29687 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 29687
BUILDING PROJECT IDENTIFTCA'FION
BUILDING ADDRESS: :SANITARY NO. APPLICATION SUBMITTAL HATE
0 30 ca f spa
OWNER'S NAME: PHONE: CONTRACTOR'S NAM -LIC NO:
^ NIC CONTROL#
CHITECT/ENGINEER: U LICNO'. ADII
UiW ❑
ONTACT: PHONE: BUILDING PERMIT INFO
Soler `i I D� �� ���, ❑ Consultant Fee$Paid by Applicant(Initial) BLIX' FLECI' PLUMB MECH
IIVI t ❑ ❑ ❑ ❑
LICENSED CONT CFORE DECLARATION QTY ELECTRIC PERMIT FEE
1 nerehy alum that I am license under provisions of chapter 9(commencing JOB DESCRIPTION
�WZ with Section]000)of Division 3ofthe lousiness and Professions Code,and mylicense ix R,CIDFMf1A .
00 PERMIT ISSUANCE RL+��
m full force and effect.
NRI I.." ❑SFDWL []KITCHEN REMODEL
Zu License Class Lic_# - GNTIgf.
�6R Dale- APPLIANCESRFSID
Connector DADDITION [I PLUMBING RE-PIPE
yf ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT DSTRUCTURAI.
Z O z I undmand my plans shall be used as public recoNs MODIFICATION
parlf-0 UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
gjjF 1"y,I Licensed Pndessinwl 201-I(KKIgMPS IMPROVEMENT
OWNER-BUILDER DECLARATION
y G I herchy affirm thin 1 nm exempt from Ne Competition',License Low far the OVER IM AMPS [I BATH REMODHUREPAIR)I DEMOLITION '
x 311,U followMiceli (section 9031,5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
Ir] IL� which requires a Permit to constmct,alter.improve,demolish,or repair any structure -
�,��� prior to its issuance,also requires the applicant for such permit n filea signed summem. SPECIAL CIRCUIT/MISC.
vWvW11} that he is licensed pursuant to the provivions ofthe Commerce.,License Leis,(Chapter 9
Cp0q (commencing with Section 71000)of Division3ot the Business and Professions Coden it
TEMP.METER OR POLE INST..
a M LL Nat he is exempt therefrom nod the basis for Ne alleged exemption.Any violation of []NEW BLDG/ADDITION ❑DEMOLITION
1+•
Section 703 LS by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEV ICES
m r are than file hundred dollars($501), .[]TENANT ❑FOOD SERVICE
FCZQ m 01,as owner of Ne Propery,ar my inormyeev with wages as their sole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
Y2 will not the work,and the structure is not amended!oroffeml for sale(Sec.70ki,Business ❑OTHER
W 3 and Professions Cadc:The Contractors License Law docs not apply a un owner of OUTLETS-SWITCIHS-FIXTURES
property who builds or improves demand,and who does such work himself or through
his own employees,provided that such improvements are not immadcsl or offered for NEW RESIDENTIAL ELECTR SQ FT,
sale.If.however the holding or improvement is sold within one year.fcompleima,the SQ.FF.FLOOR ARRA. ® $Isis:PT
owmerbuitder will have the burden of proving that he did not build or improve tin par st-
you of sale.).
D I,as owner of the propery,am exclusively contracting with licensed contractors m TOTAL
um Professions
: MAR #y
cansuthe project(See.701 Business and Code,The Conrannr's v- 199 `
cense law does not apply to an owner ofproperty who builds or improves thercnn.mtd QTY. PLUMBING PERMIT FEE
who contracts for such projects whit a component)licensed pursuum m Ne Comracmes
License Use PERMIT ISSUANCE I:I�Y wr wrulynn� -
I]1 am exempt under Sec. _ ,B&P C for this reason
Owner
ALTER-DRAIN&VENT-WATER(HA) VALUATION
Dam �.w
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �D r-
1 hereby affirm under penalty of perjury one Of the fallowing declarations:
have and will maintain a Certificate of Comunno selfinsure for Workers Comfort- DRAINS-FLOOR,ROOF,AREA,COND.
