00010098 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0.
BUILDING DIVISION APPLICATIONIPERMIT PLUGING-MECHANICAL
(,!- - 'ter BIIII,)INGPROJEC7�IDliWIFiCAT10N..:. le i)! .`
HUILDIN�UDRES SANITARY NO. APPLICATION SUBMITTAL DAPS
OWNER'SN Mli; HONE: COMRACTOR'S L - 2_ e
��
.lJ /�MD d O L"� dO SIC COMROLp
CHITECI'/ENGINEER: /` LIC NOIF) : J ADDRI35: ❑
N'TACT. PHONE: eoo CA ,�')f i;,BU1LDING PERMIT INPO "
ConsultantmPaid by Applicant Initial) BLE6 ELECT' PLUMB MECH
(J•Y V (( C"J ❑ ❑ ❑
LICENSED CONTRACI'ORl DTCLARATION QTY 1 i ILHCTRIG PERMIT { �I 'II FEE II"!
Thereby affirm that licensed d g of Chapter 9 mmmme g 1 i t .,: ) L.d:ur", 3 t - ,hi JOB DESCRIPTION
DOZ whh Sec...at 70mcofD"at„3tlmelws .,d u,Rssot,code,i,nnyl'cc RESIDENTIAL:
F1= in full farce mW effect. PERMIT ISSUANCE D SFDWL D KITCHEN REMODEL
U License Class Gc.M
-Zw Date Contactor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RF:-PIPE
ARCHITIiCFS DECLARAI'[ON ❑MUI.TI-UNIT ❑STRUCTURAL
pZF,4 l understand my plans sh ill he used.,public records PANELS MODIFICATION
�O UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR
liq Uremed 11 he"amal 201-1007 AMPS IMPROVEMENT
Y ❑SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 ❑13ATH REMODEUREPATR C1 DEMOLITION
S w Q 1 hereby.firm that I em exempt from the Cocoons Co License Law for the
W 3 a U following mawa.(Section 9onstr Business and improve,
demolish,
Cade:Any city memory
SIGNS EL AL ❑OTHER
W w h which requires a permit m uae flag alma,improve,deernat 1 or repair any atruemrc
u'��' hothevia sliensed..Lma, ,,0m,por—onofal far auchpemr's License
goad,latch, COI
C ¢�
hot he is licensed punuem nvhc tinrvinenns oRhe Cnntradnra Liansc Law fChapter9
W00
(commencing wilh Smdon]glE)nf Ulvisinn3of the lLesineasand Pmfexsionx Cadc7ar .METEI )li .E IN$T. COMMERCIAL:
a o Nat he is exempt therefrom and the have for the alleged exemption.Any Attleboro of D NEW BLDG/ADDITION D DEMOLITION
y Section]031.5 by any applicant for a pool,sohjecta the applicam m a civil pen.lD DEV :S Cf'TE*NT ❑FOOD SERVICE
not more than Bvc hundred dollen(5500)
~Sp ❑1,as owner of the progeny,nr myemplu}ees with wages as lheirsole campensmiat SWIMMI 'IYJOI.ELF. C IMPROVF:MIiNTI,
' F will do the work.andtaestrunure hoot ithemdedomlTared Futile(Sec.6B14.Business DOTH C.V
[ll a and Prnfes,io is Code:The Connector's License L,ov ,docs nal Upply In an owner of OUTLETS-SWI PCHES-MIXTURES
C progeny who hulld,oa improves IM1eream,and who doe,such workA
his own employee.,provided that such improvements arc net inteNEW RESIDENTIAL ELLC'TR SQ FF.
sale.If,however,the buildingorintpmvemem is sold withinoneyeSQ.FE FLUOR AREA $/SQ.FT.
owner-builder will have the burden of proving that he did not build
pose of sale.).
