30960 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OFOCUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. . 30960
BUILDING PROJECTIDENTIFICATION
B DING ADyI{ESS: / SANITARY NO. APPLICATION SUBMITTAL GATT
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CONTAC:: 1 PHONEPoq BUILDING PERMIT INFO
/ rs- I I Off' // ❑ Consultant Feel Paid by Applicant(Initial) BLDG ELECT' PLUMB MUCH
IV1 li ❑ ❑ ❑
LICENSEDCONTRACfOR'SDECLARATION - QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DE CRIPTION
WOO with section]11001 fDgyul'thc Rosiness dProfessionv Cnde,and my license i.v RESIDENTIAL'
FWWr. 'in full force nndc ey. OI/� PERMIT ISSUANCE " 0SFDWL [I KITCHEN REMODEL
M�UU Licens ass Lic.B '[
P V W Dam Cnmmcm APPLIANCES-RESIDENTIAL []ADDITION OPLOMHINGRE-PIPT:
F7v CHITECI"S'DF,CLA ATION []MULTI-UNIT ❑STRUCTURAL
2 I understand m I n h II he used as bl' PANELS MODIFICATION
OZ(/1^, Ypu xaa pu mrecrrds UPT0200AMPS
r4f"O Licensed Naheoohnit ❑INTERIOR ❑CHIMNEY RI7PAIR
y�Y OWNER-BUIL201-1000AMPS IMPROVEMENTDER DECLARATION OVER 1(X10 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
y O'a'U I hereby affirm thin 1 am exempt from the Contractors License Law for the
Dd 3 CF following reason(Section]031.5.Business and Professions Cade:Any city or county ' SIGNS ELECTRICAL ❑OTHER
YY17 Y.y which requires a permit to construct,alter,improve,demolish,or tiled,any swemrc
prior to its issuance,also requires the applicant for such permit to Ble u signed statement SPECIAL CIRCUIT/MISC.
f;!(} that he is licensed pummnt to the provisions ofthe Canna toh License Low(Chapter 9
^^Qj (commencing with Section 7000)cf Division 3ofine Business and Pmfecsions Craft TEMP.M=..R OR POLE INST. COMMERCIAL:
that he is o npt thercfmm end the basis far the alleged exemption
m .An,violation of ❑NEW BLDG/ADDRION ❑DEMOLITION
m Section](131.5 by any applieanl far a permit subjects the applieam toe civil penalty of POWER DEVICES
Z} not more than li5e10
Five hundred dollars(S ). ❑ ❑
TENANT h00D SERVICE
^O p Las ownerofthepmpcny,nr my employees wish wages as their totba, r,pernithin, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the wok,and the structure is not iman led orolfered for side(Sec.7614,Busina,s ❑OTHER
a m and Profesxlons Code:The Convector's License Lew does net apply m an 0wtmr of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
aide.If,however the hui ldia,or improvcmem is sold within one year ofarmaletian,the /LFT�T FLOOR ARRAV VSQ.F1',
p aoebaildo,will hove the harden of proving that he did not build nr improve fur,par- - rkp
r-nfame). 4 2
1,ie owner of the,merry,nm exclusively.humcing with licensed m nnamnrs to TOTAL:
construct the pnrjen(Sec.](144•Buddeav and Professions Co.,.,The Comn...
cense law does 1101 apply to an ownerofmcpeny who builds or imprves themon,tmd QTY. PLUMBING PERMIT FF.f? �l�VhL•1/j..` ��
who contracts for such prjens with a cnntmnm(s)licensed pursuant m the Comrncmr's
License Law. PERMIT ISSUANCE
❑ 1amexemptunder Sea ,B&PCfordUsreran
Owner Data
ALTER-DRAIN&VENTVALUATION-WATER(EA) 1
WORKEk:S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
T he ohy affinm under penalty of R jury one of the following declarations
❑I have and will maintain a Certificate of Consent to self-insure for Workers Conan. DRAINS-FLOOR,ROOF.AREA.COND.
