S 0245 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
- BUILDING-ELECTRICAL PERMIT NO.
CITY OF CUPERTINO rLUsmING-MECHANICAL S 0245
BUIL131NG DIVISION APPLICATION/PERMIT
BIIILDINC PROIRLT IDFM'LFIL'ATION
SANT"
BUILDINGADDRESS: p - TART NO. API'LICAf10N SUHMITI'AL DA'I F:
OWNER'. NAM E: P ( ) CO RNA E: 1 NO: NIC COMfROLM
ARC I .CT (NEER: LIC O: C AD Pr,
11 BUILDING PIiRMIT INP
CONTACT: �jy.
❑ Consultant Fees Paid by--- 13LOG ELECT PLUMBnn[CH
SLICENSED•CCOOWRA R'SS Dl;(CLARATION QT ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby am.that 1 am licensed under provisions of Chapter 9(commencing RESIDENTIAL'
O a'Zwith Section 9lNN))afDi ,km3ofma Business and Professions Cale,andmy license is PERMIT ISSUANCE.
FBF in full force and eRmt. ❑SFDWL O KITCHEN REMODEL
�UU License Class Lic.Is APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
rFis Ga Date CommcOsr ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION PANELS MODIFICATION
oz f"i0i�� Iunderstand myplamsholl Hasson..,publirmemids UP TO 2IN)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
-a
W Licensed Profeasi000l 201-1(NN)AMPS IMPROVEMENT ❑SWIMMING I'OOIS
OWNER-BUILDER DECLARATION Cor ION OVER His)AMPS ❑BATH OTHER MODEI/REPAIR ❑DEMOLRION
Q I hereby aurum on 11. Business
tram the Cessions o License taw for the ❑OTHER
(i.LS O Wy U following remora.Permit
o]011.5,Business and improve,
da ions Calc:Any city or county SIGNS F.L[ f.
la 4 WO y which tequircs a permit m convince.aides imprnvq demnllsh,or repair any structure
fa4+ prior m its issuance,also requires the applicant forsuch permit10 file a signed summers SPECIAL CIR IT/MI5
aN•
that he is licensed punctual to the provisions M the Contmcmr's License Law(Chapter 9 COMM R IAL
QQ (commencingwith Smtion'I(NIO)of Divlslon3rufshe Businacand PmfesslonsCde)Or 'FEMP.METERO POLEINST. ❑NEW BLDG/ADDITION ❑DEMOLIDON
tL n y' that he is exempt therefrom and the basis for the alleged exemption.Any violation of
+ -4y Section 18315 by any applicant for a permit subjects the applicant 10 a civil penalty of POWER DEVICES ❑TF.NANb. ❑FOODSERVICE
t mom than five hundred dolllds($500). POPRO�'�A�!
O1,as Owner of the property,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC [J OTHER
will dothe work,and the stature is notimmnded oroffered l'orsale(Sec.9044,Business OUTLISI'S-SWITCHES-PoXTURES
and Professions Code:The Comracto/s License Law does not apply to an Owner of
d' property who builds or improves thereon,ad who does inch work himself or through
his awn employees,provided that inch improvements are not intended or offered for NEW RESIDENTIAL EL .TR SQ FT' !,.SQ,FT.FLO $ISQ.IT.
1 sale.IL however,the building or improvement is sold within one year ofcompletion,the
owner-builder will have the burden of proving that he did not build or improve lir mr. IVa,L
from of sale.). TOTAL:
O 1,as owner of the property,um exclusively contracting with licensed contruemrx to ii/ moi/I
emcomet the Project(Sec.7044.Business and Professions Cde:)The Contmemr's Li- FEE ✓!Y�_I/v
cense Law does not apply m an owner of property who builds or improves thereon,and QTy, PLUMBING PE
who contracts for such projects with a cmdrocmgs)licensed pursumt to the Contractor's
License Law. PERMIT ISSUANCE
O I um exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT- 'P 1 VALUATIONnnn
Owner Data
WORKER'S COMPFNSN'[ON DECLARATION PACK FLOW PROTECT,UF,VICE
I- I hereby affirm under penalty of perjury one of the following declvmtions: -- - --
OlhuveanJwillmuinuinuCertiticatenlCOnsenttoulf-inmrtfor WorkeisCnmpetr DRAINS-FLUOR.ROOF.AREA,GOND. STORIIS TYPE CONSTR UCTIOP
y t sedan.m Provided for by Section 3100 of the Labor Code,for the performance of the FIXTURES-PER TRAP
work for which this Permit is issad.
