S 1110APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL
BUILDING PROJECT IDENTIFICATION
PE51T NO. 1 1 1 0
`V
BUILDINGADDHIiSS:
G e s DQ o
SANITARY NO.
APPLICATION SUBM{ AI. DAII
I, , `/�/V�/
OWNERS NAME: PHONE:
C ' 1
J N
CONTRA OR'S NAME: LIC NO:
N/C
❑
C1Nl'RULq
ARCHITECT/ENGINEEN: LIC NO:
ADDRPS:
If/
CONTnCfs'(�u'�'(�-a _PHONE:
BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant (Initial)
BLDG ELECT, PLUMB MEc i
h ocl U�8 �`I�I-i�11I
❑ ❑ ❑
IJCE F.DCONTRACfOR'SOECLARATION
1 hereby affirm thin I at. licensed under provisions of Chapter 9 (commencing
with Section90W)of Divisinn3nf the Business and l4ofessinns Gde, and mylicemci's
n full since and p �Q
QTY, ELECTRIC PERMIT FEE
I
JOB DESCRIPTION
R IDP TIAL:
:DWL ❑ KITCHEN REMODEL
Q Z
typo
W F
pIiHM1"f ISSUANCE
APPLIANCES-RESIDENTIAL
aUU
y Edi
F �,�
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F �2It 1
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MxF 0 L k%
3 LL i7
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License Class Lic.#
Date C...'heor _
ARCHITECPS E-LAR IO
1 understand my plans shall be used s public cord.
[]ADDITION [I PLUMBING RE-PIPE
❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E)SWIMMING POOLS
❑BATH BE PIi1JREPAIR El DEMOLI'ION
—�(a r' O # -
Q�` tYfH1iR �-� YA�1 M
PANELS
UP'10200 AMPS
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt fmm the Comm,.^,', License Law for the
follnwing rennin. (Section 7031.5. Business and Professions Code: Any City m county
which requires a permit to construct alter, improve, demolish, or repair any sometum
Fri., iasaanca, also repir, be of iwm further penniun filcasigncdoanmCnt
2111-1(XX)AMPS
OVER ["AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
in}
W gr'OC
E. L o C
X n LL
WM”
<QLas
ESQ
IWF il m
a 3 —
that he is licensed putsuantofire prmisionsofthe Contra„.,',License Law (Chapter 9
(commencing with Section 7W) of Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 0031.5 by any applicant for a permit vubjcn. tnc upplicam to a civil penalty ^(
not more than Five hundred dollars 051X1).
owner of Ne progeny. or myempinyccs with wag,. as thcirsolc cnmpensanon,
will do the work. anti the structure is not intended or uncmd Futile (See. 7(P,L Business
and Professions Cde The Comrannrs License Law doer not apply m rrwner, of
t w tura ane„such work nmreiflr or mmagn
pmpeny who Whoa, or mmro.en mernnn, and
TEMP. METIER OR POLE INST'.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT
[I OF
1'OW IiR DEV ICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES-FIXTURES
his own employees, provided mat such impmvcmems ale not intended or offered for
sale. If, however, the buildingorimpmveeent is sold within one yearofcompletinq the
NEW RESIDENTIAL ELEC R 5
SQ. FT, FLOOR AREA
SISQ.IT.
rwnerbudder will have the burden of proving that he did not build or improve for pur-
pose rf sale.).
1, as owner of the pm, perr am exclusively contracting with licensed contractors,.
PAID
eYf
consumer ce project (See. Bala. Business .it Professions Code:) The Canna ore, Li.
c .¢Law docs nm apply,. an owner of property who builds or improves thereon,and
whocomrans forsuch predicts with a,onset^”%)licensed inro mmme Contractor's
Unction Law.
Licen
C3I am exempt under Sec. .B&P C for this recon
At
QTY. PLUMBING PERMIT E
APR 9 ANS(®
' '
FERMI'F ISSUANCE
ALTER - DRAIN &VEN'1'-WAFER (EA)
Owner nam
CIT l,urvADD"
WORKER'S COMPENSATION DECLARATION
BACK [:LOW IROI'EC'T DEVICE
firm under penalty rte ty one nl the fallowing
1 hand Co
DRAINS - FLOOR, ROOF, AREA, COND.
ofC workers
�Ihave and will maintain aCcnifcate nfGmsent ,.self-inure for Worker Cooper-
will
sauon, its provided for by Section 39Nf of the Labor Core, for the perio nwnee of me
STOIt IIiS 'TYPE CONSTRUC'TIOI
work Int which cis permit is ismed.
