30930 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOAI'PLICAT9 3 BUILDING-ELECTRICAL PERMITNO. I'I 0930 O
BUILDING DIVISION - ION/PF,RMIT PLUMBING-MECHANICAL 3 V13
BUILDING PROJECT IDENTIFICATION
BUILD GADDRESS: ' SANITARY NO, APPLICATION SUBMITTAL DAT
t OWNS NAME.: O PHONE: C)NTRBCTOR'SNANf E: LIC O:
UU�/ VV D6 NIC CON I"ROI.#
IRC /ENGINEHR: LIC NO: DDRES "P ❑ �/ /
� 7
COWXl7T in
/JMI NE sotil,,ZA . 111 04 BUILDING PERMIT INFO
/ ElConsultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB, MF:CH
LICENSED 11N11AC1Of'111ECLA A' N 'lb
QTY s ELGCTRIC PIiRMIT FfiB
1 hereby of irin that I at licensed under pruvi,ions of chapter 9 fammnenainx JOB DESCRIPTION
DOZ with SenionOWO)of Division 3 ofthe Business and Professions Code,and my license is
FOO fu0force and eHcel. - PERMIT ISSUANCE
1,612 in : Eq- WL ❑KITCHEN REMODEL
QZW Got, Clazs Lo.# APPLIANCP_S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ryFl a a Ddle conlDECL
FDm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
ZOV, 1und<rsmnd my plars,hill tie usedaz public records MODIFICATION
OZ I"a UPT0200 AMPS [I INTERIOR El CHIMNEY REPAIR
F�.F',u� Licensed Professional 2014000AMPS IMPROVEMENT
LLS Y,F, e that I ma exempt boom he ....me)N OVER 1001AMPS C BATH REMODELIREPAIR ❑DEMOLITION
1'W� ' 1 naso.affirm maul fate exempt from me Cssion,Ca License Law lin he
W:g3 y following re n. eoraftnn7mom Bn,incs and Profession,CtNe:Any citgor county SIGNS ELECT RIC AL ❑OTHER
=O ye which requires bounce.permit bn comtran,alma tit on,. Jcmnat t or repair a d .moment '
J (hat he slicendp.[so catin res pre inions of tar Common's
Licenso file e Law
SPECIAL CIRCUIT/MISC.
E } that he is licensed pumuam m the provisions of the C.mracmr's Licenu Low ICToptcr 9 _
WC�� (commencing with Secomin70)(B.f Division 3ofthe Business and Pmfeuions C.dc)mr TEMP.METER OR POLE INST COMMERCIAL:
d c eG that he is exempt therefrom and fie basic for the alleged exemption.Any violation of _ ❑NEW B DITIO� OLITION
Section 7031.5 by any applicant fora pcnnil object,the applicant to acivil petmkyof POWER DEVICES 3
.� ❑TENA DSERVICE
FZQnot mutation five hundred dollars($500). - DMPP.py FMPy'1'
, ❑l as owner of the pr.lwny,or my employees with wages a.stheir sole compensation, SWIMMING POOL ELECTRIC 1�I'
SFO will dothe work,and theso earei.snotintendedorofferedlin%ale(Sec.7044,Bounces OTNL'NY lar lrtNTIPIC�
and is ofieWn'x Care:The Continuator',License Law dine.,not apply I.an owner.f � OUTLETS-SWITCHES-FIXTURES -
C.3-• pr.peny who build.,or improve.thereon,end who does such work himself or through
his own employees,provided mat such improvements me not intended or offered.for NEW RESIDENTIAL ELECfR SQ F E
mole.IL howeveothebmidingorimprovement is soldwimin one yeaeofcompletiumnicrr. - SQ.FT. .00R AREA
owner-builder will have Ne burden of proving that he did not build or improve for pur. -
pnse of sale.):
• ❑ 1,a,owner of the progeny,non exclusively contracting with licensed contractms to
xwu the ,,act(San.91144 B A ,.andr f :Coda:)Tho Ctmr.tetorx I.,-
cause
.esse Low doe,not,pplyl f property who but Ids ioproves thereon unit QTY. PLUMBING PERMIT - PHIS ry /
who contracts ftir such pro)eus with a conoamor(s)licensed pursuant o the Co nraetor s b'•l
Liccnsc Law. - t �•
Q l oro exempt under Sax. .B&P C for this remain ii
PERMIT ISSUANCE
Owner ` Date ALTER—TRAIN&VEST—WATER WATER/A) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FI.OW PROTECT.
