S 4307APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑KITCHEN REMODEL
[]ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
BUILDING - ELECTRICAL
APPLIANCES — RESIDEN I IAL
PERMIT NO.
BUILDING DIVISION
APPLICNI'fONIPF,RMIT
PLUMBING -MECHANICAL
SPECIAL CIRCUIT/MISC.
S 4307
'TEMP. METER OR POLE INST.
11,
.IDEN'FICATION'/1:"^,T, 11N,
It c i ' ,. • BUILDING PROJECT'PI
SWIMMING POOL ELECTRIC
OUTLETS — SWI ICHES — FIXTURES
BUILDING ADDRESS:
SQ, FT. FLOOR AREA
SANITARY NO.
APPLICATION SUBMITTAL. DATE
MIT,�'��rtt"Fit,
PERMIT' ISSUANCE
ALTER— DRAIN&VENT— (EA)
VALUATION
.
BACK PLOW PROI ECT. DE .F.
DRAINS— FLOOR, ROOF. AREA, COND.
OWN5Ii'S P.:
P L:
CONTRACTOR'S NAME:. LIC NO:
NIC
❑
CONTROL)
L
GREASUINDIISTRLWASTE INTERCEPTOR
BUILDING DIVISION THIS
\RCHITECT . GI .R: LIC NO:
ADDRESS:
CONTACT:
PHONE:
ENERGY PER
°t;`f;;, -t t;'j • 1(tgU1hDING
PERMIT INFO jj' r*f'f'•, ,
GRAVING FEE
I
❑ Consultant Fees Paid by Applicant (Initial)
BLDG
ELECT PLUMB MECH
WATER SERVICE
PAID
NEW RHSIDIt.IYI'IN. PLMB, SQ. FT.
2_ P;C�
LICENSED CONT'RACTOR'S DPCLARAT ION
1 hereby affirm th t 1 licensed ..tip s of Chapter 9 (commencing
with Secton]I0))olDl':' 3ordbe Bunine,midl motors Gale andny licunseis
in full force and effect.
License Class Lit #
Date Comracmr
ARCHITECT'S DECLARATION
1 understand my plans shall he used as public recoNs
Licensed Pndcsefuld
OWNER-BIJILD1iR DECLARATION
1 hereby affirm That 1 um exempt from the Contractors License Law far the
following reason. (Section 703 1.5, Business and Pml'esslons bade: Any city or county
which tulmres:I permit Io constmet, aluc, improve, demolish, or repair any smucture
pd ar to its issuance, also acclaims the applicant far such penman File u.vigned statement
mat be Is Ilcenwd par ant Ins the uvi,rm, of the Cnntmmor's License Low (Chapter 9
(commencing with Section ]OW) of Division 3 of the Badness and Professions Cole) or
Nm he is exempt thcmfmm and the halts birdie allegW exemption, Any vltlaio0 of
Section 7031.5 by any applicant for a Permit subjects the applicant o a civil penalty of
amt marc than rive hundred dollars MOE),
U I, as owner of the Pont or my employees with wages as their sole compensation,
will do the work, and the structure is nn, intended m allcred formic (See. ](44, Business
and Profcs,mas CWu The Caprivi License Ww does not apply l9 an owner of
propcny who builds orimproves thereon, and who does such work himself or through
his own employes, provided that such improvements arc not intended or offered for
.Jr. If, howevo9 the building or improvement is,o d within one year of cnmpddium. fire
owner-hailder will have the burden Of proving that he did not build or improve for pur-
poseoft.LA
❑ I, asr of the progeny, n exclusively contracting with licensed commetnrs m
comondidtthproject (Sac. 7044, Business and Professions Code.) The Conldieuns Li-
ne Law discs not apply to an owner of propcny what builds (it improves thererm, and
who contracts for such projects with a cotnracumis) litems i pursuant in Be Comment's
Liwnsc Eaw.
l am exempt under Sec. ,B& P C for this reason
Owner - Date
WORKER'S COM of SAIve,mTON DECLARANON
lowing
1 hand waffirm under penally of perjury one of the fallowing d o rker' Co
Ot [have and will for by Se tion icam37M of Cnnwm m ist Ginfurther Worker's ce of the
w...kf as provided for by Semina 3]1x) of the Labra Cale, for the pnrfommnce of the
work far which this permit if Issued.
1 have and will maintain for Worker's Compensation of
fi ion Insurance, h required by Section
My oche Labor Code,for theuranca canceofthework Inswhich Ibis permit is Issue].
