S 3948APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITYOFCUPERTINO BUILDING - ELECTRICAL
NGILDING DIVISION APPLICATIONIPERMIT PING P OJECT I.CHANIFUC
BUfhDINC. PR(IJF.Cq'IDF.N'I'IFIL`Al'ION
PERMITNO.
S 3948
HUILUING ADD�EiS:SANITARY
NO.
APPLICATION SUBMITTAL DATE
ER'SN ME: PHO E:
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BUILDING PERMIT INFO
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❑Consultant Fees Pail 6y Applicant (Initial)
B`,pCs T PLUMB ME❑CH
TrA-'
LICENSED CON'FRAc'lo 'S D iCLARAI'ION
I hereby affirm Nat 1 am IianxJ unJ pro.idons of Chapter 9 (commencing
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Section]001)of Division3nf thcBmin and Pr.fesslons Code,un arotheense is
in full force and effect.
RESIDENTIAL:
❑$FOWL [D KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class Lln.N
Data Conlon n
El ADDITION ❑PLUMBING RE -PIPE
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
MODIFICATION
1 ECPSGI?CLARXUON
J a f e used as public recons
PANELS
tll'TO 2111 ph1P5
❑CHIMNEY REPAIR
IMPROVEMENT E] SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑OTHER
cons tsion.
O\ •R -BUILDER DECLARATION
1 hereby affirm I I am exempt from the Contractor's License I..w I'.r the
follmving reason. (Section ]0315, Business and Professions Code: Any city or coumY
201-1000AMPS
OVER I(NN)AMI'S
SIGNS ELECTRICAL
which requirea a permit to construct, alter, improve, demolish, or repair any strontium
SPECIAL CIRCUHUMISC.
prior in its issuance. also reyuims lhcapplicant for such permit to file u signed statement
That M1e is licensed pursuanuo the provisions of Ne Comrecmrs License Law (Chapter 9
-
(c.mmm�<ing withSatipo]IXNq of Dvisirn3nfthe Busincve and l'ndeeaiona Code) nr
TEMP. M HTER OR POLE INST
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged aaenpHkn. Any violation of
❑NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for. pennh subjeeulheapplicarr u a civil penalty of
not more than Five hundred dollars ($5(X1),
❑ Las owner alone property, or my employees with wages as their sale compensation,
will do the work, and the structure is not intended or.0'emd forsake (Sec. ]DiL Business
POWER DEVICES
TENANT FOOD SERVICE
PROVEiMENT
❑ OTHER
SWIMMING POOL ELECIRIC
and Professions Gavle: The Contractor's License Law does not apply a an oof of
OUTLETS -SWITCHES -FIXTURES O
NEW RESIDENTIAL ELECTR SQ Fr.
property who builds or impmves Hereon, and who does such work himself., enough
his own employees, provided that such improvements arc rent intended or offered far
sale. 11. however. the building or improvement is sold within one year ofcompletion,the
SQ. FP. FLOOR AREA
$/SQ. FT.
saner -builder will have the human of Proving that he did not build kr improve for par -
Post, of sale).
1, as owner of the property, um cxdmivdy contracting with licensed ttmtmakn to
T
consumer Ne project (Sec. 7I14 Business and Professions Coell The Contractor's Li -
(�
.:
Law does man,ply to innnerof prnpeny who buildsnr imN
x w proves emnn.and
QTY. PLUMB INC, PERMIT' - FEE
L//JT
who Comment for projects with a commitments) licensed pursuant o the Contractors
PERMIT ISSUANCE
License Law.
I ane exempt under Sec. .R& P C for this reason
all Dna
WOR ad,, p COMPENSATION DECLARATION
I herebyalarm under penaltyNe(....wing
ALTER - DRAIN & VENT- WATER (EA)
VALUATION
r••�
z 2 D O Q
BACK FLOW PR(RECT DEVICE
leperjuryoneof
Workers
Ibave ono willnitinby Section 37W
of the Lmo. self-iCoca surehn Worker'sse of the
fpr mi Section 3]00 of the IsMr Ctme, lar the Mrromwnce .f the
smirk, as providedcthis
work for which this permit is issued.
pkAINS- PLOTJk, ROOT', AREA, CON D.
