28910 APPLIOANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^/ Q1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL - L H V 1 O
BUILDING PROJECT inEwIFICATiON
'
BUILDING ADDRESS: - SANITARY NO. APPLICATIN SUBMITTAL DATA
iozAM � cv. Avg,, Z�
OWsN/L�-R'gNAME:s PHONE: CONTRACTOR'S NAME: LIC NO:
ZZ, slC
CONTROL#
ARCHITECT NEER: LI NO: ADDRESS:
N IVC ' U
CDNTAC . `. kJ PHONE: .r BUILDING PERMIT INFO
^"1_E39rW ❑ ConSultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB . MECH
LICENSED CONTRAC DF.CI.ARATION -1-W EJ 0 El
1 hereby anion that 14m licensed under provisions of Chapter 9(commencing jQTYrMELECTRIC PERMIT FEEJQB DESCRIPTION
yRow6with Section?000)ofDivision 3 ofthe Boalmeasand Professions Code.end my license isFqW- in full fore and eRal. ANCE RFSID NTIA6 U FLicense Class Li,.# ❑SFDWL ❑KITCHEN REMODEL
[ ;7w Date TSDEmr S-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Oh ARCHITECTSDECbli Am,ON
Ma ❑MULTI-UNIT ❑STRUCTURAL
P1Z 1undernamlmyplansshellbeuseJazpublicrtcnrdsZ J MODIFICATION
MP$ ❑INTERIOR ❑CHIMNEY REPAIR
Licensed Prcfessmal PS IMPROVEMENT
OWNIiR-BUILDEROECLARA'TION '1 hereby nftmt than 1 am exempt from the Commences License Law for theMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3a,U followingtwson.(Section]03M,Businessand Pm(essiansCode:Anycity orcountySIGNS ELECTRICAL ❑OTHER
which requires a peraa a m,om,turct,alcor,improve,demulah,or repair any structure
t�y prior to its issuance.also requires the applicant lot such permit to file a signed sm¢ment SPECIAL CIRCUIT/MISC. �
yWW p. Nat he allocated parsmanflthe pruvisionsufthe Conrmemr's License law(Chupter9
(commencing withSeetion 7000)of Divieion3ofthe BusinesaadPmfessamsCodelor TEM,METER OR POLE INST. ('OMA_)
ty that he is exempt therefrom and the basis for the alleged esemptioa Any violation of FR(-LAI
❑NEW BLDG/ADDRION ❑DEMOLITION
skit W Sectior701Ll by anyapplicum for a permit subjCCB the applicant it)4 civil penalty of POWER DEVICES
nut more than five hundred dollars 1S501q. - ❑TENANT ❑FOOD SERVICE
< Q I,mowner of the propcny,nr my employees with wages aztheir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do Be work,and the struamrc is not imealed or offered frrmle(Sec.7044,Business ❑OTHER
and Profession Code:The Communion's License Law docs conn apply to an owner of OUTLETS-SWTTCHFS-FUCfURES
Nproperty who builds or improves thereon,and who does Inch work himself or through
his own employees,provided that such improvements are not intended or me ed for NEW RESIDENTIAL ELECTR SQ FC
sale.If.however.the buildingm improvement is sold within one ycarofmmpinion.the SQ.FL FLOOR AREA 5/SQ.PL
owner-builder will have the burden mf proving Nat he did not build or improve for put-
potentiate.).
