26775 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY CLPEPLUMBING-MECHANICAL IUAL PERMIT NO.
BUILDING DIVISION
sloN APPLICATION/PERMIT
' BUILDING PROJECT IDENTIFICATION
���—S CC NVV
BUILDINGADD E� 11--''•[ UNITM LOT LSANITARY NO. APPLICATIONSUBMITTALDATE
� IJD � /�1v
OWNER�NAg( uii PHONE: CO ACTORR''S^AME LIC NO: NIC CONTROLM
/`IlC�• -I�s ccJ^ Lo Y•LT1 ID Ell-epfIe q/S193
�ARCHITECUENGINEER: LIC NO: ADDRESS: O
f
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑
LICENSED CONTRACTORS DECLARATTON APPLIANCES-RESIDENTIAL �� TOB DESCRIPTION
pKz Thereby of
mision sual3 ofthnsedunss and
Professions
Carlo,and
(commencing se with FW OO Seclitin rant of Divisian3 of the Business end Professions Code,and mylicense is in PANELS
a� fullnse d effect -
FZV�,, License Cl.ClCID Lic.tl UP T0200AMPS
rn]y DareIContrectm 201
SQ.
Z O r`rir'� RCHITF.CTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.Ff.
O Z—G 1 understand my plans shall te used as public records.
SIGNS ELECTRICAL
CLiumsed ProfesvonW
OWNER-BUILDERDECLARATION SPECIAL CIRCUIT/MISC.
that 06 F 1 hereby affirm I am t
exempt from the Coni..C.License Lew for she
W 3 a y following reason.(Section 7031.5,Business and Professions Code:Any cityor county TEMP.METER OR POLE INST.
E] which requires a permit m constmeL mer,improve,demolish,or ,repair any mandare
prior in its issuance,also requires the applicant forsuch Permit to file a signed statement POWER DEVICES
yl aa� p that he is licensed pursuant 0 the provisions of the Contractor's License Law(Chapter
6Xe�' 9(commencing with Section 7W)of Division 3 of she Business and Professions Code) SWIMMINGPOOLELECIRIC VALUATION
WMs, or that he is exempt dominant=it the basis for shealleged exemption.Any violation of X
F 4 G Section]031.5 by any applicant for a permit subjects the applicant 0.civil penalty of 1�
OUTLETS-SWITCHES-PINRES
C O amid.-than five hundred dollars($500).
-
c [I1,asownerofthepropeny,ormyemployeeswithwagesastheirsolecompensation, NEWRESIDENTIALELECTR H
_SQ.FT. STORIES TYPECONSTRUCON
y will do the work,andthe structure isnot intended oroffnedforsale(Sec.9l94,Business
and Professions Code:The Cranstor's License Law does not apply to an owner of
property whobuilds orimproves thereon,andwhodces suchworkhimselforthrrugh his
own employees,provided that such improvements are not intended or offered for sale.If, OCC.GROUP RES.UNITS
hnwever,the building or improvement is sold within ane year of completion,the comer,
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,asownerofthepropeny.nmexclusively convecting wish licensee contrecmrem QTY• PLUMBING PERMIT FEE FLOOD ZONE ppN
ex nstmet the project(Sec.WN4,Business and Professions Code:)The Contractor's
License Law tloesnot epplyman ownerof property who builds orimpmvee Hereon
,and PERMIT ISSUANCE _
who commas for such projects with a confinctor(e)licensed pursuant to the Contremols
License Law. ALTER DRAN&VENT-WAT
SU MARY
❑ 1 am exempt under Sec. ,r&PC for this reason BACK FLOW PROTECT.DEVICE UTSIDE FEES
'SANITARY Y _ N
Owner Dem DRAINS-FLOOR,ROOF,AREA,CONk_, ` HOOL I YECEIPT k
WORKMAN COMPENSATION DECLARATION N
❑ ers'Coy aorto nInsurveacerlfcateofconsenttoef(See.38, yLabtirsetich FIXTURES-PER TRAP RE E
Womker%Compensmion lnsurenrooremnifiedcoPY thereof(Sec.3g00.Lab CJ which - - Y N
covers.11 cmployee'e under this permit.
PolicyM GAS-EA.SYSTEM-1 INCA OU S ___. EIPTN
Company -rr - BUILDING DIVISION FEES
❑ Cenifiedcopyishandylbmished. GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
Certified copy is fled with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed lithe permit is foronehundrWdollus(SIN)
or SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
I certify Net in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so v to became subject to the Worker' PAID
Corponsatioulawsof California. Date WATER SYSTEMnREATING
Applicant Date Receipt#
O z
z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PL HL SQ.FT. - TOTAL:
become subject to the Worker's Compensation previsions ofthe labor Code.you must
R• forthwith comply with such provisions or this permit shall be domed revoked. BUILDING FEE
gL, z CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the Performance of
V O the work far which this pcmds is issued(Sam.3097.Civ.C.) TOTAL: ELECTRIC FEE �.
Lenders Name
0 V Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
LkII certify that I have read this application and state that Ne above information is
.Fi a corer.l agree to comply with or city and county ordinances and state laws miming to PERMITISSUANCE MECHANICAL HE
building construction,and hereby aumodze representativesofrhis city m enter upon Ne
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Calcium against
liabilities,judgments.costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO l 0,000 CFM)
at ace ofm granting of Nis permit.
71/ Q AIR HANDLING UNIT(OVER 10,000 CPM)
'NigItureof AppInim,Convac r /Date/ EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Recruit
Will she opylicamt or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cade,Chapter 9.12,and me Health and Safety I HEATING UNIT(OVER 100,000 BTU)
Cada,Section 25532(.)] �•
EI Yes El N. VENTILATION FAN(SING LE FESID)
Will m.appticmi ants a,building by the
equArco enmuality eswagernet
BOILER-COMP(3HP OR 100,000 BTU) ISSUANCE DATE
mmandDismet us air contaminants as reined by the Bay Arco Air Quality Mwegemem BOILER-COMP(OVER 100,00 BTU)
�Disd 1
❑Yee ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have reed the hazardous materials requirements under Chapter 6.95 of the PAID
California Health at Safety Code,Sections 2!5505,25533 and 25534.1 understand that
if the ccupanilofthe does
nNumemrs ly have a which
temetprior myssuannsibility to notify the JUL
lU 1 •x tea:
occupant of the requirements which mos[be me[prior m issuance �Ce
f 4 of k�{�LIIS 1�iLq�6lka�i(lYl�
Occupancy. ,,- i N cQ/ 4
Owns r mnud agent ° — Date TOTAL: ISSUED BY: C1