I hereby affirm under penalty of perjury one of the following declamations l( ( J
[] I have and will mainudo aCenilicmd of Con.senuoself-imare for Workers Comhcm- DRAINS—FLOOR,ROOF,AkhA.COND' STORIES TYPECONSIRUCTIOF
cation,tie provided for by Section 3701 of the Labor 0n1a,Ibr the pierinrmmucc of the
work for which this pcnnil is issued. ' FIXTURES—PER TRAP
❑1 have and will maiumin Workers Compensation Insurance,as requited by Section -
37X)ofthe Labor Code.fur the pafarmarecof the work hlr which this permit i,issued. GAS—PA.SYSTEM-1 INCA OUTL. OCC.GROUP AIN
My Worker's Compensation Insurance carrier and Policy number are: , -
Camee - - Policy No.: GAS—EA.S YSI'EM OVER 4 BA))
/ CERTIFICATE OF EXEMPTION FROM WORKERS' �F, 4 I I
COMPENSATION INSURANCE GREAS%INDUSTRL WASTE INT ERCF:IT_)R
BUILDING DIVISION FEES
(Thissection aced not hecnmpleted if the permit is for tine hundred dollars($I W)
nr lcsxl - CR[ASF:'1'kAP r PLANCHECK FEE 0
' Iccnitylhal in lheperli.rmmaccafihe work lits which thlspermit xi,sucd,Weill SEWER—SANITARY—STORM EA.2(NIIT.
not employ any person in anmus
y imic,,, In become ecoe subject to the Wofkeri Compcn- ENERGY FEE
z ,Z sztionlawsof Califnmia.Date _ WATER HEATER WNENT/ELECTR
Q Applicant GRADING PER
y NOTICE.TO APPLICANT.If.after making this Cenificme of Exemption,you should WATER SYSTEMOREATING
a ; become subject o thea Workeex Compensation Provisions of the Labor Code,you must SOILS FEE
forthwith comply with,ach pnwkium or this gammon shall be deemed revoked. WATER SERVICE -
aA
iU. z LONS anni, iso conNLENDINGngagenY NEW RESIDENTIAL PLMB.' SQ.ET. LAID
I hereby affirm dwuhom isueonxwelinn lending nxency for the performance of Data Raxipt#
P.Q Lha work for which this pcnnil is i,a,d(Sec.3099,Cie C.)
0 U Landers Name - TOTAL:
G Landers Address _
y1 cantly the I have read this appliemim,and slate that Ne above information is BUILDING FEE L
Ir y context.)agree t.comply with all cilyand county orditmnres and state lax,relining to QTY. MECHANICAL PERMIT FEE
V Z building construction,andhcraby nuth.rize repmunla,ivesofthis city locnterupon the SEISMIC FEE
above-mcrownW property far inspection pmpaus. PERMIT ISSUANCE
(We)agree m save,indermly and keep hmmlexx the City of Caperton.again,, ELECTRIC FEE
Iiahilities,juJgmen...cos.....it expenses which may in any way acerae agaimt,old City ALTER OR ADD TO MECIL
in ssepuarecof the xrumia,al"this permit. - PLUMBING FEE
APPLICANT.UNDE' TANDS D WILL COMPLY WITH ALL NON.,POINT AIR HANDLING UNIT(TO 10,I00)CF-M)
$ 1' ,E :GULAT � Q MECHANICAL FEE
1`7107L4
, 07 —1, - AIR HANDLING UNIT IBM)CFM) CONSTRUCTION TAX
Signmure of ApplicantIContr r Data _1 EXHAUST HOOD(W/DULT) HOUSING MITIGATION FEE '
HADA )US MATEEIALS DISCLOSURE
Will the applicant or lute building occupant pore or handle haevdoaz material, HEATING UNIT(TO 100.000 BTU)
us darned by the Cupeninn Municipal Cole,Chapter 9.12,and the Health and Safety
' Code,Section 25532(a)Y, HEATING UNIT(OVER 100,000 BTU)
❑Yes- 0 N PAID
VENTILATION FAN(SINGLE kESIU) Data Receipt# '
Will the'applicant or future buildingsccupinl use equipment or device,which
, IgO1LER—COMP(3HP OR I(OWOIITU)
ani,mourou
ds air contaminants as defined by the Bay Area Air Quality Management , TOTAL:
UisWn9
❑Yes ❑No BOILER—COMP(OVER 10,000 BTU)
'
I have read the hazardous materials requirements under Chapter 695of the Cali AIR CONDITIONER ISSUANCE,DATE,
food.Health&Safety GNe,Sections 25505,25533 and 23534.1underswnd that if the NEW RES I DEN'I'JAL MECH. SQ.F r.
building Joe.not emincoly have a renanl,the,a is my reapou'Palhy to unity Iba nump int
of he requirements which nnost sennet led m l„ounce da Canlftinm ofOernpimcy. -
Ownarar authnrixcJ agem - Data TO ISSUED BY:
OFFICE