27614 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITYOI'CIJPERTINO BUILDING-ELECTRICAL PERMIT NO, /�
APPLICATION/PERMIT PLUMBING-MECHANICAL. 2'7 61 A
BUILDING DIVISION BUILDING PROSECT IDEN'TIFICA'TION lJ �T
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
9DI 8javzim wood Vim- UNIT# LOT
OI (�WN SNAME: PHONE: C ACTOR'S ME: LIC NO5-o
D_/ 1 6 50 2 Lys I� NIC CONTROL N
�ARCIIITECTIIiNGINEER: LIC NO: AJW!3 _Sir& AV& ❑
CONTACT: PHONE: [, BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB #BCH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL.
I hereb fEran helium licenseduudu fChat 9(commemod th ]OB DESCRIPI' N
GKZ ya pod Professions
Per eis
uF100
Section 7000) Divisinn3nf tha Business end Rnfessions Cade,and my license is in PANELS
full fo¢e and of ecl
�V or L`L ^ UP TOP AMPS
Zz License CP s Lia.,
Contractor I OVER
-IOW AMPS
,ZFO�4'ZJ. ARCHITECTS DECLARATION OVER IWOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
CZ-0 I understand my plans shall be used as public meduh.
Pm W SIGNS ELECTRICAL
Licensed Pmfexsianul
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
4�dOqU 1 hereby afford that 1 em exempt from the Contractors License Law for the
W3Oy followinreas
gon.(Section]031.5,Business and Professions Cade:Anycityor coolly TEMP.METER OR POLE INST.
which requires a permit to construct,aIle,improve,demolish,or repair any simian -
to its issuance,also the applicant for such t m file a signed statement POWER DEVICES
'hat he prior requires PP permit g
Cp 9icraisewiri,licensedpursuantSecrnmthe provisionsofthe Contractors License Law
n,(Chapter de)
ce y� ond gW IMMING POOL ELECTRIC
0.o 9 ,but henciooam terefem]OW)he Division Sof the Business and .Any iolaCode) VALUATION
ortha h7031.1 by anyapplic ntfnd the womtsubjfor ects theaexemant to civil
of OUTLETS-SWITCHES-FIXTURES
4 amion]03LSiv hundred
dolars($500mit subjects the epplicanuoacivil parulry of
C mnot morethanfivehundreddollarsyemp. NEW RESIDENTIALELECTR SQ.FT.
❑ Lthewrk,anheprocidenerscanreryeeswithwed forseleirsdecampBusiness STORIES TYPF.CONSTRUCIION
y will dolhewons node:The ontisnotis License
Law reoesnot apply
Boniness
and Professions Code:The Contractor's License Lew arca not apply to an owner of
property who builds or improves theuom,and who does such work himself or through his
own employees provided thatauchimprovements arcnrt immddedorofferedfrreele.If, OCC.GROUP RES.UNITS
however,the building or Improvement is sold within one yearof completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I,as owner rfthe property,atm exclusively contracting withlicersedconracmrsm QTY. PLUM GPERMIT 'E FLOOD ZONE APN
construct the projom(Soo.7044,Business and Professions(,We:)The Contractor's
License Lawdoes not apply manownerrfproperty whobuildsorimpowesthenced,and PERMITISSU CE
whocnmracaforsuchprojecrswithacomracter(s)licensed pursuant othe Contractor's L'T'ER- &VENT ER
L - EA
License Law. AIN ( ) FEESUMMARY
❑ 1 am exempl under Sec. ,B&PC for this reason B FLOW PR CT. E OUTSIDE FEES
SANITARY Y N
Owner Dam RECEIPT#
m DRAINS-FLOOR .AREA.COND.
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
hereby affirm that l have a cemricua ofcrnsent toeelf-insure,ar a certificate of FIXTURES P P RECEIPT#
Workers'Compenmtme Insurance or a rectified copythereof(Sa.3800,Lab C.)which PARK PEE Y N
covers all emple,ce'senderthispernit GAS- EM-1 INC. S
U ' RECEIPT#
Policy# S BUILDING DIVISION FEES
Company G S EM-OVE TEA) PLANCHECK FEE
❑ Certified copy Is hereby famished.
Cl Certified copy is fled with the city inspection division. GREASER STRL WASTE INTF. PTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' ,ASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nolbe completed ifthe permit is porous hundred dollars($1W) SEWS -SANITARY-STO EA.200FE ENERGY FEE
orlesa.)
I certify that in the performance ofthe work for which this permit is issued,l shell WATER 1111 RW/V /ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
z Compensation Laws of Califomia. Date WATER SYSTEMMPATING Date Receipt#
p O
Applicant
NOTICE TO APPLICANT:If.after makingthis Certificate of Exemption.you should NEW RESIDENTIAL PLM. SQ.PT. TOTAL:
VI become subjected the Workers Compensation previsions of the Labor Code,you must BUILDING FEE
�i forthwith comply with such provisions or this penmir shell he deemed revoked.
Da (� CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that here is a construction lending agency for the performance of
the work for which this permit is issued(Sec.309],Civ.CJ ELECTRIC FEB
Cry r Lender's Name PLUMBING FEE
'ter Lender's Address QTY. MECHANICAL PERMIT FEE
V I certify that I have read this application and state that the above information ie
corer.I agree to comply with all city and county ordinances and state laws relatingto PERMIT ISSUANCE MECHANICAL FEE
F^ building construction,and hereby authorize represenativiecudis city toeatutTes.the CONSTRUCTIONTAX
Vabove-mentioned property for inspection purpaes. I ALTER OR ADD TO MECH.
(We)agree m save,in mnify and keep harmless he Ciry of Cupen me against
liabil"s,judgtnen ,costs a expe eswhichmayinzny ysccmeagai mstud CAIR HANDLING UNIT(TO MOM CFM)
ce of egremi of thi
AIR HANDLING UNIT(OVER IO,OW CFM)
Signatu df ApplicanVContracmr I Date EXHAUSTHOODGYMUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0010 BTU) Date Receipt#
Will the applicant or future building occupant store or handle hazardous material
as refiuW by the Cupenind Municipal Coe.Chapter 9.12,and the Health and,Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Code,Section 25532(ap VENTILATION FAN(SINGLE RESID) Lk
❑Yes ❑No
ISSUANCE DATE
Will theepplicantorfafore buildingrccupnntuseequipmentadeviceswhich emit BOILER-COMP(3HP OR IW,OW BTU)
• hazallous air crmaminants as defined by the Bey Area Air Quality Management
District? BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑Na NEW RESIDENTIAL MECIi. SQ.FT. .f7
1 have read the hazardous materials requirements under Chapter 6.95 of the
Califomia Health&Safety Cade,Sections 25505,25533 and 25534. I understand that
ifmhe building does not currently have a tenant,that it is my responsibility to notify theRI occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
G
Owner or euthdriud agent Dae TOTAL: ISSUED BY:
OFFICE