B 0387PP ICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY - /" 1
OFFICE
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CITY DI CUPVISION - BUILDING - ELECTMECHAICALNICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMPING E T IDHANICAL
BUILDING PROJF.CT,IDEMI'Ik9CATION
- PE' °#0387 0 3 8 7
SOOO I _ /��/� J
B Al DING ADDRESS:
J a'1Kq l Cokum9an Au PCuR�k�+�a
SANITARY NO.
APPLICATION SUBMITTAL DATE
/3
WNF AME: y PHONE:
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CONTRACTOR'S NAME'. LIC NO'
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CONTACT: PHo E:.BUILDING
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F1 Consultant Fees Paid by Applicant (Initial)
.... .......
PERMIT INFO
BII�A'fC�" ELECT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION
1 hereby affirm Ih t 1 licensed under provisions of Chapter 9 (commencing
with Section 700RofDhrsimn 3efthe Btwirpx. dPofssions Code.andmy Im x
.n railforceand ellen7499
License Class _ Lic.N
Data Contmemr
. ELEQTRICPERMiT FEE'
QTYt r ' " .'
JOB DESCRIPTION
RESIDENTIAL
DSFDWL �I(Il'CHEN REMODEL'
P<DDFFION El PLUMBING RE -PIPE
[]MULTI -UNIT El STRUCTURAL
MODIFICATION
f�TERIOR El CI HMNEY REPAIR
IMPROVEMENT I] SWIMMING POOLS
- ATH REMODEIAREPAIR 0DEMOLITION
D OTHER
�J� J Z/sit /s
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PERMIT ISSUANCE. J,S�
APPLIANCES -RESIDENTIAL
CHITECq'S DECLARA
I understand my plans shall be used as public r res
_
PANELS
UP TO 200 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby erfimt Ant 1 am exempt from Om Contractor's License Law for the
fallowing moron. (Section 7031.5. Business and Professions Gde: Any city or county
which requires a permit m construed, alley, improve, demolish, or repair any ammture
poor to its issuance, also regaime the applicant for such permit m flee signed statement
License Law (Chopmr9
IMI menccenseA Section7")pmvisiena of there Businessesslons iummode) or
(hot ha n, tngwuth Sermon. and the basis f J of the Business exemption
IMI Ire is exempt therefrom and the basis for positioned exemption. Any violation of
Scetion]0315 by uny applicant forvpermit subjects the appliwnnn acivll penuhy of
not more than five hundred dollars(S500).
owner k,ofthe
and property, or myemntended with wages raid(Se. compensation,
will dvthewonsande: swContra pots Licensoroffered awdoforsale (Sec.](H4,Businee
and Professions Code: The Contractors License Ince Jces not apply to an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offernd for
sale. IL however, the building or improvement is sold within one year ofcompletion,the
ver -builder will have the human of proving that he Aid not build or improve for put-
pmenLsole.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIALCIRCU SC.-'
TEMP. METER OR POLE
COMMERCIAL:
❑NEW BLDG/ADDITION ❑DEMOLITION
DTENANT ❑ FOOD SERVICE
OTHER IMPROVE
OTHER
POWER DEVICES
SWIMMING POOL P,IM,Cq
OUTLGfS- SWITCHES -FIXTU '
-
NEW RESIDENTIAL ELECTR' SQ IU'.
`SQf. FT. FLOOR AREA
AAA k Vv q -
,
$ISQ. Up.
_ {�
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TCYIAL Z•�
construct the project (Sec. 7044, Business and Professions Code) The Contractor's Li-
cense Law does not apply to an owner ofpmpeny who builds or improves thereon, and
who wormers for such projecta with a oontmGor(s) licensed pumuanLto the Connector'I
QTY,. -PLUMBING PP.RMITPP.P.
PERMIT ISSUA
--.'-
License Law.
D I am exempt under See. B K P C for chis reason
0-1
net Date
WORKER'S COMPENSATION DECLARATION
ALTER-DRAiIa'R ATER (Efl
VALUATION
y
HACK FL Vl PROT VI
I hereby affirm under penalty of penury one of the following Awlnmtions:
have and will maintain a Certificate of Consent to sell -insure for Workers Compete
sation, as provided for by Section 3700 of the Labor Code, fmnhe performance of the
work for which this p dmil is issued.