FIXTURES - PER TRAP
1 have and will maintain Worker's Compensation Insurance, as required by Suction
31 ofthe Labor Code, (nrtheperformance of the work for which this permit is issued.
My Wra e Cynehj'M1alianlnsyrynffefc tie, and Policy ppttyy�
Cutters LTJ cM-- Policy Nn.:I�Tn"r ��%
GAS -EEA. SYSTEbf-I INCA OUTLETS
OCC, GROUT' AI'N
GAS -EA. SYSTEM-OVER4 fi A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('H is section need not becompleed ifine permit is intone hundred dollars (SIU))
or lea,.)
GREASIIINDUST'RL WASTE INTERC17MOR
BUILDING DIVISION FEES
GRF.ASP. TRAP
PLANCHECK FEE
SEWER- SANITARY -STORM EA. 2(1) FF.
O Z
Z
I certify that in the performance ofthe work forwhich this permit ix issued, l shall
uhf employ any persnn in any manners as to become sunjecuo the Workers' Compcn-
xmlon Laws of Caflfomia. Doc
Applicant 1
ENERGY 1213E
WATER HEATER WNEN'T/F,LECfR
GRADING FEE
NOTICE. TO APPLICAN'11 If, after making this Cmilieme of Exemption, you should
become svbjen m the Wmke/s Compensation pm nium of the Labor Cede, you must
forbwirh Complywilh such IT 16on, nr thr,,s r shall bedecna.Mrevoked.
CONSTRUCTION LENDING ngagerAGENCY
Ihereby th thi that them is aconewaion lending agency for Chep ora ce of
the work for wM1icn this permit is issred(Sec. 309], Civ. C.)
Lender's Name
WATER SYSTEXVI'BEATING
.Na
Q.0
Uo
LL.
0 V
} HJ
rfail
)Z
SOILS FEE
WATER SERVICE
PAID
Dare Receipt#
BUILDING FEE
NIiW RIESIUUNTIAI, PLMB. SQ. F1'.
Lenlve,Address
TOTAL:
I artily thin 1 have read cis aliplicmion and widened the alae information is
correct. I agree mcomply with all city and county ordinances and suite laws relining to
building urmhuction, and hereby aibatim rcpwwmatives of this cityu, enter upon the
QTY. MECHANICAL. PERMIT FEE
SEISMIC FIFE
above mentioned property for inspection pm,,ocs.
(Lac) agree et save, in hrunify anti keep harmless the City of Captain against
PERMIT ISSUANCE
ULECFRIC PEE
liabilities, judgments, costs and expenses which may, in any way active against said City
in mequence of rhe granting of This permit
AFTER OR ADD TO M ECI I.
PLUMBING FEE
APPLICANT U IiRSTn AND W . COMPLY WITH ALL NON-POINT
SOURCER LATIO
AIR HANDLING UNIT (TO IO,Ok) CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10.000 CFM)CONSTRUCTION
TAX
.ngnaturc ofApTfii /Contractor Data
HAZARDOUS ATERIAI S DISCLOSURE.
P,XIIAUS'F HOOD(W/DUCT)
HOUSING MITIGATION FEE
H EATING UN IT(TO 100,000 BT U)
Will the applicant or future di ng seupantalnreor hantilc hvoslouxmnuial
as JefineJ by rM1e Cupcnino Mho pal Code. Chapter, 9.12, and the Health and Safety
Crile, Sonian 255321af r
HEATING UNIT (OVER H)LON) BTU)
❑Ycs E] No
VIiNTIf.ATION FAN SINGLE ftESID)
PAID
Will thea Iicnm a, Brute budifim t ase e r or devices which
yuipr Qu
pp dby the
mit Imaallous air contaminants as defined by the Bay Arca nit Quality Management
Di.arict
Yes nNn
Dale boccie, #
BOILER- COMP OHP OR 100.0X1 BTU)
TOTAL
BOILER - COMP (OVER IIM).gp BTU)
AIR CONDITIONER
I have read the hazmJhu, mmerials nyuirement, under, Chapter 695 of the Coli-
foto Hcalc & Szfny Code, Sections 25505, 25533 and 25534. 1 uminstmd car if ce
building does nm currently hive a tenant p that it is my responsibility ¢r notify the uecupant
ISSUANCE DATE
NEW BESIDESI Al, MECIL SQ, 17.
of rhe r.gairemenrs--which must bo mer Orion^ issuanec of a Cenificme of fk,ury ncy
�\ }��� '\/�/'�J
ISSUED BY.
Ownermitucmieed agent Date _
TOTAL:
OFFICE