CrWorked Compnsmion hnurenec curlerand ,'alloy number arc:
Carries Pulley
CER'TIfTCOF; EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thl.v Fission neA not he completed trifle permit is forone hundred dollars (E It))
or less]
1 fed Ey Ilei in the an, romtmtae t as 1 work for which This thepirranW Is mx Co 1 shall
nmempltr anis pecten aenvmannereoastolucerneaanjalmmeworkersemmpelt-
O % Applicant
ant of callfornia. D:nc
'�•, O Applicant t
G NOTICE TO APPLICANT: If, altar peroutg@isocivios of of Exemption, You Should
a ; become subject to the Workers Compe...Im n provisions o r the Iardr Code, you must
�
forthwith comply whh such provinlons nrthi-v )email shall he Aecmal resolved.
Q
U O CONS'T'RUCTION aLENDING AGENCY
I hereby urm that constraints is a cotmn lending agency for the performancc of
the work for which this Permit is issued (So,. AIN)]. Civ. C.)
O U lender's Name
{>J lenders Address
I army that 1 have read this application and state that the above f ai
L Va] Loral I agree to comply with all city and county ordinances and vlate laws rcllar h to
U% building swain. and hereby au0orre representatives of this city to enter upon the
ma ve-mentioned propcny For Inspection purfovar,
(We) agmc nt save, indemnify and keep harmless the City of Cultivator, against
liahilities,judgments, costs and expenms which may in any way accrue against said City
in consequence of the granting of Ills Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applicant/Cmnractor Data
HA2:ARDOIJS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle harardons material
us debited by the Caperton Municipal Cod., Chupmr 9.12, send the Haddi send Stomy
Code, Section 25532(n)p
E] Yes DN.
Will the applicant or future building occupantace eyuipoer, or devices which
emit hamnious air contaminants as defined by the Bay Area Air Qnubt, Manogmnent
District
U Yes [_1 No
1 have mad the hnEred( ea materials requirements under Chapter 695 of the Cali-
fornia Health & Safety Cole. Sections 25505. 25533 and 25534.1 undenurad that if the
building does bol eupendy have h tenan,,,hat it May refpmabnity u, notify the occu0am
of Ne re9ui ements which mus, Fatima pdar,, issuance of a CeniBeme of Occupancy.
OFFICE
JOB DESCRIPTION
RESIDENTIAL'
❑SFDWL ❑KITCHEN REMODEL
[]ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR ❑ DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES — RESIDEN I IAL
PANELS
UP'I'O 200 AMPS
201-10(ATAMPS
OVI?R H)OAMPS
SIGNS EI.ECTRICAL
SPECIAL CIRCUIT/MISC.
'TEMP. METER OR POLE INST.
COMMERCIAL:
Cl NEW BLDG/ADDITION C1 DEMOLITION
4LT0KANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWI ICHES — FIXTURES
NEW RESIDENTIAL ELECTR SQ P.
SQ, FT. FLOOR AREA
E/SQ. FT.
TOTAL:
MIT,�'��rtt"Fit,
PERMIT' ISSUANCE
ALTER— DRAIN&VENT— (EA)
VALUATION
.
BACK PLOW PROI ECT. DE .F.
DRAINS— FLOOR, ROOF. AREA, COND.
STORIES
OCC GROUP
TYPE CONS'TRUCHON
APN
FIXTURES — PER TRAP
GAS — EA. SYSTEM -1 INC.4 OUT LETS
CAS -17A. SYS'fHM-OVI3R 4 TEA)
GREASUINDIISTRLWASTE INTERCEPTOR
BUILDING DIVISION THIS
GREASETRAP
PLANCHfiCK PF.F.
SEWER — SANITARY — STORM PA. 201 PT.
ENERGY PER
19
WATER I[EATER WNENT/I71.110R
GRAVING FEE
I
WATER SYS'I'ENVIREATING
SOILS FF.I;
WATER SERVICE
PAID
NEW RHSIDIt.IYI'IN. PLMB, SQ. FT.
Date Resit,#
TOTAL:
TOTAL:
BUILDING FEE
11' ,pr , ,f
MECIIAN[CAI,'PERMIT 1 t i., FF.P. ('f•
SEISMIC PEE
PERMIT ISSUANCE
ELECTRIC PER,
AL ER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING ON] i(TO IQIX) CFM)
MECHANICALFEL
AIR HANDLING UNIT (OVER 10.000 CPM)
CONSTRUCTION TAX
EXHAUST HOOD (W/DI1C1)
HOUSING MITIGATION FEE
HEATING UNH (TO INE )BTU)
HEATING UNIT (OVER 100.II01) BTID
PAID
VENTILATION PAN (SINGLE RISID)
Date Beceip[a
BOILER — COMP (3HP OR 100.00) BTU)
TOTAL.
BOILER—COMP (OVER IM." BTU)
AIR CONDI'fIONIiR
'SSUANCE DAE
3 a -
NEW RESIDENTIAL MECH. SQ, PT.
OFFICE