26929 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOuiLiNL=FI"'C'RICA. PERMITNO.
APPLICATION/PERMIT PLUM IIING-MECIIANICAI, n C
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION L v
BUILDING ADUNESS: 929
SANITARY NO. APPLICATION SUBMI'1.1'ALUATE
44. UNIT# LOT#
OWNI3 NA �'►'� 1 PHONE: CONTRACTOR'S NAME:
SIC CONTROL#
RCHITECT/CNGINEER: LIC NO: ADDRESS: 4 Sf Avg $4 r%LiEl
CONTACT: PHONE: > + .pp$ `¢ - L '" ,
q; 1 II�, LE�TRIC PERMIT' FEES 4'.BUILDING PERMIT INFO
BL G �ELEfT PLUMB MECH
PERMIT ISSUANCE SRI
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
0=Z I herehyaffinn that l am licensed un&rpmvisionsof Chapter9(commendngwilh OB C
Ir00 Serino 700l Division 3oflhe Basins.and Profesai Code,anJ my license is in PANELS
Iom' 8
ILII remdeflet.
'Z LmeuClasa C.nha� �0no— ]O TO 200AMAMPS
Z C iy ARCHITECTS DECLARATION OVER IOOIIAMPS SQ.FT.FLOOR AREA $/SQ.FT.
0Z•.,q 1 undersumnJ my plans shall be uxJ os public..cords.
r-LIpW SIGNS ELECTRICAL
<�L Licensed Prolessinnal
NEW Q OWNHR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Q 1 hereby affirm that I am exempt from the Contractor's License Law for the
teiw.aa followingmosnn.(Sevion9031.5,Businexsand Professions Code:Anyoitymcionoty 7MP.METEROR POLEINT.
J whicholnues.permit to onscond,elver,improve,demmbith r..pair any awclum
fyn}� prionoits issuena.alsnmquims Neappliemn f.rsuchpermiuofileMem
eaignsuleed POE 1
W E�0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aax p0- 9�commencing with S«tion]f100).f Divisinn3of the Rosiness end Rofessi.na Code) SWIM G ' VALUATION
W_m
o'(but he is exempt merefromool the basis for(heallcgd exent,dim.Anyvi0minn of - ate'#
FZQ SAtion 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of OUTL -SWITCH&$-FIXTURE D
O not more than Eve hundred dollars($5(101.
o IDI,asownernOhe properly,ormycmployeeswiNwageses Neirsulecompcnsetion, WRESIVIN`aW EL _�I STORIES 'TYPE CONSTRUCTION
d ?2 )Vill dothe work,nnd NesOuc(nrcis nettmendedmoffered forsale(Sec.9..Business
and Professions Code:The Contractors License Law does not apply 0 an owner of
propeny whnbuildsor improves Merton,and whedentauch work hinuelfumt#oughhia OCC GROUP RFS.UNITS
own employees.provided that such improvementasre not intended or offered for ale.If,
however,the buildingor improvement is sold within one year ofcnmplinu m,the.yyy(((yyyrrr TO"1'AL:
builder will have the buNe °�( NNW he do hail ��I�I�ye for p�rppya p'
�1c'1' e.l ai •�f\ fI�1� ; o v T;Y! 'PLUMBING PERMIT FEE FLOOD ZO 11 A
❑ I,m.wn<ruflhe Pm Y•emexelusively cotltrBciinBlicp �{��' Q - a APN
nsu d the project(Sec.9 4,Business'aod n C�I 1 I� pERMI'f ISSUANCE
Llecnselawdmes nompplyttmsow{urn(pr�ipseer el' ahp �ldp elLwo -
whoc.mrctsforsuchPrnjec rNae.mnm.rfs)Iicensed pursuunnu Ne Commcmr'e ALTER-DRAIN&VI'vYf-WATER EA FEE SUMMARY
License Law. 1 )
❑ Iemexemptunder Sec DATE BA mr•__..�---son
-J BACK FLOW PROTECT,DEVICE SIDS T.