1,as owner M the property, m exclusively cmnwcting with licensed contractors to TOTAL:
construct the projan(S¢.TD14, css and Professions Code)The Conundors LL
cense law does not apP3 nc an not pmpery who builds m for coves Hereon,errd FEE
who contracts for such jests oar intoxicants)license) tto the Contractors QTY. PLUMBINGPERMIT
License Law. pursuan
❑1 am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALOAD
11 y I KERS COMPENSATION DECLARATION BACK FLOW PROTF.LT.DEVICE
[firm under penalty of perju rte m(Ne following Jcdma[ions:
❑ Ihave an 'll maintain vCenificat mself-insure for Worker's Compcn- DRAINS-FLOOR,ROOK AREA,COND.
sntion,a p in for l Section 700 e r Cale,for the performance of the STORIES TYPE CONSTRUCTION
work for whic in Pertni[is issuedr FIXTURES-PER TRAP'
❑ 1 hove and maintain k�Tbb anp nsafiioa Insurance.as required by Section
3700tfthe Labor Codgfor dmommoaaf Newark for which this Permit is issue. GAS-EA.SYSTEM.I INC.S OUTLETS OCC.GROUP APN
My Workers Comperrsation In r ace catrieraad Policynumber ate:
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
t COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
OTbis section need net becompleted if the permit in forms,hundred dollars(5100) BUILDING pIVISION FEES
orlasJ GREASETRAP
I metifymbar in the permomanceofthe work for which this Permit is issued,[shall - PLANCHECK FEE
net employ any person in any manner so as to become xohjecm m the Workers'Compete SEWER-SANITARY-STORM EA,200 FT
Wind Laws of California.Data ENERGY FEE
z O Applicant WATER HEATER WNENT/ELECTIR
NOTICE TO APPLICANT.IL after making this Cerificme of Exemption,you shouldGRADING FEE
abecome subject to the Worker's Compensation provisions of the Labor Code,you most WATER SYSTEMOTRF.ATTNG
Q forthwith comply with such provisions or this permit shall he deemed invoked, WATER SERVICE SOILS FEE
oz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID
V Q l hereby affirm that then is a construction lending agency(or the performance of Dam Raeiptp
F the work forwhich this permit is issued(Sec.3097,Civ.C.)
O U Lenders Name TOTAL:
Leaders Address TOTAL:
0. 1 arify that I have rad this application and some that the above inforowdon is BUILDING FEE
fA ,tenet l agree to comply with all city and county ordinances andsmm laws relining to QTY. MECHANICAL PERMIT
U Z building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree nc save,indemnify and keep harmless the City of Caper iso agaiat PERMIT ISSUANCE ELECTRIC FEE
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. r `
In crosmquence of the graming of this permit'APPLICANT UNDERSTANDSPLUMBING FEE
APPLICANT UNDERSTANDS WILL OMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFM)
SOURCE ULAT N` MECHANICALFEE
/V 7. JC6 AIR HANDLING UNIT(OVER IQ(DO CFM) CONSTRUCIONTAX
Si'mu f 'in.—
cv onauc Da EXHAUST HOOD(W/DUCT)
HAZAR ATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will Ne applicanwr f arc buil ding occupantsmre ter handle hazardous material HEATING UNIT OTO 100,000 BTU)
as defined by the Caperton Municipal Cale,Chapter 9.12.and the Health and Safety
Code,Section 25532(,1? HEATING UNIT(OVER IOLDXI BTU)
❑Yes ON.
VENTILATION FAN(SINGLE RFSID) PAID/42--� CAA
Will the applicant or future building occupanm use equipment or devices which fl an. Recei-p
emit hazardous air cmmaminnnm as defined by the Bay Area Air Quality Management. 'BOILER-COMPOHPOR 100,000BTU)
District?
❑Yes .TOTAL:
No BOILER-COMP(OVER I W,OW BTU)
UL" UkdCa a l HVU
1 have rad the haurdous materials requiremems under Chapter 6.95 of the Cell- AIR CONDITIONER
famia Health&Safety Code,Sections 25.505,25533 and 25514.1 understand thud if the ISSUANCE DATE
building doesnm cmrmly hive a tenant that it is my respoaibility w ma;fy Ne mccupam NEW RESIDENTIAL MECH. SQ,FT. A
of the texamem,ms which must he met pdmto icon.of a Cori of Occupancy.
Owner m authorized agent Date TOTAL: ISSUED BY.-73e—
OFFICE
Y: ?3e—
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OFFICE