26056 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO R ILDI .-EI.A'FRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB INO-MtIDENTIFIC 26056/1 O r b
BUILDING PN(p1iCf IDENTIFICATION L b "V1 iV�
BUILDING A DURESS: /� SANITARY NO. APPLICAIIONSUBMITTALDATE
• UNIT# ^� LOT
OWNIiItSN E: 11110#7:: COM'RAC'I NAME: Irk"' LIC NO: NIC CONTROL#
RCIII'I'F:L /ENGINEER: LIC NO: 5DR SJ/ eV&, ,4VLU tt.+� ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT PI?E BUILDING PERMIT INFO
LW ELECT .UMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION ppPL[ANCF.S-BESIDE L JO DESCRIP7 N
tyz • I hereby affirm that l am licensed under provislonsofChal (commencing with
1 00 Sedion]WB)efDivision3of the Businesea dPr.Itf tattoos Cade unJ my license ie in PANELS
t �
It forceandeffe - UPT02M S '
LLjjZZ Date Class Liars
y6z Dale C.CT*SDr $r 2(11-1(100
ZOV,- ARC 11 tic uTSDECLARATION OVER 1000 M SQ,FT.FLOOR AREA SRQ.FT.
O Z—G 1 understand my plan shall be used m public records.
1=.viERJ SIGNS ELE 1 AL I�
Licensed Professional
44 OWNHR-BUILDER DECLARATION SPECIAL CI C T/MI. �I
I hereby n(frm that 1 son exempt from the Commerce's License Law for the
0.13LLF Iiglowing reason.(Section 7031.5,Business and Professions Code:Any city orcounty TEMP.METER OR 1101.111NST.
F f�yO which ar mates apennirm crnntnel,alter,improve,demrlish,or repair nny soucturt
� i•� prior to its issuance,alsorchadmis the applicant(orsuch Permit o rile a signed statement POWER DEVICES
y(R G pK that he is licensed pursuant o the provision of the Contractors license Low(Chapter
6i�LL 9mammencing with Section 7")of Division 3 of the Business and Pro(exsiom Code) SWIMMING POOL ELECTRIC VALUATION
_y or that he is exempt therefrom and the basis for she alleged exemption.Any violation of OUTLETS �� MYI.N
Z Q Section 7031.5 by any applicant for a permit subjects the applicant to o civil penalty of /q b
5,,SS nor more than five hundred dollars(SSW), NLWRESIDENTIALELECIR 5 . . i
❑m ElI,asownero(thepropcny,ormyemployeeswithwagesmtheirsolecompensation, Q1TSTORIES TYPECONSTRUCTION
6322 will dmhe wmk,mnd the moraine isnot irandedorOffered fondle(Sec.70a4,Business
and Professions Code:The Cmantrum,License Law docs not apply to as owner of
property whobuilds or improves t bemomand whodoes such work unwell'orthroughhis C .GR YP iS.0 1175
wa employees,prou
provided rhauch improvements are not imended mothered forsale.IL
however,he building or improvement is soldwithin one yeurofcampletion,the owner. N ��)
builder will have the burden ofproving that he did nor build or improve for purpose of IL �/ II II �EE
s❑)Lasownerofthe property.sum enclucivelycontmcting with licensedconoaetmato
QTY. PLUMBING PERMIT L'✓ �U' I'Q" ppN
nslrvct the project(Sec.TU44,Business sod Professions Cafed The Canwcttax pC:RMIT ISSUANCE s
License Lmw Jocanm apply roan nwnero(prcpenywhm buildv orimprnvea lhercan,and TE
who contracts forsuch Projects with a contmam(s)licensed raiment in the Contraetmre ALTER License Law. FEE SUMMARY
❑ I am exempt under Sec. ,11&P C for this reason BACK FLOW PROTECT.DEVICE
SANITARY YN
Owner Dara RECEIPT
GRAINS-FLOOR,ROOF,AREA,COND..
