25166 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILDING-ELECTRI AL PERMITNO.
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING-MECHANICAL 25 1 C C
BUILDING PNOJF,C'1'IDEN'TIFICAT'ION G J 1 U v
BUILDING ADDRESS: SANITARY NO. APLICA'DON SUBMITTAL DATE
UNIT'# LOT
OWNERS NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
_ N/C CONTROL x
RCIIITECUFNGINEC:R: LIC NO: ADDNF'
sz
'ONTACT: PHONE: QTY. ELECTRIC PER IT FEE BUILDING PERMIT INFO
B,L�D,G/ ELECT PLUMB M 11 EC
ll
PERMIT ISSUANCE y y
I.ICF'_ F.D CONTRACT ORIS DECLARATION APPLIANCES-RESIDENTIAL WWW
QWz Ihaeb ffi.,bal am licensed unJerpmvisions nfChap,er9(commencing with TOB DESCRIPTION
�OL) 5«tion]000)of Division J of the Businos end Professions Code,end my licrnu is in PANELS
yetE. fan fame and<flnc
F G W License Clio t L,c.x UP TO 200 AMPS
rn<y Dale Contmc,or - 2(11-If%10 AMPS
E-y! ARCI ITTECI"S DECLARATION Q.FT.FLOOR AREA Q.FT.
X.l r,�, OVER WMAMPS
O Z�I] I understand my plans shall M use]as public records.
F y F j SIGNS ELECTRICAE, '
Q EJ Licensed Professional
a:= OWNER-BUILDER DECLARATION SPECIAI-CIRCUIT/MISC, ) NILED
KOyV I hereby affirm thn I an exempt from the Contractors License law for die - R
m3ay following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER ORPoLF,INST. 9
h' O which reyuirex n pemti,m consomn,alter,improve,demaisM1,or rtpeir wy stmewre 1. '
mce I I¢issuance,also requires the I tmrxuch Ito file a,i I lalemem
POWER DEVICES
s 9uires pP is permit 8nu s
that he is licensed pursuant to the provisions of the Contractor's License Law(ChapterIt _91g
SWIMMING POOL ELECTRIC
ay e 9(cutmnencmg with Section 7(Xq)of Division lM1e Business and fsnoftssinnsCWe) ON J
taxi—m or that he is exempt therefrom and the basis for the alleged exemption.Any sodiumnof OUTLETS-SWITCHES-Fl%TURES
FZQ Seaiun]03 LS by any applicant fore permit aubj«ts tM1e applicannoacivil penalty of
not mote than five hundred dollars(1500). O
egLp NEW REMDENTIALELECTR SQ.FT. STORIES TYPECONSTRUCIION
CFo ElLasowner.ftheprnperty,ormyemploy«swish wegaasrheirs.lec.mpensation,
W3= will do the work,and the someone ianoantemed proffered for sale(Sce.90,1W,Business
said Pmressions Code:The Contractor's License law does not apply m an aware of
property e m builds or i mproves tbemon,and who does such work hirm ell'unhrough his
own employees,provided that such improvements are notimmmdedmidered horsed,If, OCC.GROUPEA
however.Ne huili ingor improvement is sold within one yearofcomple int,the owner- TOTAL:
builds will have the burden ofproving that he did not build m improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD'l.ONIB
❑ I,mownerofthepmpeny,amexclusivelymnuactingwiNlicen,e contractorsm
coasnuct the project(Sec.701,1,Business and Professions Cost The Contractors
License Law does not apply to an owner of propcny who buildsor improves thereon,and PERMIT ISSUANCE
whmimues forauch project,with momoram,)licensed pucomin Inthc Contractor's sr.Law.
