24963 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINOI A' PERMITNO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 24963[A Q
BUILDING DIVISION BUILDING PROJECII IDKN'I'IFICA'I'ION f� U J
BUILDING ADDRESS: wy' SANITARY NO. APPLICATIONSUBMITTALDATE
OESw�11 Y SOS QQ p '✓V UNIT# I.OT#
OWNC: NAMI", PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
RCHI F iLT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: (PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I� VMt/ / ' PERMIT ISSUANCE BLDG ELECT P UM MF.CH
'� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION pppLIgNCES-RESIDENTIAL JOB DESCRIPTION
Matz oc IherebyaffirmthatIs.license)inss and isionsofns Codi 9(co mmencing with
�i100 full Faned00)of DivisionJof the Business and Professions Code,and my license is in PANELS L
m;U� full force end effect. Sit
F W License Class - LIC.# UP TO 200 AMPS
E,
Dale Commctor 201-hN10AMPS
Z�toZ ARCHITECTS DECLARATION OVER I"AMPS
oz—al
SQ.
FT.FLOOR ARE $/SQ.PT.
I understand my Plans shall be useact d records.
SIGNS ELECTRICAL
Licensed Professional
,WU OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
qx Oa I hereby affirm that 1 an exempt from the Contractors License taw for the ,S P
\ I�'
uI 3 O r; following reason,(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST. �V
g(L m which requires a permit to construct,oiler,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such montto file a signed statement POWER DEVICES 7
gap that he is licensed pursuant to the provisions or the Contractor's License Law(Chapter -
dXpP,� 9(ccommancing with Section 7")of Division 3 of due Business and Professions Code) SWIMMING POOL ELECTRIC q
1y_m art than he iseaempt thercfmm and Ne basis far the alleged exemption.My violeuonof Fl%TURES
kKG Section 7071.5 byonymplium,fora pundit subjects lhempliumtto.civil penalty of OUTLETS-SWITCHES- IL
�Z�Z not marc than five hundred dollars($500). NEW RESIDENTIAL ELECTR S .FT.
�C$ ❑ I,osownerofthepmpeny,ormyemploy«swithwapsuv irwlcwmp non, Q STORIES TYPE CONSTRUCTION
willdothe work,and the swcturcis not imendedoroffeted for sale(Sec.7014.Business
and Professions Cade:The Commotors License Lew does not apply to an owner of
property whobuildsorimpmves thercou.and whodoes such work h cersdforthroughhis
ownerroployma,providedflm suchimpmvcments ere narinumdusim.f(ered fords.If. DEC.GROUP RES.UNITS
huwcvcr,the building or imp mean l is sod withinone yemof completion,theuwner- TOTAL:
builderwsilolw ve the burden ofpmving Net he did not build or improve for purpose of
sale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
r oftt(Sec.70,14, exclusivelyneand Professions
with de:)The Connector'tors s
construct the projttt(Sec.7014,Business and Rofemians Cad<:)The Contractor's
LicerseLowdoes not fousucapplytoanownommosopeny whosed puorimproves thmeon.and PERMIT ISSUANCE
License rets forsuch projccts with ecnntrnctoKs)licenced pursuanuo the Contrnctars ALTER FEE SUMMARY
License Law. ( )
❑ 1 em exempt under Sec. B&P C far This reason BACK I-OW PROTECT.DEVICE OUT ID; EL
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOP,AREA, RECF.IPfp
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_N
❑ Thereby affirm thmlhaveeurtificate of consemto self-insurt,ora cntiflemeof FIXTURES PER•TRAP RECEIPT#
Workers'Compensation Insurance ora cenified copy thcreof(Sec.3800,Lab C.)which PARK FEE YN
covers all employee'a under this permit. GAS-EA.SYSTHM-I INC.4 OUTLETS RECEIPT It
Policy# BUILDING DIVISION FEES
Companyd copy is hereby famished. GAS-EA.SYSTEM-OVER 4 EDG PLANCIIECK FEE
❑ fe
Ccnifietl copy is film with the city lnspttdon division. GREASERNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEMAP SOILS FEE
COMPENSATION INSURANCE
(This sxtion nxd mol4 completW ifthe pcmnit is forone Mmdesdollmx($100) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less)
I certify lout in the performance of the work for which this permit is issued,I shall WATER HEATER W/VHbEUHLECTR
not employ any person in any manner so ax to become subject to the Warriors' PAID
Compensation Lawsof California. Date WATER SYSTEMTBEATING pale Racipt#
O z Applicant
z 0 NOl'ICE TO APPLICANT:If,after making this Cettifieste of Exemption,you should NEW RESIDENT IAL PLMB. SQ.FT. TOTAL
Fnom-, becwne subject to the Workers Compensmon Provisions of the Lobar Code,you mum
a 1 forthwith comply with such provisions or recruit shell be deemed revoked. BUILDING FEE
1 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz I herebyufRnm chat is acanawgion lending agency for the performance of
O the wank fits which this pcEny"'u ($yr1R97.Gv.C) TOTAL: ELECTRIC FEE
LL. rr Lender's Name
F' lenders Addre�S`� f� QTY. MECHANICAL PERMIT FEE PLUMBING FEE
V 1 certify that I have read this application and some that the above information is
6w. correct.lagreelocomplywithalleityandcounty ordinances hndsome laws relating to PERMIT ISSUANCE MECHANICAL FEE
buildimgconstmetion,and herebyaathodu rcprcssamm,ex. thiscity menmruponthe
V above-mentioned property for inspection purposes. ALTERORADDTOMECH, CONSTRUCTION TAX
(Wed agree to mon,"111tcuoury and keep harmless the City of Calminn agmusl
liabilities,udgmenta, stsenesnseewhichmayinanywayancrueagslmtorand fity AIR I IANDLING UNIT(TO 10,000 CFM)
in onsc, u eof sea anti o(I is permit.
AIR HANDLING UNIT(OVER 10,000CFM)
nehimppelican tan tc EXHAUST HOOp(W/DUCq
PAID
AZ RDO SMATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dome Receipt#
Will the applicant o building aeupant mom or handle M1evMom material HEATING UNIT(OVER 100,000 BTU) T T
as defined by the Cupertino Mu 'cipml Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)t
❑Yes No VENTILATION FAN(SINGLE RISID)
ISSUANCE DATE
Willthcapplicaut mfutumbuildingoccupumuseequipmentordevicee which emit BOILER-COMP( HPOR 100,00i
harardous air contaminants as defined by the Bey Area Air Quality Management BOILER-COMP(OVER IM)"BIT) 8 ICI
coria^
❑Yes ONo NEW RESIDENTIAL MECH. SQ.FT, y##l#����####F���t�(
1 have read the hercho s materials requirements under Chapter 6.95 of the APR 1 �
Califonda Heailh&Safey Cade.Sections 25505,25533 end 25534. I understand that 1AR
if the building docs mo cumendy have a tenant,the,it is my responsibility to notify Ne
cu
pool of the requirements uireents which must Is,met prior to issuance of a Certificate of
Occupancy. ztIti L\gym]y/UU/�rtc/�/n��1 uv
Ownermauthoriredagent Date TOTAL: ISSUED BY: #�-� -