WORKMAN COMPENSATION DECLARATIONSCIIOOL TA% Y N
L Tlhereby a(frtn rlwtlhaventtnificare of coruem maelGireum,ora certificate of — REC IITp
_ orkcrs'Cam nsarion Insurance arecertif decry rhewf(Sec.3HIX1.Lab CJ which FlXTURES-PERTGI' PARK FEE Y N
coven all employee's under this permit ///✓3 IfGA. REC IPI'#
Policy 7b ft�•� GAS-G.SYSTEM-I INC.40fITLETS BUILDING DI 1 ION MI
Company
CI minified copy is hereby famished. GAS-G.SYSTEM-OVER 4(EA) PLANCHECK PER
'eni0ed copy is filed with the city inspection division. GRHASFANDUSTRL WASTE INTERCEPTOR GRADING FliE
CERTIFICATE OF EXEMPTION FROM WORKERSGRFASETRAP SOILS FEF,
COMPENSATION INSURANCE
(Mol section need not be completedHim permit is for one hundred dollars(SMB SEWER-SANITARY-STORM EA.20017. ENERGY
or less.)
I emi(yshe,in the perfmamiceoffle work far whichthin permit is issued,lion WATER HEATER W/V7:NT/ELF.CIR
not employ my person in any m m w became subject to the Workers PAID
Compensationlawsof Cali(omia.manner
so WATER SYSTEM/BEATING RettiprM
Q z Applicant
0 NOTICE TO APPLICANT:IL after making this Cenifcate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.fir. TOTAL:
(n become sobject to the Warkerk Compenstion
aprovisions of the[..bar Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked. 4EIE
I1I
CW [� CONSTRUCTION LENDING AGENCY
.:. z Ihereby afford that is a construction lending agency for the performance of
U O the work for which,, gmry i;issued(Sec.3097,Civ.C.) E
D. lenders Name /%/eM'P
O U Lenders Address' QTY. MECHANICALPIERMIT FEE
1 ceni(y that 1 have read this application and sate that the above information is
correct.l agree to comply with all city and county ordinances and slate laws misting to PERMIT ISSUANCE �� L 'CEaaassat
building cmswctim,md hereby milium a represenmriveeof this city w ctamaron theU IO TAXU z nlmve-memine,,winve"m inspection purposes. ALTER OR ADD TO MSCI I.(m greerosave,indemnnvytodCityiuhll'ie croudn tenses ich mayinanyway nerve ugainatsaid City AIR HANDLING UNIT(I010,(XIU CFM)
ce of the lFwtin Ibis iI.
'? ` AIR HANDLING UNIT(OVER Ia,000 CFM)
Jcar Data EXHAUST HOOD(WMUC)HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,"BTU) am
Will the applicant or future building occupant sore or handle baeerdous material 1IIIATING UNIT(OVER I W,(100 BTU) TOTAL:
us defined by the Cupenino Municipal Code,Chager 9.12.and the Heath and Snfmy
Code,Section 25532(a)P VENTILATION PAN(SINGER RESID)
11 Yeso
// BOILER-COMP(3HP OR 100,000 BTU) pq ISSUANCE DATE
Wilhheapplicamorfuturebuilding occupant use equipmenrardevices whichemir r A Q 0
nodous air c isman nuts as dcrined by the Bay Area Air Quality Management BOILER-COMP(OVER 1011000 BTU)
Ithet? ,,.,aE'
❑Yes }k;no NEW RESIDENTIAL MECH.—SQ,FT. IjnII O ����
I have read the humorrous materials requirements under Chapter 6.95 of the _ (,jflPj
Cali fomin l health&Safety Cadw�S•ctinns 25505,255 3 and 25534.1 understand that CIIY (ff UUYCh111YU
a 11,c building y�1ssn aeally nuvealM , Ihvf say rcsPondblllty to notify the
r¢cut_.of r k mare
whlc be m dor m Insuunce of a Ccnificale of
GccaPnot q
,Ft- Z
Owner or au g Dale ISSUED BY:
OFF