30802 APPLfCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALLPOINT PEN ONLY -
CITY OF CUPF,RTINO'., BUILDING•ELECTRICAL. - PERMIT NO
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL 30,802
BUILDING PROJELT IDPNr]FICATION
BOILDINGADDRLSS: 07 I • SANITARY NO, APPLICATION SUBMITTAL OATI
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t-e'C S 3 q_7
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\RC TECf/ENGINEER:
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NO: ADDRESS
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CONTACT: PHONE:. - BUILDING PCRMITINFO
_(.r O ❑ Consultant Fets Paid by Applicant(Initial) BLDG ELECT -PLUMB MECH
LICENSED CON CfOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy affirm that I am licensed under provisions of Chapter 9(commencing .POE DESCRIPTION'
Z withSeeton711(N17 of Division3nfthe Businessa�npPod.sin wC td,h five cin
�O Qµ1 y PERMIT ISSUANCE RESIDENTIAL
full farce orad effect.- `1.5 5U`•ut
in a FDWL ❑KITCHEN REMODEL,
aUV Livedo loo Lic.N APPLIANCES—R13SIDENI'IAL
Date—Con DECL ADDITION [I PLUMBING STRUCTURAL PIPE
ARCHITECTS DECLA A'lO ❑MULTI-UNIT ❑MODIFv2 PANELS ,
Z O P Z i undersand my plans shall be used os public rtcoNs MODIFICATION
0z=3I UPT0 2M AMPS
F1 INTERIOR c ❑CHIMNEY REPAIR
i—:gts� License)Prolessiunul ' 201-IthlIIAMPS IMPROVEMENT'
M 3 ' Oat I rad HUILDHR DECe CannaATIvino,
OVER 1000AMPS
6 1 hereby afErm that 1 am exempt from the Commmnrs License Law for the ❑BATH REMODEIIREPAIR ❑DEMOLITION
x4x MLO following renv n.(Section 703 1.5,Business and Professions Code:Any city or aunty SIGNS ELECTRICAL " OTHER
W 3 LL F which requires a permit n,construct,sloe,,improve,demolish,m.w,mu any.manure '
priorm its issuance,also requires the applicant for such Permit to Ne a signed statement SPECIAL CIRCUITIMISC.
} Out he is licamed pursuant an the provisions drake Commeace,License Law(Cbapmr 9 -
p0 (commencing with Section 7009)of Division 3 ufthe Ihishess.and Professions Code)ar 'FEMIt METER OR POLE INS T. COMMERCIAImt
that he is exempt therefrom and the busis for the alleged exemption,Any violation of _ ❑NEW BLDG/ADDRMJ� DEMOLITION
IXL u' Section 101 Ll by any apptient for v pemmit subjw,,,ha applicant m a civil lwruk,of POWER DEVICES
Z} tmore Nun five hundred dollars(SSW). ❑TINANp P000 SERVICE
pa�6 I,as nwnerofthe pncpeny,ar any empinyecs with wages us their sole onnpcnsmion, SWIMMING POOL'ELECfRIC IMPR@1"
a'q will Bothe work,nstructure intended or attend for sale(Sec.7044.Business ❑QTfiER
o.
W3 and Professions Cole:The Contractors License Law dues not apply to an owner of OUTLETS—SWITCHES-FIXTURES �Y
property who builds or improve thereon,and who does such work himself or through ay
S
his own employees,prlrvided that such intprovemcros are not intended or offered for NEW RESIDENTIAL ELECTR UN
sale.IL how<ver.the building or improvement is sold within one yearof completion, SQ.FL FLOOR AI I 5/SQ.FT.
er-builder will hathe buNcn of proving thm he did not build or improput,
for pu
pmvecafsalu.), -
❑1,as none;of the piapert,oro exclusively meormting with licensed chrobscurra at A
construct the project(Sec.70,14.Business and Profesxians CWc:)The Commctot's Li- •.
