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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
PE
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
,BUILDING PROJECT IDENTIFICATION
BUILDING DRESS:
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SANITARY NO.
LICATION SUBN5 A. ATE
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CONT
OHS I.' LIC NO:
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❑
CONTROL p
�ARCHUTCUENGINEER Plait.
AD R., O��
CONTACT: PHONE:.
}-.'' BUILDING PERMIT INFO
-
❑ Consultant Fees Paid by Applicant (Initial)
BLDGELECTPLUMB MECH
_LJ L ❑ ❑
LICENSED CONTRACTORS DECLARATION
I herchy arum thin I am licensed under prnvixions of Chupmr 9 (commencing
QTY. ELECTRIC' PERMIT,
_ FEE
JOB DESCRIPTION
with sacdan 7m]N mDivisfon3mthe Hminesxand Pra1c,,nmseadc,mdlny licenaels
in full fares and,flcm
License Class Lic.p
Date Contractor
/
/I PERMIT ISSUANCE
RESIDENTIAL:
❑SFDWL [I KITCHEN REMODEL
❑ADDITION [I PLUMBING RE -PIPE
MULTI -UNIT []STRUCTURAL
MODIFICATION
APPLIANCES -RESIDENTIAL
ARCHITECTS DECLARATION
I understand my plans shall Na hied as public records
PANELS
A P
M
I $
INTERIOR El CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHER
M
Licensed Professional
Oto I OWNER -BUILDER DECLARATION
1 herchy e1Brm Thal I em cxsmpt from the Cnnvacfors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requites a permit to conshim. eller, improve, demolish, or repair any swcture
$IG ELE 1
primmits isxunnee. also requires the applicant forsuch perminn fileaslgtedsmmmee,
spr LCI)&S Igo'ha
that he is licensed purmaten to the provistuns of the Comrucmr'x License Law Chimera
(commencing with Section 70011) of Division 3 of,he Business and Professions Cade) or
1 TB 011 POLE INST.
tllQ
'
thr, he is exempt Iherefmm and the hoses for the alleged exemption. Any violation of
❑ W BLDG/ADDITION C:1 DEMOLITION
Section 9031.5 by any applicant for u permit subjects the applicant to a civil penalty of
net ..,ban file hundred dollars (SSW).
❑ 1, a ownerof,he progeny, or my employees with wegux a their tale compensation.
will drum work, and,he.nmctum is not intended m offered for sale (Sec. iBW, Business
'S
I 1
ANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
-
and Professions Code: The Contractor's License Law drex not apply 1. an owner of
OUTLETS -SWITCHES -FIXTURES
property who builds or Improves thereon, and who does such work himself or through
his own employees, provided that such improvements are nm intended or mared for
NEW RESIDENTIAL ELECTR SQ E -n
SQ. FT FLOOR AREA
SISQ. FT
sale.If,hnwevee the building or improvement is sold within one year ofcamplerom.the
ner-buildcr will have the burden of proving,ha, he did not Imild of improve for puT-
pose of sale.).
TOTAL:
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (S a 70,14 Business d Professions Code:) The Contractor's Li
verse Law does not apply to an ow, tier of property who but Ids improves th arcon, and
who conk Itis for such p j cts with a umlretor(x) ficeuul pursuant m the Contractors
QTY., I (e, PLUMP _ f 1 FEE' ar3
PERMIT ISSUANCE
License Law.
❑ em
]amextunder Sec. ,B& P C far thixrcaxon
ALTER - DRAIN & VENT -WATER WA)
Owner Dam
VALUATION
0
IiV WOIf1KER'S COMPENSATIONIIISECI ARATION
I hefchy uffirm under penmty of pe,my one of the fmlewing declarations:
BACK FLOW PROTECT DEVICEfl
DRAINS -FLOOR, ROORAREA.CONU.
