S 2670ARRI ICANTTA PHI IN INFnMUATInN WITHIN REEF t_INES - USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING -ELECTRICAL.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
C
PERMI#SUBMI�AL
J
RU1LDING ADDRESS:
i/.voOWNER'SNAME:
SANITARY NO.
APPL7
PHONE:
JIM'S' /.vA) 993 - / 9 zy
CO Cf ORS NAME: LIC NO:NIC
nes -
❑
ARCHITECT'/ENGINEER: LIC NO:
ADDRESS. /� / ,Y
IO 59 Q Lo/ / -4u, e O L-1/
CONTACT. PHONE:
(7rrg� S 1377- 75 -IA
❑ Consultant Fees Paid hyApplicant (Initial)BID
BUILDING PERMIT INFO
ELECT PLUMB MECH
EJ 1:1 E]LICENSED
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CONTRACTOR'S DECLARATION
1 herehy affirm that Sam IicenmJ under provisions of CM1upter 9 (commencing
with Section700(yof Divlaion 3 of the lluuineve.mdl...fir,ions Cn le,andmyllcenseix
infull fume Class ellen.
Class Conor
Date Contractor
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL•
❑ADWL ❑ KITCHEN REMODEL
PIPE'
[I ADDITION [I PLUMBING Bit PIPE
❑h1ULTI-UNIT ❑STRUCTURAL.
,� M��ODIFlCATION
El INTERIOR EVIJIMNEY REPAIR
IMPROVEMENT [I SWIMMING POOLS
❑BATH REMOUEI/REPAIR ❑UF:MOLITION
❑OTHER
PIiRMI'1' ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
Iunderstand my planuhall beuscdos publiencersds
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby action ohm I am exentpi frmn the Cnntractnry Lisenxe Law for the
ream. ( Y city o y
billowingSection]031.5. Business and Professions Cafe: An t or
improve,h parro.h, fie a siganytatement
which) itsis.vpeanut tocoresthe alteapplicant
prior it) its rssuanw, also requires the applicamfor such pertninolile aligned .moment
PANELS
BPT0200AMPS
201-I0RRAMPS
UVEB IgI(1AMPS
SIGNS IiLECTRICAI.
SP[CIAI. CIRCUIT/h11SC.
toya
.J
y�}
that hcls licensed pursuunrIn the provisions mile Contractor's Liccme Law(Chapter 9
Yah
M
C
4•
'y y
�6❑L
y' p.,2
tl
l
(commencing with Sectian]gNp or Division 3 of the Business and Profie.vinn.s Code) oat
that he is exunpt therefrom and the basis for the alleged countion. Any violation of
Scotian 911315 by.ny applicam hurt permit xuhjwts the parent we civil puraly of
not more than five hundred dollars (55(X0.
its theowner
wink. the propcny,mmyor inteyee., wofferawages aa ilei(role compensation.
intercomorLaw demi not applye (Sorrt oan Business
and the he st Contractors
and do professions or The Contmereo LicenseLawdo sous not apply to if owner of
and Professions builds or through
who build, or improves thereon, and who rte,, such work
'I SNIP. METER OR POLE INST.
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
0
❑ THER
POWER DFIVICBS
SWIMMING POOLELECTRIC
OUTLETS - SWITCHES -ITXTURES
property
deal or
his own employees, provided that such improvements are not imcnJN or offered for
sale. IL however. the building nr itnprnvement'nulJwshinone yc:n of 'III n'the
NEW RESIDIiNTIAI. F.LECTR SQ F.
SQ. FLOOR:AREA
S/SQ. FT.
nerlwilder will base the burden removing that he did not build m improve for pur-
poso ar side.).
E]1, as owner of the prtpenp am exclusively commonly, with licensed cnmomm's 1.
OPAL:
instruct the project (Sec. ](H4, Business and Professions --i The Corer-- ---
coast, Law dues not apply fit an owner of protea who builds or lntprovc.s thereon. anti
QTY. PLUMBING PERMIT 4FFE
who contracts for such you is with a commeror(s) licensed pursuant to the Contractor's
PIiRMI'1' ISSUANCB
License Law.
❑ I am exempt under Sec. . B Its P C for this reason
A[MR -DRAIN R VENT'- WATI7R SEA)
VALUATION
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of Pe jury one of the following reelections:
BACK FLOW PROTECT. DEVICE
n
✓J
❑ I have and will maintain a Certificate ofConsenun self-insum for Workers Contain-
moan, as provided for by Section 3]lN) of Om Labor Code. Tenho perfarmuncc of the
oak which Nisorby is Salo ed.
