25680 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOB ILII (.-F.LMIKI AI. PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C C p O
BUILDING PROJECT'IDENTIFICATION J O O
BUILDINGADDDRES/S: / / /♦ SANIT'ARYNO. APPI,ICATTONN SUBMITTAL DATE
(/.p L. OI G/S�4 �`� UNIT# LOT p
OWNERS NAMG: PHON CONTRACTOR'S NAME: LIC NO.
---F- A 1 r/ // r C NIC CONTROL p
•AR_C.HH)JECT/ENGIINEEER: T C` LIC NO: ADDRESS: - ❑
CONTACT: I/C_0 PHONE: QTY. ELECTRIC PERMIT FEE p BUILDING PERMIT INFO
ELECT PLUMB MECH
PERMIT ISSUANCE 11El ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
❑e z I hembyaffirm that,am liccved unJerprovisinns of Cha#¢r9(commencimgwith
m00 Section]000)of Division 3of the Business and Professions Cale,and my Beene is in PANELS D
aW— full force and offer,. /
QFZW I.Perse Class Lic.# (,� Sll \S � UPT 2 AMS
h<h Dae B — C onTSID �A- f� f fJ 201- KNIAMI'
I'-,,z AR ❑ITELTS DECLARATION OVER S SQ.FI'.FLOOR AREA 5/SQ.FT.
z O._ I understund my plans shall Ix used us public records. -
w
f,gFY1 SIGNS IiI. 'RIC
QY�j
Licensed Profcsaional (I JAI pp 1
�6 OWNER-BUILDER DECLARATION SPECIALC 'UI /MISC. , TIFF II lj✓
KO W O I hereby affirm Na,I nm exempt from Ne Conuoctors Incense law for the
m 3,FFi following reason.(Section 7031.5.Business and Professions Code:Any city oromary TEMP.METER OR POLEVV� NiLi
t OQ which requires a permit to construct,alter,improve,demolish,Cr repair any trucmm V ) U
E,Y� m its issuance.also requires thea licant for such loo file a si dstatement POWER DEVICES if,
prior y pp perm signed,,m<0 Nat he is licensed pursoamm the provisiotuofthe Contractor's License Law(Chapter SWIMMING POOL EL C
aanW 9(cru mencing with Section 7000)of Division 3 offle Business and Professions Code)
W=y .,,but he is exempt therefrom and the basis for Nealleged exemption.Anyviola,ionof U- -
y my Permit J pp OUTLG'TS-SWITCHCS-FI%TERES
FZY Section 7031.5 b hundredve licollars a tsub'ects Nee licant toacivil pcnahy of — O�
OcSD nm marc Nanrofthe dollars($SW). NEW RESIDENTIAL F.LECIR _SQ.FI'. STORIES TYPE CONSTRUCT ION
Oct:o ❑ lasoiork,athepxamenuormyempl.yees wiNwagceasit for afe Chole compensation,
W 3c0
will do lesions ode TheCumisnors Liceol nse
Law
rdosnot applyts. arowner ss
of
and Professions Code:The Contractors nd who Lew docs not apply to an owner of
propenywhobuirovi lds improves hin suchimnmmentamemot chwork himueifoT Nrriughhis DEC.GROUP RES.UNITS
employces,providedthatsuehimpmv,menisarenot ewofdoroffered Tarsale.IL
he
however illhavthe e the umen of erovinghatmmut is be id one yew of improve foron,purpose f 0
builder will have the bonito of proving that he did not build m improve for purpose of
070
QTY. PLUMBING PERMIT FEE
❑ Las owncrofthe proPerty,em exclusively contracting wiN licensedcommcmrs to FLOOD ZONE APN
corawc, he project(Site.7044,Business and Professions Cod J The C.nfam,',
License law doesnmapply manawnerofprnpeny wh.b.ildimiruprovcs Nemomand PERMIT ISSUANCE
who contracts forsuch projects with acontraemgs)licensed perxuanumhe Contr icmr's
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I am exempt undo,Sec. ,B&P C for this Lemon BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Dme RECEIPT 4
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCIIOOLTAX Y N
❑ Ihereby affirm that l have o cenificam oPom
oetn to self-insum,Or a cenifeme of FIXTURES-PERTRAP RECEIPT#
Workers'CompIISutionlnsumnccnracertiricdcopythereof(Sec.3900,LabCJwhich PARK FEE Y N
coven all employcNnder N1is F`Z 7 � GAS- A.SYSM-1 INCA OUTLETS RECEIPT p
Policy#
BUILDING DIVISI NFE
Company GAS-I?A.SYS 117M-OVER 4(EA) PLANCHECK FEE
❑ Cenified copy is hereby famished. L
❑ Ccnified copy is filed wiN the city inspcnion division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF-ASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisseminn mednotbeewnpletedif Nin,worl is faronehundred dollars(5100) SEWER-SANITARY-STORM EA.20OFT. ENERGY FEE
or less.)
