B 0109APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING. -ELECTRICAL PERMIT O. 0 1 0 9
BUu,DING DI VISION APPLICATIONIPERMIT r color' rvr.-MecunlYlcAl. SQOO'
solor' III. M CHANIF'll`aT1/1N
/✓„
,i SIS 13V7
{ 1 hemby vRmrthat I. licemedde
unr provisions of Chapter 9 (commencing
,��Z with Section 7")of Division 3 ofthe Business and Professions Code, andmy license is
W in rail once and effect. 7 ' 0
�UU Licenu Cl O Lic.R
y<L Date - --� Cnmmctnr
ARCHITECTS DECLARATION
Z p Z 1 understand my plans shall he used ns public recoils
OZ O
Fob W Licensed l'rneslonal
OWNER -BUILDER DECLARATION
6 I herchy affirm ohm I am exempt form the Commmor's License Law, for the
K6 V following reason (Secumi 7031.5, Business and Professions Code: Any it, ar county
which requires a permit to comtrum, alter, improve, demolish, or relief, any structure
prion,, its katimee,iase mgniresme applicant for such prmulm file a signedstmement
that he is licensed pumuma to the nositinns of the Contractors License Law (Chapter
a0(commencing with Section 7000)of Division Sof me Business and Professions Code) or
6 L o C Nat he is exempt themfrnm and the basis for the alleged exemption. Any violation of
X ENL Section 0031.5 by any applicant for a permit subjects the applicant to a civil penalty of
11141....7 not mom than five hundred dollars($500).
CC ❑1, as owner ofthe prapeny, or my enincyees with wages m their solo confrontation.
will do the work, and the nmemm is not intended or filleted for sale (See.]IW4. Bmimss
end Professions Gild The Contractor's License Law does not apply to an owner of
a 3 propeny who builds or improves thereon, mal who does such work himself m through
his own employees, provided that such impmvemems are not intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, the
owner -builder will have the burden of proving that he did not build or Infprove for put -
,,a of sale.).
❑ I, as owner of the pro,eny, am exclusively contracting with licensed contractors at
consumer the project (Sec. TBW. Business and Professions Coni The Conuacmes Li -
remain Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with u mnmractor(s) licensed pursuant to the Communes
es
License Law.
El I am exempt under Sec. ,B&PC for this reason
Owner Dme
WORKER'S COMPENSATION DECLARATION
I hereby of rto under penalty of perjury one of the following dechoations:
❑ I have and will maintain a Certificate of Consent to sell -immmfor Worker's Compen-
s tion, as no-ded for by Section 3700 of the Labor Code, for the perfommnce of the
which this µ,mit is issued.
wo 1 have and will maintain Worker's Compensation Insurance, as required by Section
37M of the Labor Code. for the perform a of the work for which this permit is issued.
My WorsilisSfimyensutii, lgkgLmcea..gfW mdPolicy.mY'%fF?Bi..Ai O
❑
Cg0-
❑ Consultant Fees Paid by Applicant (Initial)
}TY ELECTRIC PERMIT FEE
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPTO 200 AMPS
(this section need not beeompleted ifthepecout is for one hundreddollars ($100)
or less.)
I codify that in the performance of the work rot which this permit Ls issued, I shal I
not employ, any person in any manner m as a, become subject the Workers' Compem
O Z infirm laws of C.I fomia. Date
Z Q Applicant
h NOTICE TO APPLICANT': Jr. after making this Certificate of Exemption, you should
a�beemneauhjeen tonic Worker's Compemntion proof aioits of the What Cmle. You mml
W forthwith comply with such provisions or this permit shall ba deemed revoked.
0
CONSTRUCTION LENDING AGENCY
V 0 l hereby which nn tbauhdrisaconswetionlending agency for performance nr
W the work for which This µmfit is IasuW (See, 3097, Civ. CJ
U Lender's Name
Ya Lender's Address
I ccnify that L have said this application and atom That the stove information is
► h coned 1 agree to comply with all city and county ordinances and state laws relaxing to QTY.
V building construction. anti herchy uuthorue representatives of this city,, emerupon the,
aMve tnendoned mope ly rnr inspection pemosa,.
(We) agree to save, indemnity and keep harmless IIIc City of Cnpeninn dem
liabilities, judgments, emu and expenses which may in any way acerae agaiml said Ciry
Iasequence of the granting of this pemtit.
APPLIC6PTP'CN'DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
defirand by the Cupmlino Municipal Gale, Chapter 9.12, and the Health and Safety
de, Sdueon 15532(a)'!
❑Yes Fl No
Will the applicant or for= building «cupam use equipment or devices which
it hamdous air emanatioants as derincd by the flay Area Air Quality Management
+vin'!
E] Yea E] No
I have read the hmardows materials requimrnenu under Chapter 6.95 of rhe Cali.
ria H.10 & Safety Code, Sections 255115, 25533 and 8531.1 understand that nine
ding dues not currently have a I nano that It is my responsibility to nobly the occuµnl
the mquimnents which must M mel prior to issuance,,! a Certificate of Occupancy.
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUI V M LSC.
TEMR METER OR POLE INST.
POWER DEVICES �(
SWIMMING POOL ELECTRIC%I
OU'ILCTS - S W IT'CHIS - FIXE
NEW RESIDENTIAL ELECTR
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (IIA)
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR. ROOE, AREA, COND.
FIXTURES - PER TRAP
GAS -IIA. SYSTEM.I INC. 4 OUTLETS
GAS- IIA. SYSTEM OVER 4 (EA)
GREASFANDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWER -SANITARY - STORM EA. 210 FT.
WATER HEATER WNENDELECfR
WATHR SYSTEMITREATING
WATER SERVICE
NEW RESIDENTIAL. PLMB. SQ, ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 18,000 CFM)
AIR HANDLING UNIT (OVER IQfXXI CFNU
EXHAUST HOOD UVIDUCD
HEATING UNIT (TO U10.0000 BTU)
HEATING UNIT (OV LIR 100.000 B U)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP OHP OR 100,010 BTU)
BOILER -COMP (OVER 100.00) BTU)
AIR CONDITIONER
NEW RESIDENTIAL. MECH. SQ. FT.
OFFICE
TOTAL:
FAN
❑ ❑ ❑
JOB DESCRIPTIO
RESIDENTIAL:
❑SFDWI.
KITCHEN REMODEL
❑ADDITION
El PLUMBING RE -PIPE
❑MULTI -UNIT
[]STRUCTURAL
MODIFICATION
❑INERIOR
❑CHIMNEY REPAIR
IMPROVEMENT
0SWIMMING POOLS
❑ BATH RF-„MODEUREPAIR
❑ DEMOLITION
❑OTHER le!--
T
COMMERCIAL.
E] NEW BLDG/ADDITION
❑DFNUHATION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SQ. FT. FLOOR AREA $ISQ. FT.
FEE
VALUATION
O
STORIES TYPEC(INSTRUCfION
OCG GROUP APN
BUILDING DIVISION PEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
OX
PAID
Uam Receipt#
TOTAL: _
BUILDING FEE
FEE SEISMIC FTE
IiLECTRIC ITE?
PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID
Date Receipt#
ISSUED BY:
ISSUANCE. DATE