E] I have and will mountain Wor1w,x Compensation Insurance, as terminal by Section
37Wofthe Lahr Code, for the perfommnceef the work f_oy'rlwhich
-•t�hhiis pemth uiss----
Myler. serf nLy(va9eC)ertiuPol iy No,�! /
Carries OC Y
DRAINS AtEWOR, RODE, 0
FIXTURE ITPER'rRAJb
Il M1.J
STORIES f
TYPE CONST RUCTION
I
OAS -EA. ,STEM -I LNG 40UTLETS
OCC. GROUP
^�IJCERTIFICATE
GAS-EA.'Yftlr M-OVER4(PA)
GREASFAINDUSTRL WASTE INTERCEPTORG+COMPENSATION
_
OMPESATIONiINN FROM WORKERS'
INSURANCE
ortwo.) �
QING DIVISION HP.S
GREASETRAP
� �'I
cenlfy that in die performance oflhe work forwhichthis Noun is issued, l shall
employ any person in any manner so as to become subjectmthe Workers'Cmd,m-
effort Laws of California. Date
ApplicanthNOTICE
SEWER -SANITARY -STORM EA. 200 FT.not
- O
WATER HEATER WNHNTIELECTR
WD
TO APPLICANT: If, after making this Cenifieam of Exemption, you should
subject m theWorkers Compensation provisions of the Labor Code,youmust
WATER SYSTEM)TREATINGbecome
WATER SERVICE
forthwith comply with such provisions or this permit shall he deemed revoked.'
t E''
L)
t ISILeader's
t V�1
iz
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'
CONSTRUCTION AGENCY agency
hereby amthi lhm there is sued (m . 30 lending agency fur the perinnnance of
the work for which this permit is issued (Sec 3099, Civ. CJ
Lender's Name �
Areas'
'statet ice information
Rncaipl N
NEW kESIDF.NTiAI. PLMB. SQ.PiIpI
AL:
-
- TOTAL: 79
BUILDING FEE T S '12- OV
certify mel I he ad this application andm that the n n
cntred 1 agree mcomply 'th II ty d my M" angio d t t elml g m
bmildingcnnstrvctlon, andh by Ih - rep caner oa of lh': eityn enter upon the
.abovemwnaned property for inspection purposes.
(Wc) agrce to xave, indemnify and keep harmless the Cily of Cupertioe against
QTY. ,MECHANICAL PERMIT + Fu
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC
PfAMRI y 2
Ilabili0es,judgments. costs and expenses which may in anyway accrue against said City
in consequence of the granting of this permit.
AITERORADDTOMECIL
AIR HANDLING UNIT (TO 10,000 CFM)
MF.CHI CA . FF.F: 'lay , Z�
APPLICANT UNDERSTAND AND WILL COMPLY, W I' III ALL NON -POINT
SOURCE. REG AT y(
AIR HANDLING UNIT (OVER 10.000 CPM)
CONSTRUC ION" X
Signamreo Brun ontmad Dam
HAZARDOUS MAT LS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING ITTOATIN FEE
W' vd,dcnnonfat ure build; mivardaemormleadle hazardous material
IEAl INC, UNIT (TO 100,000 BTU) -
as defin y the Cmperlime Municipal Cade, CMpt,, 9.12, aad the Health and Safety
Codd, Section 25532(a)Y'
HEATING UNIT (OVER 1(h4000 BTU)
YceD No
VEN'T'ILATION PAN (SINGER RESID)
PAID
Data keceiptM
BOILER COMP OLTP OR 100000 BTU) -
- ,
Will the arapplicant or tbuilding occupant use equipment or devices which
hardI,contaminants air ontnlaminvants a es defined by the Bey Am er Air Quality Management
UiaMct
❑ Yes El No
TOTAL
BOILER -COME (OVER 100,000 BTU) '
"
AIR CONUITIONEk
-
'hove raadthe
ry Ced,Se ems ials 2555,2553 ntsan under 6.95 thethat Cali-
that if the
forma Health &Safety Cada Sections 25505, 255JJ and 25534. I to notify
building Aoes nmc n0 en tenanp in it is my resrymeCirrylono fOthe rcuparry,m
of the I yet priors Certificate of Occupancy.
-
ISSUANCE DATE L
/)
NEW RESIUGNr IAL MECH. SQ. Ff.
_ 3v- ?y
TT
ISSUED BYyJx�e— 0101J77w��
TOTAL:'7LI, Z
net Ifagent Date
OFFICE