27290APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE 11
CITY OF CUPERTINOUHAIINix iIvLWI'RI AI"
APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING DIVISION BUILDING PROJF.CIADEN'1'IFICATION
PERMITNO.
/� (� O
G C
BUILDING ADDRESS: ) \
SANITARY NO.
APPIJCATION SUBMITTAL DATE
UNIT N LOT p
N' AME: PHONE:
CO K'S NAfylE: //
G {Y
N/C
❑
CONTROLN
'I'ELT/EfJGINCER: LIC NO:
AD DRESS: _ w
54�
COMI'ACf: PHONE:
QTY. ELECTRIC PP.RMIT FEB
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
PERMITISSUANCE
'
❑ ❑
LICENSED CONTRACTOR'S DF.CLARA']ION
Iherebyaffi.n that l am licensed under provisiomofChapter9(commencingwith
Section 7") of Division 3 of the Business and Professions Code, rand my license is in
full farce and effect.
License Class Lic.#
APPLIANCES -RESIDENTIAL
PANELS
UPT02MAMPS
O p
00
U LuE
Z
10B DESCRIPTION
N
't
Date Contracmr
201 - IOW AMPS
ARCIIITEC"fSDECIARATION
1 understand my plans shall be used as public records.
OVER 10%1AMPS
SQ. FT. FLOOR AREA
$/SQ. IT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affrm door I ram exempt to. the Contracmr's License Law for the
following mason. (Section 7031.5. Business and Profession$ Code: Any city., county
which requires. permit m consmcl alter, improve. demolish, or repair any stmemre
SPECIAL CIRCUIT/MISC.
ce<
a�
�m¢
,nJ
TEMP. METER OR POLE INST.
Y�
Op
0
pit its manince,ralso requires theapplicant f-rm,la permit,. Elea signed statement
that he is licensed pursuant o the provisions ofthe Contrectora License Law (Chapter
9(rommencingwith Section7)00)of Division3ofthe Busineassnd Pmfeasions Code)
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
!2y
ZQ
�t O
Cm
radial he isexnnpnhemination dohmis for h,alleged exemption. Any siolntirnof
Section 70311 by any applicant for a permit subjects the applicant.' a civil penalty of
mon, ere then five hundred dollen$ ($500).
tom,
weer.nd
❑ I.asdo
ntendeeswimw-gesrsil
Ot1TLITS-SWITCFI[S-FI%TURES
NEW RIiSIDPNTIAL ELECDi _SQ. Irl'.
S'IY3RIE5
TYPE CONSTRUCTION
3.
the be is not for ale(See Business
will dothewons ande:
and Professions Cale: The Contmcton, License Law does
heCoeisnon's License Law does to an memo
apply ff an owner of
property whnbnilJsnr improves thereon, and wh.dcessuch work himselfnrthrough his
or
provideddhmsuch improvcmrntaaten.timm�dMorof(credforwle. if,
__I-
OCC GROUP
RES. UNITS
TOTAL:
however,dhe buildingor improvement is sold within one yearofcomploic o, theowner-
builder will have the burden of proving that he did not build or improve for output, of
QTY. PLUMBING PERMIT FEE
sale.).
❑ Las uwnerofthcproperty, amexclusively convecting with licensed contmaox to
FLOODZONI;
APN
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License Law doetnot apply manownerufpropeny whobuildsorimpmves Narcanand
PERMITISSUANCE
whocontmctalmsuch projects with a commctar(s) licensed pursuant to the Cotnmcmra
License Law.
ALTER EA
( )
FEE SUMMARY
❑ 1 am exempt orad,, Sec. B A, P C fm his mason
BACK FLOW PROTECT. DEVICE
5
T -
SANITARY Y N
RECEIPT It
Owner -Dan-DRAINS
WORKMAN COMPENSATION DECLARATION
❑ Thereby nffvm dire lhavan ceai0cme ofron$enu. selGinxurc, orattrtifcme of
Workers'Compenaation Insurance or acenifievi copy dereof(Sec. 3800, Lab CJ which
-FLOOR, ROOFAREACOND.
