30330 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL. PERMITNO. 3 0 3 3 0
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J
BUILDING PROJECC B)KNITIFICA'I[ON
BUILDING ADDRESS: �✓ / SANITARY NO. APPLICATION SUBMITTAL DATE
IV/ � K/. K d l06 Q, `'q
OWNER S NAME: PHONE COT OR'. NAM is'w LIC NO: NIC (/y�CONTROL 001{/kms]
1 1 EP.R: LIC NO: Al E L� ❑ V l ( �+
CONTACT. PHONE:
BUILDING PERMITINFO
.5*w + ❑ Consultant Fees Paid by Applicant(Initial) 0 ELECT PLUMB MECH
0 ED
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aRrm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�0ZO with Scetion]000)of DivisionJof the Business and rofessionsC de,and my license is PERMIT ISSUANCE RESIDENTIAL:
��.. in full force and affect, 0/0 ❑SFDWL ❑KITCHEN REMODEL
aU License Class Lies APPLIANCES—RESIDENTIAL
LF.. Date - Contrecmr []ADDITION ❑PLUMBING RE-PIPE
F'p fe, HITECCS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
1 andemmnd my 1 area dads be used es PANELS
CZ C ' Pahlic ierords UP TO 200 AMPS MODIFICATION
O
F,VJ'`qq- LLicensedProfessional ❑INTERIOR ❑CHIMNEY REPAIR
� YOYOGGII OWNER-BUILDER DECLARATION 201-1000 AMPS IMPROVEMENT
eg2� I hereby affirm that 1 tan exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEURF.PAIR DE OLITION
' a a,F following reason.(Section 0031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL []OTHERNu1 Y, which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also raptness the applicant for such Permit toMeasigned document SPECIALCIRCUIT/MISC.
�(} Nat heis licensed ptrsmm to the provisions ofthe Contractor's License Law(Chapter9
(commencing with Section]B(111)o(Division 3 ofthe Business and Prefixes Code)or 'TEMP.MIffER OR POLE INST. COMMERCIAL'
6p.cuthat he is exempt therefrom and the basis fir the alleged exemption.Any violation of
x^� Section 7031.5M1 an applicant for ) pp pe yn [I NEW BLDG/ADDITION [D DEMOLITION
W y y re permit subjects the applicant n:dt f POWER DEVICES ❑TENANT ❑FOOD SERVICE
Z not marc Nan fvehundredty. am(550X)1. IMPROVEMENT
❑ Lasa swearner Its thedoc.mmyemplende,with wages astheir sea 04,LB linen, SWIMMING POOL ELECTRIC
p. will do the wons and e: he Contractor's
not imm�enseLa does r m apply to an comer
of ❑OTHER
and Professions Code:The Contractor's License Lawdoesoatapplytolf owner,f Ot/T1.RS—SWITCHES—FIXTURES
property who builds or ivided n thereon,and who does such work himself or through
for
his own employees,provided nonsuch improvements arc not amended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If.however,the building or improvement is sold within one year ofcomplction,the SQ.IT.FLOOR AREA $ISQ.FT,
owner-builder will have the human of pmving that he did not build or improve for par-
CI1.aspotentxwne - AUG 1
1,as owner of the properly,.B exclusively contracting with licensed J eomractosa.. AL: yes 1996
construct the project(Sec.]044,Business enJ Podesvinns Cndcr)The Cnmrunar's Li- a�
cense law does not apply m an owner of property who builds or improves therm,,and QTY. PLUMBING PERMIT FEL?
who contracts for such projects with a commences)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE Lr VVr LI s l 11;
43 m
laentru,s oder Sec. ,B&PCfardosrcan
as
ALTER—DRAIN&VENT—WATER H?A)
Owner Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby union under penalty of perjury one ofthe following declarations:
❑ Ihave and will maintnina Cerdficae ofCnnxm mxlGinsurc far Worker's Compcn- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCTION
union,as provided for by Section 37M of the Labor Code,for the performnce of the
work for which Nis permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation Infamous,as restaffed by Section
3700 of the Labor Code,for the performance of the work for which Nis Permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI's
My Worker's Compensation Insurance canner and Policy number art: -
Carrier Policy No.: GAS—EA.SYSTEM-OVER 4 TEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASMNDUSTRI.WASTE INTERCEPTOR y I IVISION FEES
(This sectianmeednot becompleted fine Pelt is for.hundrddallars H IBB) GREASETRAP or less.) PLANCHECK n, Oasis
Icenify Nat in the perfomtantt of Ne wmk(or which this permit is issued,I shall SEWER—SANITARY—STORM EA.200 FT.
not employ any Person in any manner so m ic m
I hce subjectto the Workers Compete ENERGY PEI'
0 Z s nwx of California.Dam WATER HEATER WNENT/F.LECTR GRADIN
7 O
Applicant CE
.^.
NOTICE subject
APPLICANT,the Wi'E If,after eking this Cision,of of Exception.Co,you should WATER SYSTEM/f1tEATING
a become stomp m the W ch pro Compensation provisions n e de Load Code,you must - SOILS 'E
LTJ
forthwith comply with such provisions or this permit shill bedamed rcvakcd. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RI?SIDP,NTIAI.PCMB. SQ.14. PAID
V Q Ihereby affirfn that them is a construction lending agency for the peAonnnnce of te Receipts -
(-'.. the work for which Nis permit is issued(Ree.309],Civ,C.)
0 V Lender's Name TO'TA
Lender's Address TOTAL:
0.t I certify that 1 have read this application and state thin the above information is BUILDING FEC
y emtecklegreemcomply with all city and county ordinances and state laws miming to QTY. MECHANICAL PERMIT FEE
V 4 building construction,and hereby authorize representatives of this city to enter upon the SEISMICFEE ,
above-mentioned propeny for ma,com.Fonseca PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Capuchin,against ELECTRIC IEE
iahilities,judgments,costs and expenses which may in any way accrue against said City ALIERORADDTOMECH.
n consequence ofthe granting of this permit PLUMBING FEL'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0011 CFM)
SOURCE REGULATIONS. MECHANICAL.FEE
AIR HAND[.]NG UNIT(OVER 10,000 CFM) CONSTRUCIONTAX
Signature of ApplinmUComractor Date EXHAUST GOOD(WIDUCI7 HOUSING MITIGATION PER
' HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle foreordains material HEATING UNIT(TO 100,000 BTU)
as defined by the Capuchin.Municipal Code,Chapter 9:12,and the Health and Safety
Cale,Satin,25532ho? HEATING UNIT(OVER 100.000 B'TU)
❑Yes (]Na VENTILATION PAN(SINGLE RESI Of PAID
Date Restates 1
Will be app ommmfuture building cecheByAea Air uerr devices which BOILER—COMP LIHP OR 100,000 BTU
•mit hazaNuus it cnnmminums as defined by the Bay Area Air Quality Mtnegement )
Jinrin7 TOTAL:
Dyes CIN. BOILER—COME(OVER 100,000 BTU)
I have rwlthe hazardous materials p AIR CONDITIONER
hands
ISSUANCE DATE
re,25533 an under4,1 nderma of the Culi-
fomis HwIN&Safety Cada,have
mom]5505.8533 and SSJ4.1 undemamd that if the NEW RESIDENTIAL MSCI I: SQ.FT.
building does mm smrcich hast atenant,(but it ismyresryoCerityefnotify the occupant
of the reyuirtmcnts which man he met prior m issuance of o Ccnificate of Occupancy.
Owner mau@orizedagent Date - TOTAL:
ISSUED BY:
OFFICE