24821 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMff NO.
PLUMBING MECHI
BUILDING DIVISION APPLICATION/PERMIT BUILDING PROJECTIDENTIFICATION 24821^ 821
BUILDING ADDRESS: /0` SANITARY NO. APPLICATIONSUBMI'FI'ALDATE
UNIT# LOT# �^
O S AME: HON AC'I'OR'SN LIC NO:
r Ih` �>• r N/C CONTROL#
X141./ NG F LIC NO: rVSS'. 3 sir S
e
Cop`TACT: //J ��(�jl PHONE: • BUILDING PERMIT INFO `
(��a, y�l. �3 4 QTY, ELECTRIC RMIT FBE BLDG LECT PLII MECH
1,d,r,-/ '� 7 — /� PERMIT ISSUANCE b
LICENSED CONI RACfOR'S DFCLARATION APPLIANCES-RESIDENTIAL. �-�w JOB DESC PTION
nozz L hereby affirm that l am licensed underpmvisionsorchapter9(commeneing with
¢100 'Section 7000)of Division 3 ophe Busineasand Professions Codo,and my license is in PANELS \ \�
Fps V E full force and effect. . S�
<z License Class Lie,# UP T02UUAMPS
du
Contractor 201-100-AAMPS
jy'z ARCHITECTS DECLARATION OVER 1000 AMPS V
SQ.FT.FLOOR AREA $/SQ.FT.
z..o
I understand my plans slmll be used os public re.nls. 33'36 [ t
n F"n1 SIG SELECT A
Y 5d' Licensed Professional
W I
OWNER-BUILDERthe CoATION SP I C Cl 1SC.
3¢ I hereby affirm that 1 am exempt fromom that Conwetofe License Low for the
fallowing raunn.(malt n 703Lmer,alter, and Pre,demolish,
e o li Code Ary city or county TEMP. T. R POLE ST
e.ONa which requires a permit m conmrum,alma improve,demoliah,nr repair any structure
��7 prior Iona issuance,alsoregaires tM1capplicant Leitch penniuo file andarommutement POWF. EVICES
DOC that he is licensed purman to the provisions of the Contractor's License Law(Chapter
y.R, 9(formtion,with Sectio.]W0)of Division 3 of the B uslnesa and limitations Code) SWIMMING POOL ELE C � VALUATT ON
y^y or that he is exempt therefrom caddie heals fore alleged exemption.Anyviolatio is. OUTLETS-SWITCIIF:S- IXTURES
zpSection N3Lpermit 5byany applicant for a peit subjects the applicant to a civil penalty of
not more than five hundred dollars($5W).
F� ❑ I,asnwnerofWeproperry,ormycmpinyeeswithwugesustheirsolecampereation, NEWRESLDENTIALELECI'R SQ.PT. STORIES TYPE CONSTRUCTION
y;_ will do the work,and the structure isnot intendedoroffereciforsale(See,7044,Business
and Professions Code:The Contractor's License Law does not apply to on owner of I V
pnspatywho builds orimproves thereon,and whodoessuchwork htmeelfi n amOd,his
employees,providedthatsuchimprovemenaarenotintendedorofferedforsale.If, OCC.CROUP RES.UNITS
however,the building or improvement is sold within one Year mf completion,the owner-
boulder will have the banded of Proving that he did not build or improve for purpose of
sale.). - - -
❑ I,as owmaofthe property.aexclusively contracting with licensed contmctore m QTY. PLUMBING PERMIT - FEE FLOOD ZONG
mAPN
construct the pmjeet(Site 7044,Business and Professions Code)The Contractor's
License Lowdoes not apply loan ownerofproperry who builds or improves thereon,add PERMIT ISSUANCE
who..[,acts for such projects with mmatractor(s)licenced pursuant to the Comments
License Law. ALTER ICA) FEE SUMMARY
❑ 1 am exempt ander Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FFS
SANITARY Y N
Owner Data DR S-FLOOR,ROOF,AREA.GOND. RF,CFu T#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihercby affirm that lhave ncertificate of consenno self-insure,ora.nificem of k RECEIPT#
Wohere'Cmm mnsminn lnsumnce ora oerti0ed. tM1mmof Sec.9RW,Lub C.7 which FI TUR
I PY ( �� m's PARK PEE YN
covers#ell employee's codcrthis Permit. GAS-EA T '.Ill Q l I RECEIPT#
y _ ` BU INGDI ISIONFEP,S
CpnmY GAS-EA.. ST: -OV�R4(E ) LANCHECK E
Cdyified copy is hereby famished.