SANITARY Y N
Owner RAT DRAINS-FLODR,ROOF,AREA,GOND. RF,CIiIPI'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑ Thereby affirm than heveaanificme.(conunnu ulGinsurt,oracmifieaIn of FIXTURES-PER TRAP ^ RECEIPT#
Wnrken'Compenulinn Insurance ort cenified copy Hereof($«.38(q,Leb C.7 which PARK ILII Y N
oversell empinyce'sunder(hispermi(. GAS-EA.SYSTEM.]INC.4013TLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-CA.SYSTEMOVER 4(CA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cettilied copy ix file)with Ne city insp«[inn division. ORHASE/INDUSTRI,WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GASH TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not becompleded if Ne permit is forone hundrWdollsn($100) SEWER-SANITARY-STORM EA.20017. ENERGY ME
or lc6s.)
I ccnify Matin ser p in any manner work fm whiche iubjectito de W,lshelfcers' WATER HEATER W/VENT/ELCCfR
notCompensation
o employ any person in any manner m m m 8«nine subject m Ne When' pglp
Cpmicant nLews of Califorie. Dam WATER SYSTEM/IREATING Data 0.eceNt
O O NOTICE TO APPLICANT:IL after making this Cerifiwm of Exam lin Q.IT.
Zr po,youu mind NEW RUSIUEN3'IALPLMB. 5 TOTAL:
f•-' .--m become hwithc subjecttoit Wnrh roComns or
rtthis provisiruofNe Lehrevoked. must
1 Ipnhwith comply with such provisions onhis permit shell be d«med invoked. BUILD .E —#
Ch] CONSTRUCTION LENDING AGENCY SF CLF.
Zs 1 hereby affirm Naa uhcre is conawai.n lending agency for the pcdoormnce of
U C) the work for which this permit is issued(Sec.3097,Civ.C.) EL C
PJsnders Nemn 17
P
O0 U Lenders Address QTY- ��` ' MECHANICAL PERMIT: . DPjB . PL B FEE
U 1 ccnify that 1 have read Nmmi
is application and state that the above inforo - t ~ -
�" Pi current.I agree to comply with all city and county ordinances and stem laws elating to PERMIT ISSUANCE MECHANICAL :U
building omouction,and hertbyarhorize r<present.fsesofthia city In emer upon the CONST0.UCf10 TAX
U above-mentioned propcny for insPcdion purposes. ALTER OR ADD TO MUCH.
(We)agree ser sav an Iy and keep harmless the City of Cupen ninm
liabilities,judgmcn nd expenses wlJchm yw AIRHANDLING UNIT(TO 10,000 CFM)
inconsequence the os u'.fmH'
Q AIR HANDLING UNIT(OVER 10,000 CFM)
namrcof APPlica LV uacmr ate / EXHAUST HOOD(W/DUCT) PAID
HAZARD MATERIALS DISCLOSURE HEATING UNIT(TO 100,(X10 BTU) Date Receipt p
Will are npplicun( none building occupant store or handle hazardous material
as defined by NeC nine Municipal Code,Chapter 9.12,and the T leahh and Salary HEATING UNIT(OVER 100,000 BTU) T
Code,Section 25 l2(e)9
Yes 1:1 No VENTILATION FAN(SINGLE REBID) six,
❑
Will the applicen(or futumbuilding occupant use equipment ordevices which emit BOILER-COMP(3HPOR 100.0(0 BTU) a" IS NC ATE
haznark s air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) AUG
n
❑Ycs ❑No NEW RESIDENTIAL MECH.—SQ.FT. C// V(� sG g4
1 have mad the honothSafety
Code,
mctionsa requircmen(s under 34, 1 Chapter erst of the tv ser
Californiaebuling dos Safcur Code,have
Sections s ant,that
t it
and 25534. I undenotif that
if the building dos not nuns w have a tenant,et it is my responsibility e notify the
Occupant of flue requirements which must he me(prior m issuance of a Certificate of
Owners amhorizcd agent Date TOTAL: ISSUED BY: V
OFFICE