26870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO liffiLImo..ir,.,.`i' .AL PERMITNO.
APPLICATION/PERMIT PLUMBIN -MECHANICAL
BUILDING DIVISION G
IIUILUING PROJECIADENTIFICATION
BUILDING ADDRESS: v 3 SANITARY NO. APPI.ICA'GOo SUIMI TALDATP
Airr
�14/ UNIT# LOT or
OWNIi HSL PHONE: C NTRACI'OR'S NA 1.1 NO:
NIC [/ CONI'ItOLN
3
ARCIVOICf/F.NGINEER: LIC NO: ADDRESS:
CONTACT: PHONE: ll BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDGELECf PLUMP MECH
PERMIT ISSUANCE 0` ICI' $ P
LICENSED COM'RACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. �A JOB DESCRIPII[OON
mwz Iherebyaffrmthml um licausedunderprovi,micanfatipter9(commencing with
1400 Scnion]03l Division 3 of the Business and Professions Code,and my license is in PANELS
IFy—�W F full force and effect. 1,((�T��--^�T 1�
EZty License Class a Lic.# s'T"47a^lq1 UP TO 20O AMPS `t-- lL[-oL�
m Q a Dam Contractor 201-t%o AMPS ✓
FyZ ARCHITECTS DECLARATION SQ.FT.FLOOR AREA $,SQ.FT.
ZOce— I understand my plans shall be used as public records. OVER IWU AMPS
0Z A
PH
SIGNS El.liLTRIGAL ^�
9yle;� Liccnscdlhofosslonnl JY t
LL OWNER.BUILDER from DECLARATION SPIiCIA1.CIRNIT/MISC.
gx�jOy V 1 hereby uffum that I am exempt from th<Cnnwnore License Law teethe tai 3n.y following rrason.(Section]031.5.Business it Profeasions Code:Any city.,county TEMP.M1zFSR OR POLE INST.
CvON¢ whichrequiresapermit racore Be alter,improvesh Permiitt ornpau ed swaure lit �'it
E TO prior to itsissuance,
puraoregtothe Provisions
fthe Copcmtinofile a Licese La statement POWER DEVICES
iC C 0 that he is rain,.pursuant m the provisions of the Contractors License Law(Chapter
yxo�' or door
exempt therefrom
TaOdthe Division Softheed exemption.
Professions Cad e) SWIMMING POOL ELECTRIC VALUATION
W_m oration 7131.5 by any uprom and the basipersf.rthe ljoars thedexempti.n. civiny l
of OUTLETS-SWITCHES-FIX'IUSES
F- 6
Section than
5v hundrddollfm$500).tsunjens the nPPlicennoacivll penalty of
pnot more than five hundred dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT. S'IYIRI 'I'YI'ECONSTRUMION
❑ I,asownerofthepropeny,ormyemployeeswilhwagesastheirsoleconi enation,
a _ will Jo Ne work,and the strvnure is not intendedoroffend for safe(Sec.701 Business /
and Professions Cafe:The Contradols License Law does not apply to as owner.f
property who buildsorimprovesthereon,and whodoessuch work I irrufforNrough his
employees,provided that suchimprom
veetnmatter tter imendedoroffered torsade.If,
OCC GROUP RES.UNITS
however,the buddiagar improvement is sold within oneyeor ofcompletion,the owner- TOTAL: l
q If
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUMBING PERMIT F13E FLOOD ZONE APN
❑ Las owner of Ne property,atnexclusivelycontracting with licensed contractors toad �' �3q
n...met the project(Sea.7044,Business and Professions Cet)The Commences
law doesnot applyto anowaerofpropeny doobuildsminipmove,Nercnn,and PERMIT'ISSUANCE _Z) t�
who contracts forsueh projects with acontnetmEd licensed pursuattuo the Commnor's ALTER VEMP-WATGR RIA)License Law. ( FEE SUMMARY
❑ 1 am exempt under Sec. ,B&PC for this rtmon BACK FLOW PROTECT.DEVICE SANITARY OUTV N
Owner Date DRAINS-FLOOR,ROOF,AREA,CONE. RECE•IPI'p
