24592 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU PERTINO BUII,DING-EI.nc IRICAI. PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL24592
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 1 SANITARYNO. AIIPPLICATIONS/UBBMITfALDAI
V
O / O I UNIT. LOT Is
OWNERSNAME: PHONE: CQi`,TRA OR'SNAM1E: n LICND: l
d ! / r ;"'Y7-i NIC CONTROL x
( K er -31 a 6 �cl. . L. f.,• ter .�.'-,,,.,
HITS ENGINEER: LIC NO: ADD ES : /
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT P,UM)1 list I
PERMIT ISSUANCE I ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL I TOB DLSCRIPTION
mbez Thereby affirm thalum liccmeJ unJerpmvisionx of CTagnr9(crmmrneing with
F:00 Stttirn 20q)laf Division LJ me tlminess and Professions Cv�le.audmylimnuis.. PANELS
F full force and Ifect. i ` I
y=CL: TS
Dla1enx IassContmcmr C� -^s' 1: t. UP TO 2W AMPS
201 1000 AMPS
b-.;ZARCHIL LCIS DECLARATION SQ ARE SISQ.FT.
Zorn— 1 understand my plans shall he used az public records. OVER IOW AMPS p InyC'o
=Ia4 SIGNS ELECTRICAL - - - \, --• ,—_ - l V
<N<_ Licemed Pmfcssianal -- - VVV
or. OWNER-BUILDER DECLARATION SPECIAL CIRCUITftVISC.
W,
1 herehy affimt that I am esempt from the Cantractor's License Law for the
—Orn following mason.(Seen.7031.5.Business and Professions Code Any city or county TEMP.METER OR POLE INST.
which requires a pemit to construct,alter,improve,demolish,or repair any swmure• —
�i!?Y� prior to in iOtunce,also rol.ims theapplichot forsuch pewiuo filen ignedsraamem POWER DEVICES
wz�O that he is licensed pursuant to the provisions of the Contramr's License Law(Chapter
as—p 9(commcncingwith Serol..IOW)of Division 3 of Ne Business and Professions Caere) SWIMMING POOL ELECTRIC
VALUATION
or that he is exemptherefrom and the basis for the alleged exemption.An t f
y.yg pion. yviouiono
F Z>- Section 9031.5 by any applicant foraOUTLETS-SWITCHES.FIXTURES
4 permit subjects the applicant to r civil Penalty of
=0 not more than five hundred dollar g50B.
�_� ❑ I,as uwncrof the r yempy g pensa' NEW RE5IDENTIALELECTR —SQ.FT.
prapernme is en mwllhwo eead arsarld(SNe core eon. STORIES TYPE CONSTRUCI'IOP
y3— will do lesions and the he ComistrotintLMnseed La deals rot apply M an Business
and Professions CW<:The Contmmors and
Law such
not apply m un owner of
own em who builds vi improves suthereon,andwhod«ssuchwork himselfedthrough his
howemployen.pmvidedtproveentch is std within
lnandemampleered forthe one- OCC.GROUP RFS.UNITS
however,the building or improvement is sold within one year of completion,the owner- TOTAL:
builder will have the burden of proving that he did Trot build or improve for purpose of
ale.).
❑ Lusowner ofthe prapeny,ameulusivdymnaacting wi0licensed<onln<mrto QTY. PLUMBING PERMIT FEE FLOOD ZONE AVN
answer the project(Sec.]Oat,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law doesnrt apply to an ownerofpropeny who buildsorimpmvcs thereon.and
who contracts forsuch projects with a camurbofs)licensed pursuant to the Coneractorx ALTER License Law. FEE SUMMARY
❑ 1 oro esempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE O TSIDF,FEF,S
SANITARY YN
Daa AI
DRNS-FLOOR,ROOF.AREA.COND. IPT
RECE .
