21322 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Wentlfleatlon PERMITNO.
B—tO')41 MA-0J DPAgE CSP ?onto CA, 9so�y 21322
IZra�s�es��ant/e1:�� on! I A A ;
p C(Jk'-1,�� 1 2S7-091 ( CITYOFCUPERTIN0.BUILDING DIVISION
Cuont_racters Name: lm. r APPLICATION / PERMIT
l V �/ k BULDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY C
A It /
1pf'. QrY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
naareaa:I LA BL Erc�l PLUMB MEL11
A Qjgiegr& &NZ PERMBTISSUANCE -)—CL) ❑
rtilf.'NsE5 CONTR OR'S DECLARATION
I herebyafforathat l amlicenseci under provlslonsof Chapter9(comment APPUANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth Secthm7000)of Divlslon3 q ofthde Bustnessand PmfessionsCode,and my
PANELS
license b In full and d(ect. / 8 a
license Chas Lk.p eLs f IO
Datmj 'j– Contactor NSI- 201-10DOAMPS
ARCHITECTS DEC ATION OVER 1000 AMPS SQ.F7.FLOOR AREA 5/SQ.FT.
I understand my plans shall be used as public records.
` U Licensed Professloeal SIGNSELECTRICAL I
OWNER-BUILDER DECLARATION 3VVV� a I L 6
`b, F SPECIAL CIRCUT/NILS[ III
L, Z (hereby affirm that lam exemptlromthe Contractor's Llcenx law lm the
following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INS!.
q�p countywhichrequircsa pemNtmconstruct,ahem improve,demnl6h,or repair /((((///l___
Y .�.t anystrutlure pronto its Lsmrance,aiso requlrealheapplicant for such permit to POWER DEVICES
ki C Cil file a signed statement that he 611¢nsed pursuant to the provisions of the v
$O�� rav
�ntmdor'sLicens w(Chapter9(mm ncingwRhSedion71X10)ofDivi- SWNIMONGPOOLEECTRIC
30 swn3 ofthe Bin
usess and ProfessWm VALUATION
Code)orthat he Is exempt therefromand ATION
the bash for the alleged exemption. Any Wolation of Section 7031.5 by any i,D OUITLETSSWITCHFSFTXTURES ObL-N�
5,yp�Q applicant for a permit dt subjects the applicant toe civil penalty of not than +.•/
ja�C"u five hundred delta.3500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSIRIfCIION'
8 M I,as owner of the property,or my employees with wages as their sole
�7¢ compensation,wBldo the work,andthesuucame is not Intended or offered for
p sale(Sec 7016,Businessand Pas essloru Code:The Contractors Lleewe Law
�S 2 docs net apply to an owner of property who builds or Improves thereon,and •ITS
who does such work himself orthrough his own employees,provided that such
Unprovements are not Intended or offered far sale.If,however,the building or TOTAL: n/I
ImprovementIswldwithin oneyeamfcompletiomthe owner-bullderwillhave ��/�
t rden of proving that he did net build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD!A A N
s owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE Da �J Weill '
lranors to construct the project(Sec.7044,Business and Professions Code: I
The Contractor's License law does rad apply to an owner of properly who ALTER-DRAIN&VENT-WATER(EA)
Wild,o improves thereon,and who contracts for such projects with a FEE SUMMARY
p4ador(s)licensed pursuant to the Contractors Llmme Law. BACK FLOW PROTECT.DEVICE
t` L_J 1 am exempt under Sec. B& P C for this reason '
DRAINSFLOOR ROOF,AREA,COND. SANITARY Y N
(Tuner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXNRES PER TRAP SCHOOLTAX Y_ N_
❑I hereby a(flnn that I have a certificate of consent to self-ts>ure,ora RECEIPT N
certificate ofWorkena Compensation Insurance ma camtial copythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE V N
3800,Iab C)
Policy N GAS LA.SYSTEM-OVER 4(FA) RECEIPT N
Com ray B UIL DING DIVISION FE ES
CertiCc
fied copy 6 hereby tthe cid. ' GREASE/1NDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
� dlled copy 6 filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP PAID �p_2-3 �3
COMPENSATION INSURANCE SEWER SANITARY 510RM EA 200FT Date Recei tq s
(Thlsxetlom need not M completed lithe permit is forone hundred dollars
(SIL()mless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I certify that In the performance of the work forwhich this permit b Issued,
1 shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
'kSrp
Workmi a/,Compensation Laws of California.Date PAID,
0 Applicant
Z O NOl10ETO APPLICANT:If,after making th6CertBiats of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Rett'1 tk
should become subject to the Workers compensation provisions of the Labor TOTAL:
H N Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
� j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE A
Il o Iherebyaffim@at there Is a construction lendingagency forthe perform- TOTAL: ELECTRIC FEE
Z amu of the work for which this permit 6 Issued(See.3097,Civ,Cd
O O Lender's Name PLUMBING FEE
LL F Lenders Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL.FL•E tO0
W lmdtfythatlhavcreadth6apphationand Aatethattheaboveinformatlon
O
is mrtect.l agree to comply with all city and county ordinances and state laws I PERMIT ISSUANCE LD FEES PAID:
} N relating to building construction,and hereby authorize representatives of this
f. Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnl and keep harmless the City of Caperton Date Receiptit
V ag Nticx'J d mems, and expenxaw Icheraylnanywayacnue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a units.
City in aeq o(the grantin this permit.. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
'k"17 mrc Iiia con tmr T Wte EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDO USMA ER LSDISCLOSURE
Willlheappllarat or future bulidi cupantatoreorhandleharardous HEATING UNIT(TO 100,000 BTU) Date ReceJ t#
materalasdrfirx by the Cupertino unicipal Cede,Chapter 9.17,and the
I;ealth and Safety Code Section 25532(a)l HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes MN.
Will the applicant orfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management D6trctl BOILER-CAMP OHP OR 100,"BTU)
4Yea n No
haveread the F r�OusmaterialsrequiremntsunderChapter6.95of BOILER-COMP(OVER100,000BN)
the Callfomia Health&SafetyCode,Sections 25505,25533 and 25534.1 FEB
understand that if the building does not currently have a tenant,that it 6 my NEW RESIDENTIAL MECI[. SQ.FT, r 6� n,La ,tf's��
responsibility,to notify the occupant of the mquirements which must be met r 2 O P1a�
prior to b dance a a Ceditiate of Occupancy.
Owneior authored agent Date \� ISSUE p g4,: l4, f(t(I ��Yd-Qo/
TOTAL: \ �V
OFFICE COPY