❑ Cenided copy in filed with the city inspection division. GR ASF/IND� `AASTE INT, CRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' GR. AT SOILS M �'
COMPFNSA'RON INSURANCE V
(This sechonneed not becmmplcled Mie permh is Income hundred dollars SEWER-SANITARY-STORM EA,2WFT. PN FEB
orlese.)
I certify that in the performance ofthe work for which this permit is issued,l shall WATER HEATER WNENT/ELECTR
not employ any person in any manner an as m become subject to the Workers' - PAID
Compensation Lawsof California. Date WATER SYSTENFTREATING Data R aim )V
1 Z+ Applicant
NOTICF,TOAPPI.ICANT:lf,aftermakingibis Cenifioamdf Exemption,y..,h.uld NEWRESIDENTIALPLMB. SQ.FT. TO L.
I OG become subject to the Worker's Compensation provisions of the Labor Code,you must
forM1with comply with such provisions or this Permit shall be deemed revoked. BUILDING FEEco
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z. I hereby affirm that then is a,mostraction lending agency for the performance of TOTAL: ELECTRIC FFE I O
t O the work for which this Permit is issued(Sec 3097,Civ.CJ
at
r Lender's Name -
t U Lender's Address QTY. MECHANICAL PERMIT -FEE
�' PLUMBING PEE
1 certify that 1 have mad this application and state that the above Information is
acorrect.l agree to comply with all city and county ordinances mid state laws relating to PERMIT ISSUANCE MECHANICAL FEE
LO bankrollstruction,and here by authorize representatives ofthis city touter upon the CANSTRUCJ1J TAX
Z above-mentimillm allllpClpDses. ALTER OR ADD TO MECH.
�(We) unify and keen hntmless the City of Caperton against
Itn "' I IS!'"e nnanyway ecaueagaiftdC AIR HANDLING UNIT(TO IO,OW CFM)
ht.p � AIR HANDLING UNIT(OVER 10,000 CPM)
Stg o Appiicam orae EXHAUST HOOD(W/DUCT)
PAID
IIAZARDOU MATERIALSDISCLOSURG HEATING UNIT(TO IW,OW BTU) Dam Receipt#
Will the applicant or finum building occupant more orhandle hazardous material HEATING UNIT(OVER 100,000 ETD) TOT
as defined by the Caperton Mmdcipal Code,Chapter 9.12,and the Health end Safety
Code,Section YSca32(a)? ❑No VENTILATION FAN(SINGLE RESID)
' ISSUANCE DATE
Will thea licamorfumrebulldln equipmen BOILER-COME(DEP OR IW,OW BTU)
pp gn.upnm use mcdevlceswhlch emit
azandous air contaminants m defined by the Bay Area Air Quality Management BOILER-COMP(OVER IBQWO BTU)
Istria? PAID
� pp
❑Ycs ❑No NEW RESIUFNTIAL MECH. SQ.FT. P A f D
1 have read the hazardous materials ocalmo rents under Chapter 6.95 of the f
CulifomiaHwItM1&Safety Coda,Sections 25505,25533 and 25534. 1 undeadan that
if
building does not currently have a tenant,that it is my impressibility to notify the Wnev r0 IQ
occupant of the requhemans which must be met prior m Issuance of o Certificate of 1 V
Oct"marcy. IITY ys
V
Owner or motorized agent Date 'TOTAL: ISSUED BY;
OFFICE