❑ I have and will inammin a Certificate of Ghnssnrfo self -insure for Worker's Conspso-
smion, as provided for by Section 3700 of the Labor Code, fonhe performance of the
STORIES
TVPE CONSTRUCTION
FIX TURES - PER 'FRAP
work for which this permit is issued
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37Mofthe lrhar Code, for the Performance ofthe work for which this permit is issued
My Workers Compensation Insurance carrier and Policy number are:
GAS - EA. SYSTEM -1 INC. 40UTLIES
DEC. GROUP
a 7 APNI
J
Cartier: Policy No :
CERTIFICATE O[' EXHMPDON FROM WORKERS'
GAS - EA SYSTEM -OVER 4 (EA)
1034/
COMPENSATION INSURANCE:
(Thiacclumieednm be completed iffhe .it is future hundred dollars($100)
or less)
GREASMNDUSI'RI. WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASE TRAP
PLANCHUCK FEE
SEWER -SANITARY -STORM EA. 200 FT.
I cenify that in the perfurmanceof,be workforwhich this permit isiasued[,hall
not employ any Pnson in any manner so as to become subject to the Workers' Compen-
cation Lows of California. Dam
APplicom -
EVER EE
I
WATER HEATER WNENT(ELECTRj
GR,<viNr,,FbE
LI11�
NOTICE ID APPLICANT: If, after making this Ceni from of Exemption, you should
become subject mthe W'orker's Compensfumn Provisions dom tabor, Cmle, you must
forthwith comply with such Provisions or Nis permit shall be deemed revoked.
WATER SYSTEM[] HEATING
WATER SERVICE
SOILS FEE A I �f
if
NEW RESIDENTIAL PLMIL SQ. ET.
CONSTRUCTION LENDING AGENCY
Iherehy ulBrm Nat there lsxcnnxwmion lending agency for the perfnrmm�ce of
PAID
Dam Receiptp
Ire wmk for which this pcmdt is Iasned (See. 3097, CO,. C.)
Lender v Nmnc
TIAL:
Leul,,Address
TOTAL:
1 cenify that I have mad this application and shoe thin the above information is
BUILDING FEE
- -
nee[. I agree m comply with all city and county ordinances and state laws rela,ingm
building construction, and hereby authorize representatives of this city to cntar upon the
QTY, MECHANICALPERMIT 'FEE
SEISMIC IEE
abve-mentioned foularty for inspection purposes
(We) hires m save, imiemnify end keep hannlnss Lha City of Caperton against
PERMIT ISSUANCE
ELECTRIC
Iiabilities,judgmems, costs and estemses which may irony way aceruea,mus,sid City
in nseghenee gra
of the num, of this permit.
ACT ER OR ADDI0 MECH.
PLUMI3IN E
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANIC FEE
APPLICANT UNDERSTANDS AND 'L COMPLY WITH ALL NON -POINT
REGULATIONS.
AIR HANDLING UNIT(OVER 10,0(X] CFM)
CONSTRU ION TAX
)SURC,f6
of Ap Ilcem/Cmannahr Duro
I IA7 s RDOUS MATB ALS DISCLOSURE
EXHAUST HOOD(W/DUC`U
HOUSIN ITIGAT]ON FEE
HEM ING UNIT (TO 100,000 R' IT)
Will theri,licam or future building accepamscore nr handle hazamo., materiel
as defined by the Caperton Municipal Code, Chapter 9.12, and the Health and Safety
Cade, Section 25532001
HEATING UNIT (OVER 100,001) BTU)
E] Yes ❑No
Will the r ileans Of fours hui Wing occupant useuseequipment or devises which
emit hnzarou
ds air
ar cmwminama its Jdlned by the Bay Areu Air Qualify Monagemenf
PAID --
Ua,e Recei
VENTILATION FAN (SINGLE RESID)
BOILER -COMP (31113 OR 100,000 BTU)
District?
❑Yes 0 N
BOILER - C100.000(OVER I00,IXBTU)
AIR CONDITIONER
I have rcwl the hazardous mmmals reyuireinents under Chapter 6.95 of the Cali-
ISSUANCE DATE
NI?W RESIDENTIAL MECH. SQ. ET.
fomia Health & Safety Code, Sections 5505, 25533 and 255331 understand that if the
building dmsnnf Cnrlcray haven TO,, 11, y •phonsibilifymnotilylbencenpant
'Itre ht�hrenhvnt uxlh tinct pct a fu CertiECd d c
y �^ // L,/� w!i�
IF—or
C r r T
ISSUED BY:
riumahori dagenf AFDale
TOTAL:
OFFICE