LiceaipL'I'I?R-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ l am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OU'I:SIDE FEES
Owner Dae SANITARY V N
DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT'N
r WORKMAN COMPENSATION DECLARATION SCHOOLTA% YN
❑ I hereby affirm thatI have a certificate ofcoment to salt-insum,or a cenificare of FIXTURES-PER TRAP RECEIP #
orkeo'Compensation Insurance ora certified copy thereof(Sec.3800,Lab CJ which PARKFEE Y N
covers aIle pl�e' cr this etmit. GAS-EA.SYSTEM-1 INC.4 OUTLETS REC
Policy x _I+�— BUILDING DIVISION SION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK PER
❑ Ceni ted copy is hcrcby furnished.
❑ CenifiW copy is flet with the city inspection Division. GRFASEpNDUSTRL WASTE INTERCEPTOR GRADING ME
CER'TIIICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(this section need not be,completed ifthe permit is Intone hundred dollars(SELL) SEWER-SANITARY-STORM EA.2001ef. ENERGY FEE
or less.)
I certify that in the ptamonancenfthe work(..whichrhis permills issued,I hall WATER HEATER W/VENT/FLECTR
not employ any Person in any manner as to become suhjecl to the Workers' PAID
Cmmperawasu Lawsof California. Date n. WATER SYSTE VIRPATING Dam Receipt#
Q ZApplicant
z 0 NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you shouldNEW RESIDENHAL PLMB. SQ.FP. TOTAL:
En become subject to the Workers Compensation Provisions of the Labor Code,you must
a ; forthwith comply withmch provisions or this permit shall br deemed revoked. BUILDING FEE
CONSTRUC ION LENDING AGENCY SEISMIC FEE
1 hereby affirm that,here is a couslruction lending agency for the performance of
U O the work for which Olapermit is issued(Sec.YN7.Civ.Cj TOTAL:rFEE
ELECTRIC FEE
Ismdee,Name PLUMBING FEIi
0 F QTY.Least Address MECHANICAL PERMIT
V 1 cenify the,I have read this application and aside'hot the abase information is MECHANICAL.FEE
cored.I agree to comply with all city and county ordinances and slate laws relating to PERMIT ISSUANCE
F-' building construction,and hereby authorize representatives ofthis city toenmrupomhe CONSTRUCTION TAX
Vz alrosc-mentioned property for inspection purposes, ALTER OR ADD TO MECH.
(We)agree air entre,indemnify and keep harmless the City of Capstan.against
liabilitics,judgmenta,rants and expenses which may inany way.,,.c City AIR HANDLING UNIT'('1'010,(HIII CFM)
conxcyurnce of the g.Ii.,.f Qi,p.it AIR HANDLING UNIT(OVER I0,010 CFM)
Signalw of ApplicanVConwctor I u EXHAUST HOOD(W/DUCT) PAID
I IAIARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Receipt#
Will the appllcanl or future buildin8 rceapanl store or handle hazardous material
as defined by the Cu,cntoo Municipal Code,Chapter 9.12.and the Health and Safety HEATING UNI'1'(OVIiR 100.000 BTU) TOTAL:
Code,Section255J2Ia)P VENTILATION FAN(SINGLE RESID)
❑Yea ❑No
BOILER-COMP(JIIP OR 100,000 BT1f) ,1$S NBCE DA e
Will air contaminants
sbefine by the Bay Area
Management
p++
zardoua air atmemirunts as defined by the day Area Air Quality Menagemem BOILER-COMP(OVER I00.000 BT117
District' 1:1I UAI
Ycs ❑No NEW RESIDENTIAL MECH. SQ.FI'. J0(VJ,rpV� 1
9993
1 have mad the hazardous materials rcyuiremen¢under Chapter 6.95 of the
CI T Y Uf (;UY[ft
California Health&Safety Code,Sections 25505,25533 and 25534. l understand Nat
if IM1e building does not currently have a tenant,that it is my responsibility to notify 0e l�
Occupant of the ra minems which must be iota prim to issuance of a enific te of
CWy
Ic
Ma aathmi,od.,a, Dat '101'AL: ISSUED BY: