30590APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO. X(�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL 3 O 5 FQ 9 O.
BUILDING PROilicT IDI?NTIFICAI!ON
BUILDING
ADDRESS .r VNrrNF. A rn�morrvrnr vre. SANITARY NO. APCp�NSUA1l
.DATE
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ADDRESS:
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CONTACT: I PHONE:
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BUILDING PERMITINFO
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❑ Consultant Feint Paid by Applicant (Initial)
Bl,pr[ ELLEgCT PLUMB MECH
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LICENSED CONTRACTOR'SrroviCons of Chap
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1 ion 70 ,filum that I nm f he Hd under provisions er Chapter 9 (commencing
with Seorcean10ffec t. Division the Busineea am l'ndessinns Code, nth my license is
in full force and effect.
-
Date Cnntmctor
Dataaw Cines Contract.,
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
El SECANT, ❑KITCHEN REMOOEI.
DITION ❑PIAMBING RF. -PIPE
- MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR EI CHIMNEY REPAIR
IMPROVEMENT
D BATH RFMODEUREPAIR [I DEMOLITION
DOTHER
PERMIT ISSUANCE -
APPLIANCES -RESIDENfIAI.
ARCM rECTS DECLARATION
Imul,amnduty plans shall be used as Public mcord,
Licensed Pmfessional
OWNER NUILDER DECLARATION
I hereby affirm that I am exempt from the Co dr cto's License Law for the
following reawn. (Section 7031.5, Business and Pones ire, Code: Any city nr county
which requires a Permit to construct, alter, improve, demolish, m repair any tantalum
Prior w'nxissuance, aHo Tequires theupplanal kx,awh pannus. Blau signeJNmemera
that he is licensed pursuant to the provisions ofthe Contrannr'a License Low (Chapter 9
PANELS
UI"f0AMPS AM
-1000A PS
201-10(10 AMPS
OV
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISE.
TEMP. METER OR POLE INST.
CO MERCIAL-
IrL�CC
(commencing with Section 7")o'Division 3 of Ne Business and Professions Code) or
6 q e tY
4X1 !°•
}
OD
that he is exempt iherefmm and the basis far the alleged exemption. Any violation of
Section 703 L5 by any applicant for a permit subjects the applarom to a civil penalty of
nut more than five hundred doll., ($500).
1, ns owner of the propertyonny employees with wngeaa,their sole comPmannon,
will do the work, and the swchra is not intended or offered far sale (Sec. 70,14, Business
and Professions Code: The Contractors License Law Jas not apply to an owner of
progeny who buii& ar impmva thereon, and who Jan such work himself or IN gh
D NEW BLDG/ADDITION D DEMOLITION
❑TENANT ❑FOODSERVICE
IMPROVEMENT .
D OTHER
POWER DEVICES
SWIMMING POOL ELECfR IC
OUTLETS -SWITCHES -FIX'[ URCS
his own employees, Provided ohm such improvements arc not intended ar .Rued for
NEW RESIDIMIAL ELECfR SQ FT.
sale. IL however, the building or improvement is sold within one year ofcompletion, the
SQ. FT. FLOOR AREA
$/SQ. FT.
owner -builder will have Ne burden of proving ,hat hu did not build or improve for par.
pose of sale J,
El I,secowner ofthe Propcny, amexclusively contracting with IicanwJcontractnors m
,
I
-
oswat thepori. (Sec. 7000, Business and professions The mrs L
naeLnwdas.plytoaaoywnobuildscompmvcs duarreo.Mi-
whocontacts framchpmjccts wvi,h.conmmus(e)IiccmW
spursuannuthe Contractors
QTYPLUMBING PERMIT FEE
PERMIT ISSUANCE
License Law. for this
❑Tarn as rex
S
ALTER- DRAIN & VENT- WATBR (EA)
Owner Uate
AL'HATION
L•//r L/ 2, 0�/'�
7 V
WORKER'S COMPENSATIO IECLARATION
I herebyaffnn ado Acuity of Ierjuryoneufthe following deciarrinns:
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF, AREA, COND.