STORIES
2
'TYPE CONSTRUCTION
��
FIXTURES - PER TRAP
❑ 1 have and Will maintain Workers Co of thl.n Insurance. which his sed by Section
pertnil isissued.
HebronC.dgfonthsurance
OCC. GROUP
APN
GAS - EA. SYSTEM -I INC.0 OUT
MyOof cancer and Poork roamram,
hC.mpen.umion Insurance carrier and Policy numl+er arc:
Cameo Policy No:
Cromer:
,fir
ITL-J�
kl L
�I�`OLr 107
GAS - EA.SYSTEM-OVI? [:A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRCASEIINDUST ASTE INTERCEPTOR
---
BUILDING DIVISION FEES
(Thissection need not he completed ifthe Permit is fur one hundred dollars 18100)
or kssJ
I certify that In the pedormancu ofthe work far which this permit is issued, Ishalle
not employ any Person in any manner so as to become Nm
subject to e Workers'Copcn-
GREASE TP AK
PLANCHECK FEE
SF:WF -SANITARY-STORM EA. 200 Ff.
ENERGY FEE O
TBR IIIIATER WNEN'I'/F.LIiCfR
station Laws of California. Data
Applicant
GRADING FEE
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become snbjcct to the Worker's Compensavna anew sions If the Labor Code, ,at most
WATER SYSTE1,1/IREA'1'ING
SOILS PEP.
rorthwith comply withsuch provisions or this Permit shall he deemed revoked.
WATER SERVICE
NEW RESIDENTIAL. PLMB. SQ. FT.
CONSI'RU(THON LENDING AGENCY
L hereby affirmttim there is a construction lendikgogency out perfo..... f
PAID
D Receipts
the work for which this pemmit is issued (Sec. 3097, Civ. C.)
Lender's Name
TOTAL:
Lender's Address
TOTAL:
BUIL FP .
I certify that I have rend this application and slate that the above information is1,,.
correct. l agree m comply with all city and county ordinances and stale laws relating to
building constriction. and hereby authorize representatives of this city to enter upon the
(gy, MECHANICALPERMIT FEE ;
SEISM c 2_0
PERMIT ISSUANCE
ELECTR HE
above mentioned prnpeny fur, n.apal am lu rrenee.
(We) agree to save, indemnify and keep harmless Ne City of Cupcnino against
liabilities,judgments, costs and expenses which may in any way accme against said City
an meyuenc•of the g&,.nllfpermil.
ALI FR OR ADD TO MECH. 0PLU
TNG PT?E
p1µ HANDLING UNIT (TO Ifo" CIM)
MECHA ICALFEE 3 3�
OULICN�'2 IF I LD WILL COMPLY WITH ALI NO POINT'
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRU ON TAX
6
fifirmanyo pylic /Cont, no Dom
HA -LA 0 S MATERIALS DISCLOSUR
EXHAUST 11001) (00/DU TI
HOUSING MITIGATION FEE
HEATINGUNITUOutit IB'IU)
Willlheapplicanl f reM1uilJing occupant store or handlehamNous materiel
its dcOned by the Copan, Muni spin Code. Clatter 9.12, and the Health and Safety
Code, Section 25532(a),
1 HEATING UNIT (OVER 100,000 BTU)
❑Yes No
Will the .,It .,It. o future Wilding occupant use equipment or devices which
lit moardous air criminalas defined by the By ay Area Air Qu it Monegement
isvict?.t
E3 yes
n¢`srtquiremcnts
PAID
Data Receipt p
V 17N ILA'1'ION PAN (SINGLE RPSLD)
gQ1LF.R - COMP (3HP OR IOO,IXNI BTU)
TY,
BOILER- COMP (OVER 100.0/0 BTU)
AIR CONDITIONER
I have rand the hazarovs undo Chapter 6.95 of be Cali-
ISSUANCE DATE
NEW REy1DENT1AL MECE. SQ. PP.
form. Heealt ty S ti 505, 255]3 and 255341 trade tend i .t if the
huildingd I t lava n Nmilismyrecp.nsihilitylo hyl occupant
—r d9
ofr le . rwissutimmofa Cory is
(3
ISSUED BY:
Owner. a u zed agent
A e
OFFICE