Order,asst provided for by Section 3700 of the IaMv Code,for Use performance of the STORIES TYPE CONSTY
CTION
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insumn<e,as smuired by Section
3700 of the Lahr Cndq fur the performance of the work for which this permit is mmed, GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUPM,W APN
Curfew mens 'min- sur_ce carie PolcY NaYJ_]'KE�/ GAS-EA.SYSTEM-OVER 4IRA)
C. fl IZ�7C�fIp:,Z[S,F(FXF-MPTION FROM-{ K�iJ
COMPENSATION INSURANCE GRIiASEIINDUSTRL WASTE.INTERCEPTOR
or less)
(This section need not he completed If the permit is for one hundred dollars(51(0) GREASETRAP BUILDING DIVISION MILS
PLANCHF.CK FE8
Ioyainy pamat anthe allyliomince rofsto ork become
bjectch to perthe Woris kers
ed,C..Upco. SIiWBR-SANITARY-STORM EA.21XtIl'.
1
not employ any perste in any manner as as m hunrme subject to ma Wnrkrrk Conlan, ENERGY F88
action Laws of California.Data WATER IILATER W/VENT/ELECTR
Q AppTicam GRADING FEE
y�r NOTIGH TO APPLICANT:If,after making this Certificate of Exanptlon,you-should WATER SYSTP.MRREATING
.�•' l become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
K-t forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE -
Q
]z CONSIatthe is aconNLUNDINGAOENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
L1 P Ihereby affvd,permcre issue (So,. 0lending agency for perfo,mantt of Data Bar eiptN 17
� P me work for which this permit is issued(Sec.309].Ci,CJ
CULenders Name OT -:
Undcrs Address TOTAL:
H0. 1 certify that T have mad this application and state that the ndwe information is BUILDING FEE
p) coned.T agree to comply with all city and county ordinances and state laws almingm QTY MECHANICAL PERMIT FEE
U ,Z, building enmwetion,and hereby authorize mpasenmtives of Nis city to enter upon the SEISMIC FF.F
above mentioned pmperty for inspection puryous.
(We)ishan us save•mdmnnify and keep harmless the City of Caperton againel PIiRM1'I'ISSUANCE ELECTRIC TO
IiabilitieO,judgmems,msuend expica s which may many way accrued,mum said City ALTER OR ADD TO MECH.in asequence of the running of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UND'(TO Io,000 CFM)
SOURCE REGULATIONS. MECHANICALF
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCT TAX
Signature of Applicam/Commcmr Dam EXHAUST BUGG W/DUCI) HOUSING MITIGA N4RWmpr
HAZARDOUS MATERIALS DISCLOSURP.
Will the applicant 0r frac building occupantslam or handle hazanlom nalmial I]RATING UNIT(TO 100,000 BTU)
as defma4 by the CuporBno Muniuipul Cale.Chapter 9.12,and the Henhh and Safety
Code,Section 2.5532(x)'! - I TEXT ING UNIT(OVER 100,00X1 BT U)
❑Yes ❑No
VENTI LATION FAN(SINGLE RESID) PAID Data
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HPOR IW,WO BTU)
mit hamNous air amo mirams as def nal by the Bay Areu Air Quality Management
District? TOTAL
❑Yes C]No BOILER-COMP(OVER 100.000 BTU)
I base it the hmardeus matelots AIR CONDITIONER ISSUANCE DATE
nyuiamems under Chapter 6.95 of me Cnli-
fomia Beall It&Safety Cada,Section 25505.853]and 25534.T undcntand mal if the NEW RESIDENTIAL.MECH. SQ.FT.
buil ' does icur ntlyhaveatenanl,m titismymsponvbilitymnotifytheoccupant
t which moa he met prio}Io issuanre ofaC ifi f VPyy.
J
rte r- M1olredagenl Da TOTAL: ISSUED BY:
OFFICE '