31018 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �] a� O s� e
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J1 10
BUILDING PROJECT IDENTIFICATION
ILDINGADDRESS: \ SANITARY NO. APPLICATION
SUBMITTAL DATE
t
OW S ME, ,s— /HONE: R. LCNO
I! 5 _ NIC CONTROL If
RCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT PHONE: _ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG -ELECT PLUMB MECH
a� ❑ Jac' ❑
LICENSED CONTRACTOn DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
00 with Seclhm]000) J of the Rusinessm dPmfes int m ode,and my license is RESIDENTIAL:
�— in] foes end eBe PERMIT ISSUANCE
�U cent las user Litt. ❑SFDWL ❑KRCHEN REMODEL
y G Dote Convector APPLIANCES-RESIDENTIAL - C1 ADDITION F1 PLUMBING RE-PIPE
ut, A CHITECFS DECLARATION B ❑MULTI-UNIT ❑STRUCTURAL
PANELS
I understand my plans shellu be used public records MODIFICATION
oz—,, UP0 2M AMPS
❑INTERIOR ❑CHIMNEY REPAIR
�� u1 Licensed Prome,imal - - 201-1(g)(IAMPS PROVEMENT
•..11 OWNER-BNLDER DECLARATION OVER IBIIOAMPS ATH REMODEUREPAIR ODEMOLITION
I hereby,off,.that 1 am exempt from the Contractor's License law far the
OyU following mason(Seaion 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL [I OTHER
Cwhich resryires a permit to canswct,oast,improve,demolish,or repair any awaure
prior m its issuance,also acquires the applicant for such paonit to file a signed statement SPECIAL CIRCUIT/MISC.
ythat he is licensed pursuunOo the provisions of the Contractora License Law(Chapter 9
00 (cotnmencin with Section of Division J ofthe Business and Professions Code COMMERCIAL for TEMP. OR PoLE INST.
a a ,barSec cat is exempt therefrom and the basis for the alleged exemption.Any viNnaly of [_1 NEW BLIXi/ADDITION ED DEMOLITION
la Session]OJLS by any applicant for a pernm subjects Ne applicant m e civil penalty of POWER DEVICES
�zN not more than five hundred dollan($5WIMPROV
). ❑ ❑FOOD SERVICE
QEl1,u�wner al'the properly,car my employes with wages msheir ante compensation. SWIMMING POOL'ELECTRIC IMPROVm
will do the work,and the structure is not inmadialmoffeand fm sale(Sec.]OW,Business THER
and Probeasiom Cade:The Contractors License Low does not apply to m owner of OUTLETS-SWITCHES-FIXTURPS
a 3.. propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvemems arc not intended ar offered for NLW RESIDENTIAL ELECTR SOFT.
sale.If,however,Ihehuildingur improvement is sold within oncyearufcompleslun,the l SQ.IT.FLOOR AREA WSQ.FT.,
owner-Wilder will have the burden of proving that he did not build or improve for pur- MAR as 3 RECT '
pose of sale.). .
❑1,as owner of the properly,am exclusively caroming with licensed contiadms m TOTAL: P
construct the pmjcet(Sec.]OMT,Business and Professions Ctde:)The Contractors Li-
se Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE fV
�I I i ser isUrEH(IND
who contracts for such projects withaconuamods)licensed punuan0o the Conr tor's
t License Law. - PERMIT ISSUANCE -
❑IamexemptunderSm. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER GiA) VALUATION
WORKER'S COMPENSATION DECLARATION
I hambyaffinn under pends of BACK FLOW PROTECT.DEVICE
y of Con eneuRhefnstare orW declarations:
Camper- a
❑Lhwe and will mai my nation 37W of the Laor Codemsure far Worker'sce of thDRAINS-FLOOR.ROOFAREA.COND, STORIES TYPE CONSTRUCTION
whom, r provided for mi Section 3]W of the labor Cade,for the performance of the
work for which this permit is issued FIXTURES-PER TRAP
1 have and La will Cost,
Workers erne of the Insurance,which required by Section
My orthe kerlatvsr Cade.fonthsuranc career athe work fnumram permit is issued. GAS-EA.SYSTEM-1 INC.MOIITLETS OCC.GROUP APN
Co Worker's Compensation Insurance carrier and Policy number are: - -
Cumri<r. Policy No.: GAS-PA.SYSTEM OVER 4(EA)
CCRTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FTiFS
(Thissalion need mol be completed if thepemmit is(or one hundred dollars Is 100) GREASE TRAP
car IessJ PLANCHECK FEE
Loy my East arrive performance the work for which this the Wakis es'Cmpsn- SEWER-SANITARY-STORM EA.200 W.