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that l have a certificate ofconsenno self-insure,or t certificate of RECEIPT of
FI%TURIiS-PER TRAP
Workers Cameroonian Lnsurance oreartifiNcopy Ncrwf(Sea.3gg0,Lab C.)which PARK PI!C Y N
cov #'
era all employees mod"is permit GAS-HA.SYSTEM-1 INCA OUTLET$ RECEIPT
Policy or BUILDING DIVISION FEES '
Company GAS-EA.SYSTEM OVER 4(EA) PLANCHEC )�
❑ Certified copy is hereby famished. 'VV
❑ Cenifiedcopyisfiledwith 10 city inspection division. GREASFANDUSTRL WASTE INfIiRCEPfOR GRADIGFEE Zr OD
CER'HPICAT'E 41F EXEMPTION FROM WORKERS' GRIA.SETRAP SOIL IF
y,nh
COMPENSATION INSURANCE
(This seetionnoed nm hcpmnoploted Bone permit is furom hundred dollars(SIIlO) SEWER-SANITARY-STORM HA.2O0FT. ERGY FEE
or less.) cif%
Icanify that in the Performance of the wink for which this petrnit is iuued.I shall WATER HEATER W/VENOOHLEM R p 7I
nun employ my person in any manner so as to become subject to the Workers AID Z[
Compensation Lawsof Califomia. Date WATER SYSTEM/IREATING Data Receipt to
O Z Applicant
Z0 NOTICE TO APPLICANT:If.after making Nis Ccniflcateof ExemptiOn.yous told NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
p . ILchwith comply
t1.theywit Wnrh provisions
provisons.f the ust
� ; forthwith comply with such provieione or this pennittshnll M1e deems 1 US G BUILDING IHC
W Q CONS''RUC ION LENII GA SEISMIC FRE
Z I hereby affirm that is econsw d. I do g ge perfomtence of TOTAL �, ELECTRICITE
O the work for which this pemtit is issued IS c. .C)
Lenders Name
O � Lender's Address Q MECHANICAL PERMIT FEE PLUMBING FEE
I cmify Nat 1 have read Nie application or stem that v�nfe MECHANICAL FEE
correct.I agree m comply with all city and count oNinances ate Wws relatingto PERMITISSUANCE
ha0di ng construction,and hereby authorize representatives of this city m enter upon the CONS'IRUC'I'ION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO solLI elms
(We)agree m save,indemnify and keep harmless the City of Copan into ngainst
I iabilities,judgments,costs and expenses which may in any way accme against said City AIR I IANDLING UNIT(TO IBWO CFM)
,'.inc onsequence ofN renting of Nis pe,mit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signem of Appie tlContmemr Dae EXHAUST HOOD(W/DUCI) AI
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10J."BTU) Date Receipt#
Will the al,heatt or future building occupant sorm or handle hazardous material HEATING UNIT(OVER 100,01(g)BTU) TO
as defined by the Cupenian Municipal Cole,Chapter 9.12,and Ne Heath and Safety
Code,Section 25532(u)T VFNITLATION FAN(SINGLE RESID) ft
❑Yes ❑No
Will NeapplicamorfmurebuilJingoecupant useequiproentordevim who chemit
BOILER-COMP(3HPOR 100.00 BTU) ISSUANCE DATE
hazardous air contaminants as defined by the Bay Ana Air Quality Management BOILER-COME(OVER 100,0000 BTU)
Districfl
El Yea 11 No NEW RESIDENTIAL MECII, SQ.ET.
I have read the lummdous materials requiremems under Chapter 6.95 of the OCT — 3 19
California Healtb&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify Ne (sfry�r 1
oe,....I of Ne rcquiaments which muse be inn prior to issuance of a CeniHcum of _— CITY yUNkrl-( I Pt(
Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE