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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL
PEN
BUILDING DIVISIONv APPLICATIONIPERMIT PLUMBING • MECIIANICAI. - '/ 8 4 9 5
anunouraaOuzr-.arara ou"rrmv LV 95J
M
ARCHITF,CUENGINEER:
❑ Consultant Fees Paid by Applicant (Initial)
I hereby affirm ohm Iran licensed under provisions of Chapter 9 (commencing
with Section 70100) of Division 3 ofthe Business and Professions Cole, arW my license is
in full force and effect.
License Class Lic.k
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used ea public records
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Conlndor's License Law for the
following reason. (Section 1031.5, Business and Professions Code: Any city or county
which requires a vennt to consumer. alter, improve, demolish, or repair any sauemm
prior to its issuance, also requires the applicant for such permit o file a signed sentiment
that he is licensed pumuam to the provisions of the Convectors License law (Chapter9
(commencing with Section 9010) of llivision 3 of the Bari ness unit nsfessiono Code?nr
ohm M is esemlt mare and the basis for the aIle eilempn n. Any violation of
rnd1.,Zvsions
031.5 by any applicant for a permit subjects i a I' to o civil penalty of
honOvehunit.B1500).
wneaofthe pro Pc n my cm loye 'an re a nlecnmpensatirs,
work,and rhes ur'so in n trash m.16W.Busitass Cod 'The n is ice a Law does not apply to nn ner of
ho builds or erton. and who does uch rated. or xTcough
his own employees, prod) d i such iotpr cots mend m i J for
sde.rLhuwev will
have
men of a Id yh t ee,, eb i.the
will hove the odea of pm g rho he did t hum o i pr r pur-
poao cattle.).
1, as owner of the property, stn eAme sivdy contracting whh Ilwnsed ca can's m
cormava des not (Sm c.oan BusinessmnJrty who builds
or i pre Cs thersm. nd
x law doe not apply m an uveae( of property who builds nr improves thereon, and QTy,
who convects for each projects with a contractor(s) licensed pursuant to the Contractors
License Law.
I um exempt under Sec. , N & P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I 1 hereby off rets under penalty of perjury one of the following declummions:
❑ Heiveand willtmimnina Cmifc.tmfConammsdGinzurc for Worker's Compcm
smion, as provided fm by Section 3100 M the Lubar Code, far the verfornnmce of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as acquittal by Section
37010 of the Labor Code, for the performance of lm work for which this permit is issued.
My Wnrkels Compensation Insurance carrier and Policy number are:
Carver: Policy No.:
cluctE CATS OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed if the perosis is future hundred dollnm ($1001)
or less.)
I certify that in the performance ofshe work for which this permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker' Compen-
�$ women Laws Acalifomia. Date
Z Q Applicant
NOTICE TO APPLICANT. If, after making chis Cenifirwo of Extra tion, you should
h
>F)
become subject to the Worker's Compensation previsions of the Labor Code, you must
W Q forthwith comply with such provisions or this permit shallh deemed revoked,
04
CONSTRUCTION LENDING AGENCY
V n I hereby affirm that hem is a convection lending agency for she performance of
{Lo Lt_.o the work for which this Permit is issued (Sec. AN], Civ, C.)
O L) Leaders Name
{7a Lender's Address
1 cervi fy that I have read this application and some that the move information is
raa0 correct. l agree to comply with all city and county indicators unit state laws refining to QTY.
V4 building construction and hereby authorize reposeamtives ofthis city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep hartnless the City of Capeninn against
liabil'ties. no esu coed experucs whicM1 may in any way occmc.gainet said City
in vane, of the mit.
SOURCR REGANT I)N, NS N S .L CnMPL�WITH
// Will the applicant or fadk1 ilding oaeupant smrt or handle harmalm s maternal
a defined by the Cupertino Mu�ireipal Code, Chapter 9.12, and the f{catch and Safety
Code. Section 25532(.)?
-1 Yet ❑No
Will the applicant car finire building occupant use equipment or devices which
mit hma dous air conwmi..ms us defined by the Bay Arca Air Quality Management
Dicoria?
❑Yes ❑No
I have read the hazardous amaerials requirements under Chapter 6.95 of the Cali-
fomia Health & Safety Coon, Sections 25505, 25533 and 255M 1 undersand that if the
building does not currently have a tenant, that it is my responsibility m notify the oecupant
of the requirements which mud be mea prior to issuance of a Cenificate of Occupancy.
Owner or outhorized agent Date
ELECTRIC PERMIT
PERMIT ISSUANCE
PANELS
UP 1'0 20h AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'HEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC -
OUTLETS - Spill 'CITES -FIXTURES
NEW RESID13NTEAL ELECTR SQ P -n
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (FA)
BACK FLOW PROTECE DEVICE
DRAINS- FLOOR. ROOF, AREA. COND.
FIXTURES -PER TRAP
GAS- PA. SYSTF.M-I INCA OUTLETS
GAS- EA. SYSTEM OVER 4 (EA)
GREASIVINDUSTRI. WASTE INTERCEPTOR
GREASBTRAP
SEWER -SANITARY -STORM HA. 20017.
WA'I'BR HEA'L'ER W/V RN'DELECTR
WATER SYSTI3M/fREAI'I NO
WATER SERVICE
NEW RESIDENTIAL PLMIL SQ. ET.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO I0p00 CFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
EXHAUST HOOD(W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER By," BTU)
VENTILATION PAN (SINGLE REMO)
BOILER - COMP IMP OR 100.000 BTU)
BOILER-COMP(OVER 100,I1()OBTU)
AIR CONDITIONER
NEWRESIDENTIALMECH. SQ. PT.
OFFICE
FEE
ENERGY FEE
GRADING
SOILS P
PAID
Date ReceiptM
TOTAL:
HUILDING FEE
FEE51?ISMIC PEE
MECHANIC LFEE
CONSTRUCT AX
HOUSING MITIGAT NFEE
PAID
Date Re ipt p
Tf
ISSUANCE DATE
❑I
.
BUILDING PERMIT INFO
LE PLU B ,MECH
DG AIX
FEE
JOB DESCRIPTfbN
RESIDENTIAL
_
❑SFDWL t ❑ KITCHEN REMODEL
[]ADDITION ❑ PLUMBING RE.PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
MPROVEMENT
ATH REMODEUREPAIR (]DEMOLITION
OTHER
COMMERCIAL:
❑NEWBLDG/ADDITION ❑DEMOLITION
❑TENANT FOOD SERVICE
IMPROVEMENT
❑OTHER
FEE
ENERGY FEE
GRADING
SOILS P
PAID
Date ReceiptM
TOTAL:
HUILDING FEE
FEE51?ISMIC PEE
MECHANIC LFEE
CONSTRUCT AX
HOUSING MITIGAT NFEE
PAID
Date Re ipt p
Tf
ISSUANCE DATE