cense Lawdoes not apply to an ownerofphopeny who builds or Improves themon,and QTY. PLUMBING PERMIT -
whnconirodtsfnrenchp feels wlthaumtraetor(s)licensed pursmmuothe Cummmnr's - �/��License Low. PERMIT ISSUANCE
I am exempt under,Sec. _ ,B&P C for this reason
Owner Data ALTER—DRAIN&VENT—WATER IEA) AAA VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRfyPECT,DEVICE _ / 4o O��w �•
I herehy affirm under penvhy of perjury mo ofthe following declson ions:
]I have and will maintain a Cerci licate of Consentto self-insum for Worker's Comped. DRAINS—FLOOR,ROOF,ARFA,COND. `
..tion,as pnwided for by Section 3700 of the Labor Cone,for the performance of the STORIES TYPE CONSTRUCTION
work for which this .or is issued, FIXTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,;is berated by Semina
371X1 ofthe Lahar Coale,for the performance ofthe work for which this permit is isaucd. GAS—EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Bostonian carie;anumber o2
nd Policy :
Carries Policy No,: GAS—CA.SYSTBM-OVER 4(EA)
CERI'T171CAI E OV EXEMPTION FROM WORKERS' GRGSVINUUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE
(]Tis section need not be completed Blinn permit is fmonehundred dollars P$Bku 111ILMNUIONVISION FELS
or less,) GREASETRAP. . PLANCHECKI:E
c - Icertil'y Nat in the perfnrnance oftbe work for which this permit is issued,I shall SEWER—SANITARY—STORM EA.2gI PT.
nal employ any person in any man r st b pm s*2".the Worker,Comped. ENERGYI
Z
cation La o Califon e V
Q Applicant - Lw.. WATER I HEATER WNBNTIELF.LTR GRADINGFBE
rA NOTICE L1 .If,afar kin this ar ilir le of Excmpfion,you should WATER SYSTEMRREATING '
a , became subject to the Workers nn provWcum;of Ne labor Cade,you mon SOILS
W forthwith comply with such provishi or this Throw shall be deemed revoked, WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLM SQ.PT PAID
UO
I hereby af0rm thauhere iso construction lenJing agency for the perfonnvna of Date ReceiptN
the work for which this penmu is i.saad(Sec.3097,Civ.O) 1. t
0 U Lender's Name
- TOTAL:
U Lemice Address TOTAL:
yI cenify Nat I have brad this application and state that the.have information is BUILDINGFEB
W correct,I agreed.comply with nn city and county aminunces and stem kawartlaaingm QTY. MECHANICAL PERMIT FETE O
V Z buildingcoretmction,a ad herebyawhom
ristepreseatits,ofthis city m enter upon the SEISM IC PEE
aboveadentioned property for inspection purposes' PERMIT ISSUANCE
(We)agree to save,indemnify and keep hamdess the City of Capetian against ELECTRIC FEE
Iutilities,judgments,costs and expenses which may in any way accrue against void City ALTER OR ADD TO MECH.
in consequence or the gaming of this permit. PLUMBING FEE 0
A4AW DERSTANDS AND WILL COMPLY WITH ALL NON OINT AIR HANDLING ON IT ITO 10,(0 CFM) .,4SmAT10NS m MECHANICALFEEAIR HANDLING UNIT(OVER 10,WCFM)' CONSTRUCPIONTAX
Sicant/ c a or Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATIONAP D US MATERIALS DISCLOSURI:c building occupant store or handle hazuNous material HEATING UNIT(TO IW,000 BTU)
as defined by the Cupertino u nfcipel Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7, `, c HEATING UNIT(OVER 100.0(X1 BTU)
-
❑Yes .[]Nu c VENTILATION FAN(SINGLE RESID) PAID
.WPI the applicant or furore building occupant use equipment or devices which - Dale Rcceiptit
nut hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP(311POR no,orro BTU) -
IstrictF1 Yes �No BOILER—COMP(OVER 10X.0011 BTU) TOTAL:
I hwv'oad tie haeallous materials AIRCONUITIONER t
re.ZE03 an under Chapter 6 95 of the Cali ISSUANCE DATE
'forma g it.Hershlb&Safety Cedc,e a teras 25505,25533 untl 25534,I understmth Nm if the NEW RESIDENTIAL.MECH. SQ,FT. -
buildingdoesnmt,.1ai iodus, a tenant.Natio is..betidocs,sure
Ceritytonoifytbupancy m _
of rho nquirnnems which most be amt prior to issue nc afu Ccnilicafa of(kcupmrncy.
Owner or amhorud agent Date TOTAL: ISSUED IIY:
OFFICE