I,as owner of the property,am exclusively contracting with]le
mot t th p 1 (4 .9044 B d P f :C b )c a 1. I Sdy Ip pry 1 b ild: ' tIaI m exempt under S ,B&
Owner D. C D AIN :N A'I
�OfU_UATION
)� WORKER'S COMP'rper PI ON DI3CLARAII 1 /� O
I hereby affirm under penally a 1perjury one oflhc milowi ti 66
I have and will maimaina Cenifeaeof Consoil motif-insure for Wnrkch Camper- RA 1. R, 00 I STORIES TYPE CONSTRUCTION
Irian,as pnrvided for by Section 37M of the Labor Code,for the performance mile,
weak for which this permit is issued FIXTURES-PER TRAP
D 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance ofthe work for which this pmol,is issued. GAS-EA.SYSTEM-]INC. OUTLETS OCC GROUP C AP]�
My Workers Cooluensalian In,mnnce carrier mint policy number ere: / 6U e�
Cartier. Policy No.. GAS-EA.SYS'I FM-0V 4(EA) 11k000
CERTIPICArp OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASUINDUSTRL-4h-4 ERCEPTOR Cot
Mo section need am be ctmpleted if Ne permil is(or one hundreadollars(5100) BUILDING DIVISION PI?GS
or less) GREASE TRAP
PhANCHECK FEF.
lemony Ilialin the
nof the work for which this U ,Ishall SEWER-SAN]TARY-STORM I?A
m cnttiayany pcnnn in an, it;nsersu as m become uFteet Ia nor Wnrkm,'Cnpen-
41 13NI31iGY PEE
C) Z ,abort Laws nl'Cahrona a.Dale WATER HHA'1'13R W/VENT/E
Z Applicant L li GRADING FEB
= NOTICE TO APPLICANT:If,after making this Cenifcme of E.aemption,you should WATER SYSTBMG`REATING
hecume subject to the Worker's Compensation provisions of the Latin GNe,you must 50145 FEE
w forthwith comply with such provisions or this permit shall rte deemed revoked. WATER SERVICE
�O CONSIytOGI ION LENDING AGENCY NEW RESIDEN'I'I Al,I'l SQ.t1', PAID
I horehy affirm that there is a construction lending agency for the scrrormmree of Date Receipt#
Fthe .,it for which this permit is issued(Sce.3097,Cie C.)
Q Lenders Nano TOTAL:
Lamilet's Address TOTAL
Fy Icrify that I have read th's appl' t I state that the h information s - _ BUILDING FEE
rw (A cont e I g t ply with II ty a county f and same lrelating to QTY ,. MECHANICAL I ERMIT) I . , 12E}
V � build g wlr.I r,adhrely tlhr,rw p uml vcs of ll city mcaterupan the r 4., , 1" . tea t, SEISMICFEE
abo e-rua l aid prapeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hannles.s the City of Cuticular,against ELECTRIC FEE
liabillties.judgmays.costs and exgcnus which may in any way evince against said City ALTER OR ADD TO MECH.
in asequence of the granting of this pent PLUMBING FEET
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,()(N)CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of ApplicamiContmcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA XRDOUS MATERIALS DISCLOSURE
Willfne applicant orfuture building mcuparn,ane or handle btuardousmamrisl HEATING UNIT(TO 1110.000 B'N)
a,defined by The Caperton Municipal Code,Chapter 9.12,and the Health and Safely
Gale,Section 25532(a)1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nn PAID
VENTILATION FAN SINGLERI351U1 Will thea Ilan,or future building Deco I use a ui t or devices which Date Receipt
pp g pan q Amen BOILER-COMP 3HP OR 108,(x10 BTU)
nithazvduua air cnnmminamssdefned by the Bay Area Air Quality Management (' TOTAL:
FstrlcC
❑Yes [D No BOILER-COMP(OVER 100.000 B I U)
I have read in,record... ralroalsreumment,antler Chafer 695 of he Coh- AIR CONDITIONER
q A ISSUANCE DATh
fomiU Hwl1h&Safety Code,Sections 2me,xis any and 25534.1 undemm�J tam if the NEW RESID13NTIAL MECH. SO.FT.
building me not,which havet mount,tum.is my rc.ode Cirdfi,e notify the ogre, '
of the requirtmm�ls which mot be nret priono issuance of a Cenifi<a¢of(krupancY.
Owns or uwhnrireA
nor Dale TOTAL: ISSUED BY:
OFFICE