31077 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERNUT PLUMBING-MECHANICAL - K 1 077
BUILDING PROJECT IDENTIFICATION 1_ J 1
BUILDINGADDRFSS: SANITARY NO. APPLICAT[ONSUBMITTALDATI
s83 Ca���e 1a7. f• ,, fin., /r -9'7
OWNER'S NAME: PHONE: [Y CONTRA IrGndAMH. / LIC NO: n.�,G NIC CONTNOLk
c✓ICII�I... •6Sj(.1.� 257'—&as /7 nam fIX.� 1 nZ4Zv'
ARCHITECTIENGINEift: LIC NO: ADDRESS: ❑
r
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ C ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
GRZ with Section70W)of Division 3ofthe Business end Professions Code,end my license is RESIDENTIAL:
O O PERMIT ISSUANCE
C W F infaia rceClass d effort. ❑SFDWL ❑KITCHEN REMODEL
aUZ Dan Class Limp APPLIANCES-RESIDENTIAL ❑ADDITION 'B.PLUMBING R&PIPE
F>ae 1E Dv,e Contra CL
ypaj ARCHITECTS DECLARATION - - C1 MULTI-UNIT ❑STRUCTURAL. '
pZ_F Iundermm�d myplens shell be used vs public records PANELS MODIFICATION
P.O UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
r4gm Licensed Professional 201-101a AMPS IMPROVEMENT
2 OWNER-BUILDER DECLARATION
1 hereby amen thin I an exempt from the Contractors License Law for she OVER HM AMPS ❑BATH REMODEIJREPAIR DEMOLITION
X 3 d U following reason.(Section 7031.5,Business aW Professions Com:Any city or coumy SIGNS ELECTRICAL ❑OTHER
ttii7l LL LLO which requires a parrots,o anuwm,elmr.improve,demolish,or rcpdr nny suucwre
Frimto its issuance,also requires she applicant for such permit to file u signed statement SPECIAL CIRCUIT/MISC.
ythe,he is licensed Pursuant o the provisionsof Ne Convvcmr's License Lew(Chapter 9
GC (commencing with Section 7")of Division 3 ofthe Business and Professions Cade)m TEMP.METER OR POLE.INST. COMMERCIAL:
c oe than he is exempt therefmm and the basis for the alleged exemption,Any violation of ❑NPW BLDG/ADDITION ❑DEMOLITION
ti• Section 703 L5 by any applicant for a permit subjects the applicant o a civil Penalty of POWER DEVICES
w ANT
L„ y tmnra than five hundred dollars(5500). ❑FOODSERVICE
ROVEMENT
aC E]1,as owner man,propry,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is no,intended or offered forsole(Sec.7044,Business ;HER
and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-MIXTURES
prolsery,who builds or improves thereon,and who does such work himself or through
his own employees,provided that such intpmvemems are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT.
sale.If.however.she building or improvement issold withinone yearofcompletion.,he SQ,PT.FL $/SQ.FT.
caner-builder will have the human of pving that he did not build or improve for par- // D
pose of eowne L�
❑ I,b th rof o ject property.,Business exclusively connecting,with licensed contrxmas i- TOTAL: q(n
esnawcl the project pply.o0 n wnofand Professions ds or i TheContractorthecmr's Li-
c se Lawdoesforschply,oan with
aofpmpeny whobuildsNorton,and QTY, PLUMBING PERMIT PEE V
who teas for such projects with ammr aortsl licensed pursuant to the Contractors V�' L nI
Littmaelaw. PERMIT ISSUANCE - �urt+IIj I/vu
❑I am exempt ander Sec. ,B ffi P C fonhis reason z■
Owner Dam ALTER-DRAIN&VENT-WATER(Es) VALUATION '
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby mE m under penalty of Perjury one of the following declarations:
❑Ihvvevndwiil maintain a Certificate of Consenuo self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYYECONSTRUCDON
ea ion,as provided for by Section 37M of Ne Labor Code,for the performance of the
work for which this Permit is issued, FIXTURES-PER TRAP
❑1 have and will maimain Wo ImA Compensation Insurance,as required by Section
37W of flue Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Won 'sCmpepswt Gln urnncec d Policy nomM�((arc:
Canes nn s carrier Policy Nu:CSK ��IAd61 GAS-EA.SYSTEM-OVER 4IL'A)
C ItTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEHS
(This section need not hecompleted ifthe permit is ferme hundred dollan(SIW) GREASETRAP,
ca less.) PLANCHECK FEE
I certify that in the perfomaneeofthe work forwhich thispewis is i...ad.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so a in become become subjecto the Workers Cc mpen- ENERGY FEE
O ,`� action laws of California.Date WATER HEATER WNENT/ELECfR GRADING FEE
7 O Applicant
q y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTE.M?REAI'ING
(-' become subject to the Workers Compensation provisions of she labor Cade,you must SOILS ME
foMwith comply with such Provisions minis permi,shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
z
L7 O Dam RecaiptN
I hereby affiw Nenherc is o ion lending agency for the prbnnance of
she work for which this panni,is issued nl See.
ec,led],Civ.CJ
W. F" Lender's theme TOTAL:
O V lenders Address T( A
'y QUI
tL4 1 certify that 1 have read this application and emu that Ne above information is BUILDING FEE
I) correct.)agree,.comply with all city and coumy ordinances and sure laws remtingm QTY. MECHANICAL PERMIT FEE
Ll7 building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
abo m-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hersnless the City of Cu,saurm against ELECTRIC FEE
Iitimities,judgmena,curtained expemaes which may in anyway acme stairs...id City ALTER OR ADDTO MECH.
in consequence of the granting ofthis sam t. PLUMBING HE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Els"CFM) MECHANICAL FEE
SOURCE EGULATIONS.
AIR HANDLING UNIT(OVER 10,1110 CFM) CONSTRUCTION TAX
Sig a,um of ApplicmNContractor Dam EXHAUST HOOD(WMUCq HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
'Will the applicant or future building occupant store or handle haznmous material HEATING UNIT LTO 1 oo, (1 Brut
ex defined by the Caperton Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532m)7 HEATING UNIT(OVER 100 X10 BTU7
❑Yes . ❑No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt%
Willthe air amitntart usasbuilding aseby the ill Bay Area
AirQsoty islaeewhich BOILER-COME(3HP OR 100."BTU)
mi,hvzvmous air comvminanu as dehnal by the Bay Area Air Quality Management TOTAL
Distrim7 BOILER-COME(OVER IW,W10 BTU)
❑Yes T-1 No
AIR CONDITIONER
1 have read the haramous ma,cruds refinements under Chapter 6.95 of Ne Cali. ISSUANCE DATE
fomla Health&Safety Code,Sections 25505,25533 and 25534.I undersand Nat d the NEW RESIDENTIAL MECH. SQ.FT. -
Wilding does rout comedy have a mount,that it is my responsibility to notify dm occupant
of the mquircments which must W me,prior to issuance of a Certificate of Occupancy.
Owner or authovcJ agent Dam _ TOTAL: ISSUED BY: XW
. . ' OFFICE _�)-