V
no Luton ll an,f r Worker'...n t of Irk fit, hi h squired by Section
M1 of
)]011 of the labor Cale, far performance of the wnrk for which this .it is issuer.
My Work'er>'sAContpenseinp Iry/ Tier anA lTlicy nu the
Carrier. 1L� ii'�// faiM�LY.�- Policy No.:
DRAINS- FLOOR. ROOF. AREA, GOND.
STORIES TYPE GDN$T'RUCr1UN
OCC. GROUP
FIXTUNIS-PF.R TRAP
GAS - ISA. SYSTEM- 1 INC. 40UTLE'I'S
GAS- I?A. SYSTEM -OVER 4 (EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
CRRTIFIC OMPE SATION I N FROM WORKEkS'
COMPENSATION INSURANCE
lfz -3
BUILDING DIVISION fFES
(This arminn neermal hecompleted Rhe permit is hunts, hundred doR.O100)
or Ica)
GREASETRAP
PLANCH[CK FF.F.
SEWER - SANITARY - STORM IA"21XTFT'�-,
,�
h ti
2
C.1 0
0 U
W
G
h
V ,a'7.
Icertify that in the Performance urine work forwhich this Moral is issued.)shall
not employ any parson in any ntunner so as to hmmte IiI to the Workers' Cnmpen-
ration laws of Culifnmia. Date
Applicant '
,Y FEE
WATER HEATER W/VENT/EL
LNG FEE
NOTICE TO APPLICANT: If, after making this Cerifeee of Escalator, you should
become subject m the Workers Compensation provisions man, labor Code, you must
forthwith comply with such provisions or this remit shall he Jecu ed revoked.
AGENCY
CONSTRUCTION n;ian lending
Ihcreby affirm thauherc isaamnmeion lending agency for performance of
the wnrk for which this permit is is ... d(Sm. 3097. Ci, C.)
Lenders Name
WATER SYS TEM11 REA'1'INO
11,,
WATER SERVICE: fA R W9
1 FHF:
I
Um Recciptp
NEW RESIDENTIAL PLMU.
SQ 17
U
TOTAL:
TOTAL:
Lenders Address
BUILDIN'
I cenify that 1 have read than npplitimor mW ,are that the above rumination is
correct. l agree to comply with all city and county ordinances and nam laws relating to
builJingevnstos,dim, and hewhy vuthndzemprc,entativesofihr, city roomer upon the
QTY. MECHANICAL PERMIT FEF:
SEISMI .G
PERMIT ISSUANCE
BLP.CTR ' FEE
aW ve-memionesl propery, for inspection purpose..
(We) .,mc m mor, indemnify and keep harmless the City of Caperton against
ALTER OR ADD TO MECH.
PLUM .FEE
liabilities, judgments, costs and expenses which may in any way vocmeagaint sail City
in .sequence of the granting of this permit.
AIR HANDLING UNIT ('10111,1101 CFM)
MECHANIC FEE
APPLICANT I'NDERSTANDS AND /ILL COMPLY WI 111 AI.1. NON -POINT
SOURCE. REI LATIONS.
AIR HANDLING UNIT (OVER IO,gW CPM)
CONS'PRUCTION TAX
Signature orApplicant) racer Date
EXHAUST HOOD(W/DUC)
HOUSING MITIGATION PEE.
ARDOUS M HUALS DISCLOSURE
Will the applicant or future buil ag occupant more ar handle hazardous material
HEATING UNIT CFO 100,000 BTU)
,as defined by the Caption- Mm iciry Cale, Chapter 9.12, and the Health and Seloty
Ctan, Section 25532(a)?
HEATING UNIT (OVER I010,000 BTU)
VEN'T'ILATION I'AN(SINGLE RESID)
[I Yes No
PAID
Date Receipt#
Willthe air conmtinants cbandied bythe Bdo y Apar ipmvntlity Mnagenintesice,vOich
emit h.raNws air contaminants as defined by the Bay Aren Air Quality Monagnm'nt
BOILER- COMP QHP OR 1011,(0X) 111 U)
TOTAL:
BOILER -COMP (OVER I0R000 BTU)
District?
❑Yn ❑No
e
AIR CONDITIONER
ISSUANCE ATE
I have read the hazuNnus mamrialx requiretnents under Chapter 695 of the Cah-
NEW RESIDENTIAL MGCIi. SQ. FT.
(can He hh & Safety CMe, section 35115.25533 and 25534. I uakrstanJ ohm if ate
bulldln es not comemly have. tont , ohm it is my rcsponaiailty m ratify the occupant
c NQc`u
of far immenrs which must lj_-m dnrmissuanceofaCmif mi
i
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TOTAL:
C[„r
ISSUEDBY:
Owneroraulhnnz cot )a,
OFFICE