31136 IAPPLICANTTO FILL IN INFORMATION WITHIN RED LINES'-'USE BALL POINT PEN ONLY
. CITYOF CUPERTINO ! vhv BUILDING-ELECTRICAL'+, r PERMITNO. s] � /I 16
�C
BUILDING DIVISION APPLICATION/PERMIT J PLUMBING-MECHANICAL', .a ,
IIUII,DING PRt3JF,CT IIIENTIFICATION,,
DING ADDRESS: SANITARYNO„ APPLICATION SUBMITTAL DAD:
NER'S NA PHONE!: CPNTRACTORS NAME: LIC NO:
CAT !.✓1, oo Cf) 3 $ we •' corvraoLx
ARCHITECT/ENGINIM LICNO, )DRESS: Y.' ❑
Lid
CONTACL PHONE: BUILDING PERMITINFO
' ❑ Consultant Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB MECH
❑ ❑ El
CENSED CONTRACTOR'S DECLARATION -
QTY ELECTRIC PERMIT FEE
I hereby affect that l am licensed under provisions of chapter 90rommeacng '
J06 DESCRIPTION
mow= arm Section
rsadde)ecDivision3 raphe Businessland Rafessinns Gyle,and.1 license is - - RESIDENTIAL'
at-l- L erase lass effect PERMIT ISSUANCE _ ❑SFDWL ❑KITCHI3N RI'MODF.I.
aUV License Class Licp pl'PLIANCFS—RFSItlENT1AL ❑ADDITION ❑PLUMBING RE PIPE
HQ S Date-- - Contractor
ARCHITECT'S DECLARATION ❑MULTFUNIT ❑STRUCTURAI,
F. 'z PANELS
Z IundentanA my plans shell bcuud as public¢cords _ e MODIFICATION
p o UP TO 20a AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F.4t:C1 Licensed Professional .. 201-1000AMPS " IMPROVEMENT
C Q 1 hereby e(Brm ha N am exemptFGom the Ci,nmOurn License Lew fnr the OVER IffIl S, ❑BATH��'11 RREAMODDIiELMIITA�IR ❑DEMOIA FION
x��(O a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. CIOT IY"
W�+IL y which maladies a permit to consumer,alto,improve,demolish,or repair any s0umua
prior to its issuance,also requires the applicant for such perming file a signed statement SPECIAL CIRCUITIMISC.:
tbar tie is licensed pursuant to me provisiamsef the Contractors Licence Us.(Chapter 9
'hQ (commencing with Section]00(BofD,,kiim 3.flhe Business and Professions Gavle)or TEMP METER OR POLEINST. COMMERCIAL:
m C that he is exempt theafrom and the basis for he¢flaked exemption.Any violation of ❑NEW RLDG/ADDITION ❑DEMOLITION
Section]031.5 by any applicant fora Permit subjeau the appli,ma to a civil penalty of POWER DEVICES ❑TENANT ' OFOODSERVICE
not mare than five hundred dallma(S5001.£Sp IMPROVEMENT❑I,as owner of the property,or my employees with wages as their sole compenwtion. SWIMMING POOL ELECTRIC
will do the work,and me structure is not intended or offered for salt(See:](H4.Business - n C]OTHER
Wan and Professions Code:The Conbacim's License Law ox,not apply m an owner of OUTLETS—SWITCHES—FIXTURES '•
property who builds or improves bottom.and who doe,stmh work hintssclf in through
his own employees,provided that such improvements arc not imemdcd or offered for NEW RESIDENTIAL ELECTR ` FT.
sale.IL however,ihehudding or improvement is sold within one year ofemarenon,the SQ.Fr.FLOOR ARBA SISQ.IT,
ownerbuilder will have the burden or moving than he did not build or improve for pun- -
' pose of 1.1 - - TOTAL:
❑1 fthe prPry, I .' Iyc t t N thl d t t 'm p. .
mn,mat hep j ct(Sit9144 Br : ..d l [ ,Corn,'.. Conal :.... ➢ PIA I D
wnncents,La does not apply l ,fpr, ty h burns a the t and QTY PLUMBING PERMIT FEE ,
cal-rev. For,nanprl I. in dno-nt ul licensed tt n c tan ra - ��"�� _
Ltense Law PERMIT ISSUANCE;. n
lamexeinmilet Sra _ II Fri 6l ullisrc':, IF
ALIdR-DRAIN&VENT-WATER(BA) V III UI' VfA�LI])pl'fI,f1I/N�
Owner D t 11 Ir UY`�HNA10'.