ncr�. WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
hereby atBdo that 1 have a ce tificme mcamsem m self-in...,mit certificate of RECEIPT'x
FIXTURES-PER TRAP
` nrkers.'Compensarion Insurance oraccnifiN copy NercrorySce.3800,Lob C.l which PARK FEE YN
'ovPolicy xll emplgseh yea er'tNs PE�tt,- GAS-EA.SYSTEM-1 INC.J OUTLETS RECEIPT
11 `7 J < BUILDING DIVISION FEES
Company `-�^r CAS�EA.SYSTBM-OVER6(EA)
❑ IBsile.,is hereby fumiebed, PLANCHECK FEE
CcrtifeJ<opy is fled with the city inspection division. GREASF/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be campintrd if Ore Permit it forme hundreddollar(s IW) SEWER-SANITARY-STORM EA.20OFT, ENERGY FEE
ar Ica.)
I cenify that in the perfnmance rfthe work for which this perainkileued,Ishan WATER HEATER WNENTIELECTR 1^ •S��
not employ any person in any manner m as m become subject to the Workers' PAID
COmperamim Lawsnf California. Date_ WATER SYSTEMT]ICATING
Z Date Raciptp
Q Applicant
ZO NOTICE TO APPLICANT:If.idler,making this CeeiBcate of Exemption,youshauld NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
V) bmbo c,ubjmno the Workers Chairperson.provisions ofthe Labor Code.poo must
5 forthwith comply with such provisions or this Proof shall be deemed revoked. BUILDING FEE
0. D CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z) Z 1 hcrcby affirm thawhere is a construction lending agency far the performance of
() O the work far which this permit is issued(Sm.3097,Civ.C.) TOTAL: ••��) ELECBIC FEE
Leaders Name _ s
QU IsrWcrx Adders QTY. _ •.MECHANICAL PERMIT •FEE PLUMBING FEE SL`)
LAI cenify that 1 have read this application and state that the above information is -
cortect.l agree in comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
building construction.and hereby amhmiee repmsenmivesaftho city 10 enter urym the
C) Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(we)agree to save,indemnify and keep haxi the City of Collector against
Iiahilities.ju mr,covh,mdvs,b es ich may+n anyway amoral said City (T
AIR HANDLING UNITO 10.000CPM)
I n con efthc granu>m,of thrs/y�ym�Ilt.
n AIR HANDLING UNIT(OVER 10.000CFMI
bog 'V1pp IlntlCam m r Date EXHAUSTHOODIW/DUCT)
PAID
IIA'Z�.RDOUSMATF,RIAES DISCLOSURE HEATING UNIT(TO 10,000 BTU) Dale Receipts
Will the applicant or l'murc building oeeupant store or handle hazardous material —t\ /
as defined by the Casinos.Municipal Code.Chapter 9,L,and rhe health and Safe, HEATING UNIT(OVER IW,IXA)BTU) TOTAL:
Code.Scaion 2553?Avg vENI'ILA'I'ION PAN(SINGLE RESIDI
❑Yes ❑No
W ili the applicant or future building(x�cuWt us eyuipmmn rr devices which emir
BOILER-COMP I'D R100.1KK)BTU) ISSUANCE DATE
•wnlu.1 air comaminam,,m defined by the Bay Area Air Quality Management BOILER-COMPIOVER W.I. PTU)
aid!
❑Yes ❑Nu NEW RESIDEYTI,\L MECH. 5Q.FT.I
1 have read the lut dous mmcnais obviamems under Chapter 6.95 of the
Califnmialinith&Snfey CWe Semions'_5505,255JJand255JJ. Itudersrandtha
ifthe hut'If' duosnalcurrentlyhave ichdaa he me, it is my responsibilityeratify I of
oup;rnt of the us nor currently
which matt ea ren prior m amancems,m s of il Cto haeme he
ocenpamy. �` 17
(omm rr atihmved agar, One TOTAL:I ISSUED B.r
OFFICE