D 0328APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPIiRTINO BUILDING - ELECTRICAL PERMIT NO,�f� O
LL
nmLHING DI VISION APPLICATIONIPERMIT aisr rlvulMB^Nre,rmecB,MN.Gr "axed S0001
IIILN`aDll
❑ Consultant Fees Paid by Applicant (Initial)
LICENSED CONTRACTOR'S DECLARATION
1 haehy aldr t that 1 am licensed under Provisions of Chapter 9 (commencing
❑0�0 with Section 7000) of Division 3 afthe fuslnessand Profession, Code,and my license is
in full face and effect
<UU License ClassLiaR
N�6
Date—
I AI—. u. TomtmCrtrnu 1
plans
hereby .rima Ihit 1. s- 1 Gnat he Commcmr's I,leeme Law Ga the
du 1 wing rwxon. (Section `fusiness and Professions Crde: Any oily nr wunty
t y which requires a permit to consumer, alter, improve, demNish, or repair any structure
prior its issuance, also requires the applicant for such Permit file a signed statement
or,
m that he is licensed pursuant o the previsions of the Contractor's License Law (Chapter 9
(unntnenci n, with Section 7000) (if Division 3 of tiro Business and I'I'ofvoseens Code) nT
C
art, lie is exempt Therefrom and the basis for be alleged exemplimt. Any vmin®r of
V1 Section ]1131.5 by any applicant for u permit suhlecta the applicant it) a civil Penally of
net nmre than Eve hundred dollars ($500).
SQ Las owneref rhe P"anorc,onnyemntendedwith wagesmnc�irenle7044.Bumion,
will do the work, nod the re Comm nor intended in alw do for solopply to an Baseness
m
property
erty who
Code. imp Commoner, License Law does nal apply s an owner of
property who builds or improves Inc...,reoend who dcea such ware himself offered
for
his own employees, pmlding that such improvements are not intended or oBered foe
sale. ILhowever will
building of advint issold within one year improve for the
ownerbuilder will Love rho burden of proving thin Ira did not build or improve lirr pur-
prnc of sale J.
❑ I, as owner of the primary, am exclusively contracting with licensed cnntmnors in
mslruct the project (Sec. 7014. Business and Profession, CwM:) The Coa m mr's Li-
cense Law does not apply manowner ofproperty who builds or improves thereon, and QTY.
'whoc onecte far such Projects ,In aenntra arts)limnsed pursunou tithe CnnOne.er's
Litt La
le emp.under. .B& P C for his ream.
Ot, Dule
.R:S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dccleratinne,
niO
1 have and will maintain a Caeate ofConvent.n self -insure for Workers Compen-
sation, as provided for by Section 37(X1 of the Unfair Code, for the Performance of the
work for which this permit is issued, r
37olof hand will anoode. for Workers
pcifor Cate of
w rk for hi h required by Section
37INI nl the Labor Cude, for the Performance of the work for which this pertnil is issued.
My Worker's Compensadpn Insurance camcr and Policy ngnther are. _ _
COMPENSATION INSURANCE
(Phis station need not heannpleted Ifthe permit is hereon hundred dollars ($I(NB
or less.)
1 certify that in the performance of Ne work for which this Permit is issued, l shall
not employ any Person in any manner so as to become subject to the Worker Comped-
%. sation Laws of Cull Iontiu, Dam
z Applicant )
NOTICE TO APPLICANT: If, after making ibis Cenif¢me of Exemption, you should
abeams subject to the Workers Compensation provisions of the Labor Code, you mu s.
ikI
hardball comply with such provisions or this permit shallM deemed revoked.
Q
G
CONSTRUCTION LENDING AGENCY
L) 0 I hersbywhich
tma i issue (S.. 30617.
agency far me peRnrmence of
(•-' .he work Irr which this pemlil is issued (Sec. 3119], Civ. C.)
Q Lender's Name
Len. I Addrevidayx
f•-' I certify tlmt I have rend Ibis
ty and application and state ces the shove laws
rilinis
Yl ding agree mcomply
nd withall yrutyand eoumynrdinancesand city
la ntrelating m QTY.
