26650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINOBU11A)�LMIRI AI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL N� O
;BUILDING PROJECT IVENTIF'ICATION L
BUILDING ADDR S: SANITARY NO. ].KATION SUBMI'1'1'AL DATE
UNIT# LOT#
OW
IS NAA :: P110NG: IC( ICter! N/C C N 101.
•ARCHII'ECTIENGI :ER: LIC NO. ADDRESS: ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MEC#
PERMITISSUANCE 1 Iff ❑
LICENSED CONTRAerproc ions of RATION APPLIANCES-RESIDF,NTIAL r�u� CIt
pKZ Ihertby affirm that I CENSE licensed CONTRACTO visDECL RAT( 9(commencing with JOEDD
u100C Section 7000)of Division 3 ofte usiness dP fessions ;d my license is in PANELS
&, V IJ full force and f C Q Y
PQ.,ZW Liccns ,las. Lich �J C UPT02W AMPS
rn6 y Date Contramur 201-1000 AMPS
ZOHZ' CHITECTS...f RAI'0 OVER IOIXIAMPS SQ.FU FLOOR AREA S/SQ.Fr.
OZo, Iundersmmd my plans shall be.sed as public records.
F y l_W I SIGNS ELECTRICAL
Q— � Licensed Professional
L�daQ OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC.
XO y V 1 hereby affimt that 1 wo eaanpt from the Contractor's License law for the
W 3Wy follawingfeunn.(Senioo 71131.5,Rminessand NuE. .Tei Code:Any city or county THMP.METER OR INST.
which requires.pemtitm concoct,otter,improve.demolish,or repair any structure
SSW prions its isstmnce,alsomquites the upplic To...ch Permit o filcaaigned ataumemt POWER DEVIC'
to tY p that he
is licensed pursuant m the prmision.of the Commctorx License Law(Chapter
s4 Yor he is acing with Section Division the Rosiness mtl Profession Cotle SWIMMIN OOL ELECTRIC
,s�oty 1 VALUATION
W-m orihat he is excmpuhcrefrnm and the basis for theall,ed exemption.An ioletion of
Q Section 7031.5 by any applical for a permit subj ritheapplicat t penaOIITLE'1'S-
ltynf SWITCIIIS-FIXTURES
our morethan five hundred dollars($500). ryEW RESIDENTIAL ELLCfR IT.
❑ I,usmwneroftM1epropeny,ormy mplo a wugesnthei snsation, —�' STORIES 'rYPECONSTRUCfION
i _ willdothe work,and the structure is o ' t o fertdforsale c. om,Business
and Professions Code: Lot Conmacm's 1 m apply to an owner of
pmpenywheb 'dsorimpmve a e Imo ljOd himulfonhfuughhis
hoemployees. Ovide n rnveme s no m deddinceredforaale.IL OCC.GROUP RIiS.UNITS
wevegthebuil P ve em' Idwityin gn fcompletion,theawner
builder will he et en ofpmyf h;lPhe dl(rY.1 build or improve for purpose of TOTAL:
sale.). 1/I// QTY. PLUMBING PERMIT FEE RI ODD APN
❑ Lm the profs a cc.70 a a Qivelycmrofessio sCods:)nxed Contractor's
construct the project cc.]044, usiness and Professions Cods:)ITe Cnntra<lers PERMIT ISSUANCE
Licensetrawdfor such
hoof pfopeny licensed
puorimprothe Concogaod
wicenseho masLrtsuch projen.withncontmctor(xllicenxd punuanunthe Contractor's ALTER,DRAIN License L.w. PEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE SANITARY Y I .... N
Owner Data RECEIPTp
• DRAINSFLOOR,ROOF,AREA,GOND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑
Workers
reby Compenrtnthudhoveawrocariof cwasent to self opythereof(ins.re,or.can.)am which
RECF;IPI'N
Compensation IgXTURFS.PER TRAP
Worken.'Cam tion lnmrmce ura<Mified copy thertof(Sec.3800,Lab C.)which PARK FEE YN
rsallem yrye �i��ni GAS-V.A.SYSTEM,INC.4 OU'ILIH S RECEIPT N
Y l
Polley# s 1 BUILDING DIVISION FEES
Com'"""" V - n GAS-PA.SYSTEM-OVER 4(EA) PLANCIIECK FEE
Ceed mq is hereby furnished.
rtifieA copy is fled with the city inspection divisiaa GREASPONDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERITFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forone hundred dollars(Slotp SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
erless.)
I certify that in thepedonnance of the work for which this permit is issued,I shall WATER BEAT HR W/VEN'I'p?LECI'R
not employ any person in any manner so as to became subject to the WorkersPAID
Compensation laws of Callfomia. Dam WATER SYSTEMITREATING Uam Rcceipnp
O z Applicant
z P NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FI'. TMAL:
L•-' rn bccmno subject to the Workers Compensation provisionsofthe Labor Code,you must
� ; northwithcompiy withsuch provisions or this permitshnll adeemed revoked. BUILDING FEE
w O CONSTRUCTION LENDING AGENCY SEISMIC IEE
^� 1 hcrehy uffinn thunhcre is a ronsvuction lending agency for the perfomnance of
the work for which this permit is issued(Sec.307,Civ.C.) TOTAL: ELIiCTRIC FEE
Lender's Name
PLUMBING fEI:
O F Lender's Address QTY.= MECHANICALPERMI'T 'FEE
V 1 certify that 1 have toad this application and amre that the above information is
>" c
correct.I agree to comply with all city and county ordinances and state laws relating to P17RMIT ISSUANCE
MIiCIIANICAI.IEE
U hb.dingcofitmed
i mend horinsputhonz impose,
repreamtarives of this city menta upon the CONSTRUCTION TAX
(� 7 uhuv(We)
i,.pmpve,ind inspection keep ALTER OR ADD TO MECII.
F7 IWe).gree nt save,indemnify and keep my
handles,the City of eaganits against
inconses,jodg of the grand and expensewhich may in any way ecerveegainst said City AIR HANDLING UNIT(TO IO,IXp CFM)
ennxquence of the granting of this permit.
AIR HANDLING UNIT(OVER 10, FM)
Signature of AppliasUsCmmanor Date EXHAUST HOOD(WM
PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(T 00,000 BTU) Date Receipt#
Will tM1c applicam or fuwre uildingoecupmtsmreor handlehinomouxmatcnd
n.defined by the CupeninnM ipalC.daChapur9.12,an the Health and Safety HPATINGU OVER 100,001 BTU) TAL:
Code.Section 25532(e)? VENTII ION FAN(SINGLE RESID)
❑Yes No
BO :R-COMPUBPOR100,0110BTU) (SSU ED TE
Wiilthe applicamorfmure bmlrJt'ngacupamuse equipmemordevices whichemit K r
• hazardous air contuminanty s tl➢Rned by We Buy Arca Air Quslity Management BOILER-COMP(OVER IIHI,WU BTU)
Dismla? /�'rV/
❑Yes NEW RESIDENTIAL MLCH. SQ.Ff. Y! 5 �n��
I have read the hazardous materials requirements under Chapter 6.95 of the Cin'I J
Califontia llealth&Safe Code,Sections 25505,25533 and 25534. 1 moderamnd that la t
ifthebuiIdinUhqa
no, trrsm y haves union,that it is my respon' ility to tify the t s�lh.7
ro pm of eat st hemet prior to of o CrBo m ofOceOwm Date TOTAL: ISSUE BY:
OFFICE