WORKER'S COMPENSATIONtno,on UI GI A llo in, PACK PLOW PROTF.Cf.DEVICE t
hindwilffrmuin CendhctirofrJ y •oTmefIDn g1•Lhnsmta.
❑ (have andwill for
neCcmi Beata of[lie Labor
Code,.for(for Worker's Cmnpem DRAINS—FLOOR.ROOF,ARF:A,COND. SB'ORIES. 9'YPE CONSTRUCT ION
work Pas provided far by Section J]INI of aha Lnbnr Code,for me perlitrmunce of the - - -
Ljlharwbichthiapaintain issued, FIXTURES—PER
❑1 have and will maintain Worker's Camper rex squired S
J]W ofme Lahr Cada for the perfonnnccofthe work for which this permn Is wind. ,a -
OAS—EA.SVSTEM-I INC.40UTLETS. . . OCC.GROUT' MIN
work e tF,Csimpensa�>�ce rrtierundl'sNo.:numbenm:', GAS—EA.SYSTEM-OVER4EA
CuCartiee V�%.CERTIC Palley RO - ( )
CERTIFIC ATIONINSURAN WORKERS' - _
' COMPENSATION INSURANCE GREASI%INDUS'fRL WASTE INTERCEPTOR
BUILDING DIVLSION f4iH5
('Otis section teal mot tocompleted iftheperunt is Entire hit dotaldollars($103) '
or less.) - GREASETRAPPLANCHECK FEE"
''4' leerily mat in the performance of the wnrA ram whichthis pemtit is issued,l shall ^
s
not employ any person in any manner so as to become subject the Workers' SEWER—SANITARY'—STORM fA:2W FT.
tts.' ENERGY FEE
_ z timing Laws of California.Date WATER HEATER WNENT/F.LF.CfR
z Q Applicata GRADING FEE
fn NOTICE TO APPLICANT:IL after making this Cenifierm of Exemption,you should WATER SYSTEMITREATING
a ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOUS IEE
forthwith comply with such provisions or this perm shall be deemed revoked. WATER SERVICE
0. �.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL ,SQ.FT PAID
UO
(hereby affirm that them is a conewaion lending agency fomhe performance of - Dam Receipts
it. F the work for which this permit is issued(Sec.309/,Civ.C.)
a Q
0Lenders Name TOTAL:
} [1.1 Carders Address TOTAL:
•1 certify that 1 have mad this application and nate that the above information is BUILDING FEE
CL,
comm.l agree to comply with all city and county nolinances and state laws aiming to QTY. MECHANICAL PERMIT I FEE
V Z. buildingconswctlon,andhereby murborizcncpresentativesefmiscny tocnar upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Caperton agoing ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way areme against said City ALTER OR ADD TO MECH. "
in coaselaexe of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PC;4;00 I AIR HANDLING UNITUD 10,0110 CFM)
SOURCE REGULATIONS. - t ^ C4 1 MECHANICAL FBI!
AIR HANDLING UNIT(OVER 10.00)CFM)
LJClntmCONSTRUCTION TAX
rtle,
])are EXHAUST HOOD(W/DUCT)
ATION FEE
Sight,, oQ'HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGDISCLOSUREWill the applicant or fmurc building nccupam Wore nr handle hazardous materiel OIEATING UNIT TO 100,00()BTU),
as dented by the Capenino Municipal Gale,Chap cr 9.12,and the Health and Safety - -
Cade.Swoon 25532(0)7 - HEATING UNIT(OVER 100,0011 BTU)
ElYca --ONa
VENTILATION FAN(SINGLE RESID) PAID
` ,. se ._
Date Rcce pt x
ardauaau nlI BOILflR-COMP(3HPOR 100,000BT )it baradiants as derided by the Buy Area A' Quality Aa egt eel
- TO I'A L:
n�Datnid ..,
. ❑Yea No BOILER—COMP(6VERI00,000BTU), 1.
1
I have ad(lie landankar, nurrial,rc,l,orenern,muter Chalon,6,95of he Cali- AIR CONDITIONER. ISSUANCE DATE,, `
y forma Hoole&Safety Code Sections 25505,25533 end 25534,1 umderwmd Thal[I ho NEW RESIDENTIAL MECII. 9Q.fG'.t
huilding dxs not ei;rmtly have o mnanat,that it la gry casrymi...lity to nmil'y the xcupunt _ •r
ofinerclmithonved age t Ibe epnnrt .. tfn Can'I t 10 npn n,.y.
Owner or authorized neem Uum TOTAL: ISSUED BY:
OFFICE