, , .
SCHOOLTAX Y_N
RECEIPT'#
FIXTUR[5-PL'R TRAP
PARK HE Y N
GAS - HA. SYSTEM -I INC. 4 OUTLETS
overs all employci s under this permit
Policy #
RECEIPT #
BUILDING DIVISION FEES
eY
GAS - EA. SYSTEM -OVER 4(PA)
PLANCHtiK FEE
0 Certified copy is hereby furnished,
GREAS sIIUBDUSTRLWASTEINTERCEPIOR ,
GRADING FEE
❑ Cenifed copy is tiled with rhe city inspection division.
CERTIPICATF. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASE TRAP
SOILS 17EE
SEWER - SANITARY - STORM EA. 200PT.
ENERGY FEE
(This section -cede.' becompleWifme permit is faro., hundred dollers(S 100)
or les,.)
WATER 11FATER W/VFNT/ELECTR
I certify that in the pedormanceof the work for which this permit is issued.lshill
z
nod employ any person in any mann,, so as t. become tubjecd to the Wmker%
C.mpensntion Laws of C-lifnmiu. Dale
Applicant
WATER SYSTEM/TREATING
PAID
Date Receipt#
V)
NOTICETO APP LICANTer's Co penning this
hechwithcno the Workers Compensation ovisio sof of Latour Exemption, should
Code, must
NEW RESIDENTIAL PCMB. SQ. FT.
TOTAL:
omplyect
forthwith comply with such provision$ .nils permit ahedl be domed revoked.
Permit she]
BUILDING FEE
Q
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
z
17
F
V
0.
Ln
z
I herehyaffrnn Chad there isoc.nsuuctior leadingagrncy for the performenee.(
the work for which this permit is issued (Sec. 3097, Civ. CJ
Lender's Nam.
TOTAL:
F.LECIRIC FF?E
Lenders Address
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
I really the, I hast read this applic hmat and sham that the.hove information it
correct. l agree to comply with all city and county ordinances and stare Iowa relating to
building construction, and hereby audomicerepresrntmives oflhis city toemer upon the
above-memi.ned properly for inspection purposes.
PERMIT ISSUANCE ^
MECHANICAL FEE
ALTER OR ADD TO MECH.
CONSTRUCTION TAX
(We) a to save, inde nify and k harmless she City of Cu managed.
I'abili's,j cnta, costa expenses h inranywrayaccru< msdtaid
AIR HANDLING UNIT (TO 10,(100 CFM)
L of the gof his
AIR HANDLING UNIT (OVER 10,000 CFM)
Ig roof pplicanavc actor Dam
EXHAUST HOOD(W/DUCq
PAID
HEATING UNIT (TO 100,000 BTU) e
HAZARDOUS MATERIALS DISCLOSURE
Dam Receipt#
Will the applicant or future building occupant stem or handle hazardous materiel
m defined by the CaPenino Municipal Code, Contact 9. 12, and the Health card Safety
HEATING U141T OVER I00,W0 BTU)
TOTAL:
Cede, Section 23532(,)'!
❑ Yes El No
VENTILATION FAN (SINGLE RESID)
Win. rut confirmlocon eon. as building by the Bay equipment Quality es
igemech it
huzmd.us ur conheminants as defined by she Boy Area Air Quality Management
Dittrich?
E)x ❑ No
BOILER - COMP (UP OR 100,010 BTU)
ISSUANCE DATE
"}Y p pp
NOV�•IVI i r
BOILER - COMP OVER IW,000 BTU)"Y
(
NEW RESIDENTIAL MECH.' SQ. FT.
&I have read the hazmdo s materials requirements under Chapter 6.95 of the
California Health Safely Cole, Sections 25505,25533 and 25534. 1 understood that
d Q (�/� ,,
�994
\r �Y
if the building does not currently hove a tenant. that it is my responsibility to notify the
occupant of the requirements which must he met prim In issuance of a Certificate of
Uh
V LlrCr,
Occupancy.
ISSUED BY:
Owneror todlnritcd.Fut Date
%TATAIll
OFFICE 11