O 1 have and will mountain Worker's Compensation Insurance,as required by Section
37Mofthe Labor Code,for the performance Ofthe work for which this permit is Issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number oro: GAS-EA.SYSTEM-OVER 4(DA)
Cartier. - Polioy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR I -DI VISION PF
COMPENSATION INSURANCE
Mossectionneedna be completed if Ne permit isforeachundreddollatx($INh GREASEI'RAP PLANCHEC EE
art leen.)
I ceritythm In Ne perfnrmanceofthe work l'nrwhich this permit is issued,lshall SEWER-SANITARY-$'FORM EA,200 r'4. ENERGY
not employ any person in any manner m as to become subject o the Wollm s'Compen-
,7, scion Lossuf Cnlifnnow Date WATER HEATER WNENT/ELECfR GRADIN ' E
1 Applicant - s
y NOTICE TO APPLICANT:If,vfter,making Nis Cornfields,of Exemption,you vacuum WATER SYSTEM/TREATING SOLI_
(~ become subject to the Worker's Compensation provisions of the labor Code,you must
forthwith comply with such provisions or this permit shall be dated revoked. WA'T'ER SERVICE '
O sPAID
�z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT ate Receipt
LJ 01 hereby affirm that hem is a commuuiun lending agency forthe perfomsance of
the work for which this permit is issued(Sea 9(191,Cis.C-) TOTAL:
QF Leader's Nome
U TOTAL:
Lender's Address BUILUIN PF.E
1 certify o c 1 have read thirty and coun and sum that the above informldiot is F,E
t..t Vl camct.l agree to comply with all city end county ordinances and sum laws relmingm QTY MECHANICAL PER SEISMI fF.E
building constraoion,and hereby ddlimiee representatives ofthis city to enter upon the
1 above-mentioned Property for Inspection purposes. PERMITISSUANCE ELECTR '
(We)agree to save,indemnify and kap harmless the City of Caperton against
1' 'hies o ems,costs and expenses which may in any way aacme against said City ALTER OR ADD TO MECH, elm PLUMBING FEE
the granting of this r, t.
PPL . SOU DERSTAND. D ILL C)MP.Y WITH ALL 'ON-P INT AIR HANDLING UNIT(T010,IXCFM)p MECHANICAL FEE
. )U :E E 11 TIONS.
AIR HANDLING UNIT(OVER 1011 CFT4),00CONSTRUCTI
HA.AUS MATERIALS ON TAX
n s r ate EXHAUST HOW(W/DUCT) HOUSING MITIGATION FEE
R Car
Will the applican rfmu builJing mcupwt s�oxmiCiRIOSU rJ1 hnaardnun ma¢riml HEATING UNIT(TO 100,001)BTUI
as defined by she Cupertino Opal Crude.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU)
Code,Section 25531(a)'I .-
❑Yes ❑No VENTILATION FAN(SINGLE RFSID) PAID Dam Reccipt
Will the applicant or future building occupant axe equipment Or devices which BOILER-COMP CHP OR IW.000 BTU)
mit hasandous air contaminants as defir by she Bay Area Air Quality Management TOTAL:
d
DAtricr? BOILER-COMP(OVER IWI%p BTU)
y ❑Yes ON.
AIR CONDITIONER ISSUANCE DATE
I have mad Ne h ode.S e tions 2lx requirements under Chapter Ian ucta Of the Call-
hernia Health&Safety Code.Sections 25505,25531 end 25534,1 udetxmnd that it the NEW RESIDENTIAL MECH. $Q.FT,
buildingdoes net
n,which
have utenant,that o isua ce of.C,rafivinotify the
pancy.occupant
of the regv'vements which must be met prior m issuance of v Cenifcute of Occupancy.
Owner or sound xed agent
Date ISSUED BY:
OFFICE