CI Ihavcand will maimmina Cenificmeof Conwnl mselGinsurefor Wohers Compen-
sodov, as Provided for by Scnlom 3700 of the Latin Cole, for the performan o of ma
STORIES r I
' L
TYPE CONSTRUCTION
FIXTURES - PER TRAP
work for which this permit is issued
D 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofthe Labor Code. for Ne performance ofthe work for which this permit is issued.
My Workers Compensation Insurance contained Policy number are:
Cxnien Policy No.;
GAS - EA. SYSTEM-1INC. 4 OUTLETS
OCC. GROUP
APN
GAS - EA. SYSTEM -OVER 4 (ILA)
Z
O
N
.`•I
CIIRT1171CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('I'hisseudon need not bocmnpleted ifthepennit is foronehundadJollors(g10B)
or less)
I oy any that north.in performance of the work me which ibis parent is issued.) shall
not employ any person in an mennerwmto become subject We Workerx''Com n-
Y a
amionl.awa of California. Data
Applicant
GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVI.1 NFEES
_
GREASETRAP
PLANCHECK PEE
SEWER -SANITARY -STORM VA. 200 FT.
ENERGV FIC O
WATER HEATER WNF.NT/ELIiCTR
GRADING FEC
NOTICE TO APPLICANT: IL slier making this Ceniticum-of Exemption, you should
become subject to the Worker's Compcnwtian provision, of the Latour Code, you most
WATER SYSTEMITREATING
SOILS FEE
a
(l•1 i�
7z
U0
LL
forthwith comply with such provisions or this Permit shall deemed revoker.
CONSTRUCTION LENDING AGENCY
1herehysffvm Nanhere iso cmswetlon l,thingagency Tote perfona,neeof
the work for which this Permit is i vall E m, 3097, Civ. C.)
Lender's Name
WATER SERVICE
PAID
Dts Recaija#
NEW RESIDENTIAL PLAfB. SQ. PT.
'TOTAL::
0
Lender's Addrcax
L
{U
I certify that 1 have mad this application and also, that the all mformmlan is
BUILDING FEE
i -r IZI
correct, l agree to comply with all city and county ordinances and smm laws relating to
building coas0uction, and hereby maorive representatives oI this city to abler upon Ne
QTY. MECHANICALPERMIT FEE
SEISMIC FEE D
abov, mentioned property for inspection purposes.
(We) agree no save, indemnity and keep harmless the City of Camarillo against
PERMIT ISSUANCE
ELECTRIC FliE
iuhilines,judg,nents, costs and expenses which may in tiny way acerae against said City
in continuance of the granting of this permit
ALTER OR AUU O'O H.
PLUMBING FEE
AIR HANDLING UNIT(TO l(y(XXICEM)
MECHANICAL qE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,(XXI CEM)
.
CONSTRUCTED M1 TAX
Signammof ArSlicanUt7mr us, IA,a
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST 14001)(W/DUCI)
HOUSING MITIGA
HEATING UNIT('( 100,000 BTU)
Will theapplicantorflime holding acupantnore or handle havnrdcas material
as defined by the Cupcnin, Municipal Code, Chapter 9.12, and are Health and Safety
Code, Section 25532(x)?
HEATING UNIT (OVER 100,00 BTU)
❑Yes Fl No
PATO
VENTILA9'ION PAN (SINGLE RESUE
Will the applicant or future huilding Uccupam ono equipment or Acvices which
emit halardous air contaminants m defined by.the Buy Arta Air Quality Management
District'!
DYu El No
Date Receipt N
BOILER-COMP(311P OR 100,(0(1 BTU)
TOTAL:
BOILER- COME (OVER 100,000 BTU)
AIR CONDITIONER
I have rend the hamukars mmcrinlsreuiremenm under Chapter 6.95of the Cali-
9 P
ISSUANCP, DATE
NEW RESTININ'TIAL MECI I. SQ. PL
fomia Health &Side,tamon Coda Secdun,,the,i 25533 and255J4.I to norsumd that ifthe
not currently have natant than o is my ca notify the
6/
of the
of the requirtmentx which most le, ma prior issuance of a Cenificute of (keupancy.
ce ofa Candy panty.
OFFICE .