I ccrdfy Nat in the performance of the work for which this permit is issued,I shall WATER BEATER W/VENT/ELF.CIR
no,employ Any#arum in any m `.o as m become subject to the Worker' PAID
Compemation Lawsof Celifomia. DateWATER SYSTBM/TRUATING Date Receipt
0 z Applicant
NO i'ICF.TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENT IAL PLMB. SQ.FT. TOTAL:
become subject to Ne Worker's Compensation provisions of the Lahor Code,you mus,
� > forthwith comply wiN such provisions or this Permit shall for directed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC ME
1 hereby affirm that here is a construction lending agency for the pechmoence of
U O the work for which this permit is issued(Sec.3(19],Ci,C.) TOTAL: ELECTRIC FEE
Linda's Name
0 F Lender's Address QTY. MECHANICALPERMIT FEE PLUMBING FEE
U 1 certify that l have mad this application and mare that the above information is - MECHANICAL FEE;.r1" W comet.Iagree to comply with all city and county oNinanees and state laws relating to PERMITISSUANCIi
F" D,, buildingeon.muctum,and hereby authrrimix resenwives of Nis city loemerupm the CONSTRUCTIONTAX
U Z above-mentioned proheny for inspection purposes. ALTERORADDTOMECH.
(We)agree,.aay.,indemnify and keep harnlesa be City of C,wri no again., -
hathilitics,judgment, ...U andespences which may in anyway me .in said City AIR HANDLING UNIT(TO 10,(100 CFM)
in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I0,13110 CFM)
r77,
Signamrto ApphcanVCon Da¢ EXHAUST FOOD(W/DULT) - PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IW,OIXI BE U) Due Recei,#
will the applicant or future building«,Chant store or handlem material TOTAL:
as retired by the Cupcnin.Municipal OttHsafth ane,Chapter 9.12,and,he HeW,h d Safety HEATING UNIT(OVER 100,0011 BTU)
Code,Section 25532(a)]
0Yes ❑No VENTILATION FAN(SINGLE RESIDE
ISSUANCE DATE
Will Neapplicunmrfmurcbuildbtgoceupanmuequilnneot ordevices which emit BOILER-COMP(313P OR I00.0N108TU) p
)hawdmus air contamm mw m defined by the Bay Area Air Quality ManagemI�Air BOILER-COMP(OVER 100,000 BTU) Ir A f
District^
❑Yes ❑N. NEW RESIDENTIAL MECH.—SQ.Ff.
I have mad the hazardous materials reyuimnams under Chapter 6.95 of the OCT 27 1993
California l Iwhh&Safety Cole.Sections 25505,25533 and 25534. 1 understand,ha,
if the building does not currently have a renam.that it is my responsibility to notify the
occupant of the mr mmu ems wh'N mut be met prior to issuance�a Cerf care f CITY Ur G I
Occupancy.
O
Owner or onced agent C TOTAL: ISSUED BY:
OFFICE