soden,as provided for by Section 37M of the Labor Cafe,for the performance of the ST( IF.S TYPECONSTRUCTION
work for which this permit is issued. rixTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,es required by Scelion
39W ofthe Labor Gale,far the performanec of the wort far which this permit is issued GAS-PA.SYSTEM-]INC.4OUTLETS OCC.GROUP APN
My Workees Compensation Insurance carrier and Policy number ate: /
Currier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRI.WASTE INTERCEPTOR
(This section nein not hommpldd ifthu permit is forone h'mdred dollars($100) BUILDING DIVISION FEES
or less.) GREASE TRAP
PWNCHIiCK TEF?
Ioyary Nmin se anymanneeof the become which Nis the W rker'Commit- SEWER-SANITARY-STORM IA.2(1011'.
urn employ any person in any mannerso as m become subject to the Workers'Compen- ENERGY FEE
sation laws of California.Dam WATER HEATER W/VENT/ELECTR
O Applicant GRADING HEy NOTICE TO APPLICANT:If,after making this Certificam of Exemption,yon should WATER SYSTEMO`REATING
a ; become subj.,'.the Wnrkees Compensation provisions of the Labor Code,you must SOILS FBF
forthwith comply with such provisions or this permit shall be demand revoked. WATER SERVICH
Q
UO CONSTRUCTION LANDING AGENCY NEW RRSIDENTIALPLMB. SQ.P. PAID
I hrehwhichhisli mthin intthere lsncamwefon len ding agency far the perfonnanee of Dom ftceeiptp
f1, . Newark for Nis prer is issued(sec.3097.civ.CJ
O U Lendces Name TOTAL:
LcndeeAddress TOTAL
I :
certify Na'1 have rtad this application and ,are that he above infnnnaion is BUILDING Flit•
CM p.l.I agree to comply withal)city and cnumy ordinances and store laws rdmingm QTY. MECIIANICALPCRMIT FEE
U Z building construction,and hereby uuthonxe representatives of Nis city'.enter form the SEISMIC FEL'
r. above-merniond property for inspection purposes I
PERMIT ISSUANCE
(We)agree 1.save,indemnify and keep homeless the City of Caperton against ELECTRIC FEE
Iiabil ries.judgments costs and expenses which may in any way accme against said City AU[ER OR ADD TO MECH. PLUMBING FEE
in consequence of the granting.(,his pcound.
APPLICAN UNDERSTANDS AND WILI CO PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Input CPM)
SOUR( I ULATIONA MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUC'T'ION TAX
Signreef ApptieanVCommcmr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERI S DISCLOSURE
Will the applicant(it future building oc pain more or handle haturdous materiel HEATING UNIT(TO I00,000 BTU)
as defined by the CaNhino Municipal Code,Chapter 9.12,and the Ifeatth and Safety
Code,Section 25532(x)1. tet' HEATING UNIT dOVER 111,000 BTU)
❑Yes WIN. PAID
/- VLN3'11.A'1'ION FAN(SINGLE.RPSIU) Data Receipt#
Will the applicant infurore building by the B use Area
Air Qu or devices which
emir hazunlnuv air contaminants as AcfincJ by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100.000 BTU)
OtstrlmP vv�AJJ BOILER-COMP(OVRR IN),"BTU)
TOTAL:
❑Yes No
1 have read the has infous materials Alit CONDITIONER
requirements under ,1 and rsta of Ne Cali- ISSUANCE DATE
fomiu Heals no Safety Code,Sections dna it I,my
and 25534.1 understand that if the NEW RES] GAI.MECH. SQ,ET
building Jae nommreichday have hi emetp or'o ismyce ofa Certificatof
of re tion,
Of the'ryuiremen's which must he inn poor to ofe Certificate of'Occupancy. '
Owner.,suNanzed agent Dam TOTAL: ISSUED BY:
OFFICE