S 1443 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITYOFCUPERTINO - BUILDING-ELECTRICAL PliI'I'NO.
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL 1443
BUILDING PROJECT IDF.NI'11+IC-ATION
BUILDINGAUURE S: SANITARY NO. APPLICATION SUHMI'ITAL DAAE
11. 58 erste1 .��• 3t -9�
OWN' .i NAME: I �� P%CNH: CO AC'[OR'S NAM 9: / LIC NO:
NIC CON'1'ROLX
• ARCHI I'17CDENO.INEER: LIC N(1: ADDRh,I( El^ Td r
CONTACT: PHONE: V (�y_ BUILDING PERMIT INFO'
❑ Consultant Pees Paid by Applicant(initial) IILDG ELECT PLUMB ' MECH
❑ ❑ C, ❑
LICENSED CONT'RACTOR'S D17CLARA9ION QTY. IiLECfRIC PERMIT FEE
1 hereby aill.that I am licensed under,provisions of Chalne,9(commencing JOB DESCRIPTION
won with Section 7HBtu of DivisionJof the Business and Pmfcsnions Q,Jq anJ my licenu is RESIDENTIAL
I+ - In PITRMI'T ISSUANCE
~UWI• fene Classnd clic,. ❑94)WL ❑ ITCI{ITN RE-DIEL
UW License Class Co.X APPLIANCES-NESIDENTIAI. ❑ADDITION FTBING RE-PIPIT
F•a a DaIC Contractor /
f/ ARCIII'I ECPS DECLARATION ❑MULTI-UNIT ❑STkUCTI1RAl.
F D m PANELS MODIFICATION
Z p m Z 1 understand my plans shall be used as public records
OZ=-0 UP"102WAMPS ❑INTERIOR C1 CHIMNEY REPAIR
h-�tWLicensed P..ficx,ionol 201-1000AMPS IMPROVEMENT ❑SWIMMING POOLS
9s4�" OWNER-BUILDER DECLARATION OVER 11%XIAMPS El REh10DEDREPAIR ❑DEMOLITION
L hereby aRtm Tm hal I aesempt Eon,he Commens",License Law for Ne
,70.,�( G O following mason.(Section 7031.5.Business end Profca,innn Codc Any city or county SIGNS ELECTRICAL ❑OTHER
LL73 a F' which acquires a,obao In eon oma.uIlu,Trepans,dboulkln o,,cpm,ahy,auctam
D prior to its issuance,also reclaims the applicant for such permit n rile a signed statement SPECIAL CIRCUIT/MISC.
!!I j that he is licensed pursuant to the provisions of the Contmclnfs license Law(Chapter9
a�p0 (connmr,ing with Section 7000)or Di aim 3 of Ne Heine": I PmfessionscodcHa '1'EMR METER OR POLE INST. COMMERCIAL
a q y that he is exempt Iherelrom and the basis for the alleged exemption.Any violation of — _72 [I NEW
[INEW BLDG/ADDITION ❑DEMOLITION
uX) N Section 703 L5 by anyaPOlicism far. ramit,idjorn,abrOpplicanuo a civil penalryof POWER DEVICES El TENANT ❑FOODSERVICE
nt mora than f vc handrd doll.,,(tiMi).
H r IMPROVEMENT
C=d (] I,nx ownsr of the pn,pcty,.nny cniployecs wird wages vs their role compensation, SWIMMING POOL ELECT
aFD will do the work,and doorunore is not intended or offered forxale(Sea.7044,Business ❑OTHER
`
❑1 to Pude+cions Cdu:The Commons',License Law Jnes not apply to nn owner of OUI'LES-SWITCHES-FIXTURES
pmpety who hold,or improves Ihleon,unit nim does such work himself n,Ihoagli
his own employees,pfbvided the tech improvements are not intended or offered for NEW RESIDENTIAL CH.IiC:'R
sale.If,however,the building or improvement is sold within one yearof contplaion,the so. L RFA S7SQ.F[
ner,hadder will have the humeriof paving Ihw he did not build a,in,aov,Iw pur-
piwe.faowne MAR 91 ANS
❑ I,tf owner of the propmy,am exclusively contracting with licensed nmhrnnlh u, TOTAL: rf�
novae the prna,,'(set.7044,Bnsincss aml P'ol'cssions Cool The Cnnvncto,'s U. b u
cense Law does not apply to un ownerofpmparty who hands or lmpmves thereon,;ta1 QTY. PLUMBING PERMIT FEE '��! Ur
who commas for such projects with o enntracmrls)licensed pursuant m the Comment/a UUrCry 1IND
Licemc Law. PERMITISSUANCE
❑ Ire;esempt ander Sce. ,H&PC frnthi,reason
AUD!R-DRAIN&VENT-WATER(EA) VALUATION
Owner Dam
WORKER'S CO,Mm ur,ODECLARATION BACK PLOW I'ROTECI'.DEVICE
I hereby skim under penalty of perone of the following Worker's
tions:
❑Ihave and
mvid,d For
u fiom 37aa of oil LullloCode.in'the WOfkcFs Comped- DRAINS-FLOOR.ROOK,AREA,CCNU. STORIES TYI'13 CONSTRUCTION
,abut as hick thi fur by Section 3]1X1 of the hobos Crvlc,fur the Pcrfnnmmcc of,hc -work for which lilt maintain esuOJ, D FIXTURES-PIiRTRAP „
167
❑1 hath and will maintain h, thus Compensation work for
has lag Aria by Section
1700.1 the LahnrGnde,fur the perlinnumcc oOhc work for whish this peuni,is isslhel. OAS-EA.SYS'I'IiM-1 ING4UlIT'LETS fICC.GROUP APN
My Wit 's Co On,. I a...e.cwflc+and Policy; a��C"/
Policy No: V OAS-I?A.SYSTIiM OV1iR4(FA)
Cartier LC
CR'I'IFICATH OF IO.iAPI ION FROM WORKERS' -
COMPENSA'I'ION INSURANCE GRIIASIANDUSPRL WAS'11i IN'l1iRCE1'IY)R
BUILDING DIVISION FIiIkS _
('Ibis section n WnotMcon,pletd if the permit is formal hundteddnllarslSllgl GREASETRAI'
nr less.) PLANCITF.CK ETF.
