL P MB. Q.FT. TOTAL:
F' y become subject nt the Workers Compemaim provisions ofthe Labor Code,you must r O
> forthwith comply with such powkims.,this permitahall be deemed revoked. BUILDING FEE
W [] CONSTRUCTION LENDING AGENCY SIiISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
U 0 the work for which this permit is issued(Sec.3097.Civ.C.) IOTA ELECTRIC FEE
lenders Name PLUMBING FEU:
D"' F Lenders Addrtsa QTY. MECHANICAL PE IT FEE
U I certify that 1 have read his application and state thinthe above information is MECHANICAL FEE
�" D-1 correct Iagree ,,comply with all city undommy ordinance,andstme law,ml.ting at PERMIT ISSUANCE
F-' � building construaion.and hereby nor iae reprasemativesof lhix city,.emer.lam the CONS"TRUCTION'1'AX
Uz above-mentioned property for inspection purposes. ALTER OR ADD T'O MF.CI 1.
(We)agree to nave,indemnify and kecp harmless the City of Cupcnin.ii,mmt
liabilities,judgmems.cost itvt,m. which may in any way seente.,suct said Cry AIR HANDLING UNIT IT ,10.000 CFM)
consequenee.ftheg e,8 of thi reit.
AIR HANDLING UNIT(OVER 10.000 CFM)
umof Applicant/Contractor Date EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MAI[RIALS DISCLOSURE HEA'I'INC,UNIT(TO II 0X)0 BTU) Date Receipt p
Will the applicant or future building occupant store or handle hamrdous mammal HEATING UNIT(OVER FOR"BTU) TOTAL:
m defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(x)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑Na
ISSUANCE DATE:
Will the upplieantor future buildingoccupantise equipmenmrdevlcea whlehemit BOILER-COMPQHPOR 100,000BTU)
mous air contaminants as detlned by the Bay Area Air Quality Management BOILER-COMP(OVER IORWO BTU) p� pp
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.Pr.
r I have,cad the Incautious materials rcquirementa under Chapter 6.95 of the (BAR 2 2
California Ifi alth&Safety Cade.Sections 25505.25533 and 25534. 1 um
ndeand that 19.9
if the building does not currently have a tenant,that it is my responsibility to notify the /x
ccarpent of the requircmcros which nm.a M me,prior to issuance of a CcrtiOcure of Cit Y ser
Occupancy. �Uh'
Owner or uu lusimid agent Date TOTAL: ISSUED BY:
OFFICE 6