not employ my person in any manner se as w became subject m the Workers'Compen- ENERGY FEE
La
Z swsof California.Data QOession Applicant WATCR HEATER W/VENT/CLECfR GRADING FEE
h NOTICE TO APPLICANT.11 of er.muking this Ccrifcam of Exemption,you should WATER SYSTEM/TREATING
become subject to the Worker's Compensation provisions of Ne Labor Castle,you most SOILS FEE
Qforthwith comply with such procm
visions or this pdt shall he deemed revoked. WATER SERVICE
VZ) CONSTRUCTION LENDING AGENCY• NEW RESIDENTIAL PLMB. SQ.FT. PAID
0 I hereby affirm that them is a construction lending a&m¢y for the performance of Date sip
Fthe work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name TOTAL:
LULi Lendcr's Address TOTAL:
04 1 cerdfy that I have mad this application and sum that the above information is BUILDING FEE if �
V) contact.1 ague to comply with all city vad county ordinances and stow laws relating m QTY. MECHANICAL PERMIT FEE
U 7- buildingcavouction.ind herebymboomm reprevemativesofthis chymemnerupon the SEISMICFEV.. MyB
above-mannered propcny far inspection purpnes. PERMIT ISSUANCB -
(We)agree to save,indemnity and keep harmless the City of Cuperino against ELECTRIC
FIT
liabilities,judgments,costs and expenses which may inany wayarorveagainst said City ALTER OR ADD TO MECH.
consequence of the granting of this permit. PLUMBING FEE
m LICANT UNDERSTANDS AND WiLL .OMPLY WITH LL NON-POINT AIR HANDLING UNIT TO 10,0011 CFM) MECHANICAL FEE
SOLF EGULATIONS. '
AIR HANDLING UNIT(OVER A"CFM) CONSTRUCTION T X
Sig rare of ApplimnVComractor D. EXHAUST HOOD(W/DUCD HOUSING MITIG ION FF.E
TiA1=DOU MATERIALS DISCL S
Will the applicant or future building occupant store or anile hazardous mearial HEATING UNIT TO l Og000 BTU) a f
as defined by the Capetian Municipal Code,Chapter 9.12,vad'the Health and Safety
Code.Section 2553260? HEATING UNIT(OVER 100.00)BTI)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RCSID) Date - Be rpt X
Will the applicant or future building campantuse equipment or devices which ROILEK-COMP(7HPGR 100,000 BTU)
emit humorous air contaminants as defined by she Boy Area Air Quality Management AI
District:' BOILER-COMP(OVER 00%000 BTU)
E)Yea ❑No
1 have mad the promotions materials requimmenu under Chepmr 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomiu health&Safety Code,Sections 25505,3. 31 unJ 255]4.1 undersand that if the NEW RESIDENTIAL.MECIL SQ.rL
ing does not cumrtnmly hoveamnanLt eti ' my asponsibiliryt dfy Ne cecupan lQ/TJI '
ofth immrmnm which muss be met missuarme ofaC to of mmcy Le J_l
n authorized agate Dae TOTAL: ISSUED BY')Lk
OFFICE