I ccnify hill,in poperformancuof the work for which this permit it Issued,l shall SEWER-SANITARY-STORM EA.2nd F1.
not employ any person in any manner so as or become subject to the Worker:Compton- ENERGY PEE
Z cation laws of Culifomii.Date WATER HEATER WIVENEMLIiCTR
7Z Q Applicant - GRADING FEE
N(MCE TO APPLICANT If,after making this CenNcac of Fiamr,ion,you should WATER SYSTEM)TRP.ATING
F beeome.abjee n,the wmkcrs Compensation provision,of the Labor Coal,you tare SOILS FEE
Whmhwith comply with such provision,or this permit shall be related revoked WA'I IBR SERVICE
oQ
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.fT. PAID Doc RO v X
U Q Ihercby uflirm than hherc ixacnnswchnn lending ngeney l'nnhe perlimmmcenl'
the work far which this permit is ixwed(Sec.3(ri Civ.C.)
C) F' Lendets Name TOTAL:
U IsnJers Address I TOTAL:
W 1 entry than I have hcad,hi+application and bill that the uMwe iamnnmion is BUILDING FEE
P.i(A correct.L agree to comply with all city and county ordinances and sate laws relating a QTY MECI IANICAL PERMIT PEE
UZ hi ildingconamction,and herehymahnrimrepresentalvesof this lily m Odic,upm the SEISMIC
Ilhhve-nantioned pugmty for inspection pa,e),c, PERMIT ISSUANCE
(We)agree a save,indemnify and keep harmless the City of Caperton.against ELECTR 'FEE
liatuddies,judgmenm,costs and expense.,which may in any way a<eme against said City ALDER OR ADD TO MECH.
amsepne;ca of him granting of,hls,croon PLUMBING F.I?
APPLICANT UNDERSTANDS AND Skid.COMPLY Will 11 AL1.NON-POINT AIR HANDLING UNITOO 10.00OCFM)
"ON MECIIANI AL rind
SOURCE
_?/_,264 AIR HANDLINC.UN1'1'(OVFR 0000CFM)) CONS'1'R TAX
Signawr IicamfContracmr Dae EXHAUST HOOD(W)DUCT) HOUSING MITIGATE PEE
HAZARDOUS MATERIALS DISCLOSURE
Will,he applicnm or future handing hceapent.vmbe..handle at,cal un nmm,ial IIBATING UNIT T110 I(IO,don 11'1111)
as,defined by the Colima.Municipal Core.Chapter 9.12.and the Health and Safety
Code,Section 25532(a)? HEATING UNIT'(OVER I W,000 BTI!)
❑Yh., 0 N PAID '
VF.N'I'ILATION PAN(SINGLE RES ID) Dam RtteiptX
•1 Will,he applicant or future building occupant use equipment ordevices which -
abi,ho,ol.us air e.ntaminmlu as defined by the Be,Arca Air Quality Manage ou BOILER-COME'(3HP OR 1010,0 RI BIT)
District'? '1 OTAL
(3 Yes ❑No BOILER-COMI'(OVF.R 100,000[]TO)
Iia.read the huvenhms riagoalsreyuiranenu under Chapter 6,954 lbs Cali. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Sections 25505,5533 and 255)4.L understand Lha if the NEW RESIDENTIAL MUCH, SQ.FT.
hulloing ties not etmnntly have a tenant khat it ism,reslmnsibilay m mad the naps
W file raryacrocatn which urea he met mato)I...ani a Ceni licam of(kcapadey.
Owner nr amho,cill agent Ih,e TOTAL: - ISSUED BY:
OFFICE