V z agrovengantioned construction, and hereby auction p reiescs. Lives of this city ro enter upon the
aMrve-I(We) are property o Ime farinspection keep m
(We) agree ei save, indemnify andkeep hurntless the City of CUPenlnn ngalne
Iishilities,judgmen.s. Costs and expensesn It nay Ina 'y accrue against said City
in consequence uf.he granting nf.his permit.
APPLICANT'UN ERSTANDS�D B')LI ,_'WITH ALL NON -POINT
SOU EGAF /
HA 1111 MA'1ERIA1 S DISCLOSURE.
Will the applicamo rc building occupam score nr handle himardnus material
as defined by the Cnpe n Mmticipal Code, Chapter 9.12, and the Health and Safety
Cndq Senior 25532P0]
C] Yet, ❑Nn
will the applicam or future building occupant use equipment or devices which
enor hinandous airGunn minunts us def ed ana
by the Bay Area Air Quality Mgement
Qisuin]
Cl Yes Na
I have re ad the ha vdous anterial./-zz
derChapmr695oflheCali-
fnrniu Ira & SId'cty Cnde, 55534. I understand Ina If the
hlgktltgi to-ylnl cnrrendypf5 sihility to notify the occupant
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 210 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP MITI ER OR 1 OIX INST..
POWER DEVICES
SWIMMING POOL ELECTRIC
OUT'LI1'S- SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
PLUMBING PERMIT
PERMI'I'ISSUANCE
ALTER- GRAIN & VENT- WATER (EA)
BACK FLOW PROTECT'. DEVICE
DRAINS- FLOOR, ROOF. AREA, CONED.
FIXTURES -PER TRAP
GAS - V.A. SYSTEM -1 INC.4 OUT LETS
GAS -EA, SYSTEM -OVER 4 (IiA)
GREASTYINDUSTRI, WASTE INTERCEPTOR
GREASBTRAP
SEWER - SANITARY- STORM EA. 200 FT
WATER HEATER WNEN'IMLECTR
WATER SYSTEM RRA'1'ING
WATER SERVICE
NEW RESIDENTIAL PLMB.' SQ. Fn
MECHANICAL PERMIT
PER M IT ISSUANCE
ALTER OR ADD TO MUCH.
AIR HANDLING UNIT (TO 10.000 COD
AIR HANDLING ON I'1' (OVER 10.(100 CFMI
EXHAUST HOOD (WIDUCT)
HEATING UNIT (TO 1010(10 BTU)
HEA1INC. UNIT (OVER Iin,odd R'fU)
VENTILATION FAN (SINGLE RPSID)
BOILER - COMP (711P OR 100,000 BIL)
BOILER-COMP(OVER Birt," ITN)
NEW RESIDENTIAL. MECH.SQ. IH'.
FEE
S
PERMIT INFO
BLDG ELECT
PLUMB MECCHH!
El Cl
Cl0
JOB DESCRIPTION
RFRF II�TIAI:'
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑ PLUMBING RF PIPE
❑MUI:I'I-UNIT .,
❑STRUCTURAL.
MODIFICATION
❑INTERIOR
❑ CHIMNEY RI7PAIR
- IMPROVEMENT
[ISWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ot HER
( V�
P
COMMERCIAL_
❑ NEW BLDG/ADDITION
El DEMOLITION
❑TENANT
❑ FOOD SERVICE
IMPROVEMENT
Q7S77i. FLOOR AREA ASQ. PC
i
FEE
VALUATION
ORIFS TYPECONSTRUCI
' SR
OCC.GROUP APN
rL
BUILDING DIVISION FEES
PLANCHECK FEE
RADING PEE
Y117S FEE
III 666L :p .1 At1W
Uate Receipt p
FEE
4L,
SEISMIC FEE
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FEE y Q
CONS'TRUC'TION TAX
HOUSING MITIGATION FEE
PAID i sz5_iG9I Date Receipt # - _
ISSUANCE DA
!91