S 0103 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUD.DINO DIVIS10N APPLICATION/PERMIT vLUMBInc-MF.CHANIenI. S 0103
RUILOtNG PRO EC 1 IN'ICATION
BUILDING ADDRESS: 1KI215%A SANITARY NO, APPLICATION SUBMITTAL.DATE
OWN.R'SN E: PHONE: (}A'S CONTR CTORSN LIC NO
N/C CONTROL#
ARCHITECT/ENGINEER: LIC NO:
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affam that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Od'Z with Section 7Nknmf Division 3ofthe Businessand Professions Code,and my license isRESIDENTIAL,
O O PERMIT ISSUANCE
n full forestal ❑SFDWL ❑KITCHEN REMODEL
�L) Li c lass Lia#
yGate Contrannr APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
E.Pm .ARCHIT'ECT'S DECLARATION PANELS ❑MULTI-UNIT [.]STRUCTURAL
ZOvn6 I understand my plans shall be used as public records UP TO MODIFICATION
oz-a 0INTERIOR El REPAIR
Licensed Pmfcssinnal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
Im
OWNER-BUILDER DECLARATION OVBR IIIf1AMPs (]BATH REMOUBL/REPAIR MOLIT]ON
1 hereby affirmthat I am exempt from the Connectors License Law for Bhe ❑OTHER * f
6 following reason.(Section 70315.Business and Professions Cale:Any city or county SIGNS ELECTRICAL �t r--'
a W F which requires a permh m construct,alta,improve,demolish,or repair any swemre -
p7 prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC.
a that he is licensed prompt m the provisions of the Contractor's License Law(Chapter 9
u1 OC (commencing with Section]0W)of Division J of the Business and Prafessions Code)or TEMP.ME TER OR POLE INST. COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W fz. S,chair 10315 by any applicant for apermiImbjects the opplicum to a civil penalty of POWER DEVICES ❑TENANT ElFOOD SERVICE
r.y} not more than five hundred dollars( an. IMPROVEMENT
r62-J-' O Dl,as owner of the properly.lar my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
will do the work,and the amounts,is not intended menaced hirsute(See 7044,Business OTHER }}
W � and Professions Code:The Contractors License Law doe..not apply to an owner or OUTLETS-SWITCHES-FIXTURES 4•' P s^.
n' property who builds or improves thereon,and who does such work himself or through .r'p
his own employees,provided that such improvements are rat intended or offered for NEW RESIDENTIAL ELECT SQ Cr.
sale.If,however,the building of improvemeron sold wallinone ymr.fcompfichim,the SQ.FT.FLOOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve for put-
pose of sale.). CID
+
❑1,as owner of the propeny,am exclusively contracting with licensed contractors Bo L'
combeart the project(Sec.7044,Business and Professions Code:)The Contractive,Li-
cense Law docs not apply to an owner of propeny who builds or improves Bilateral,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a conameba(s)licensed pursuant to the Contractor's -License Law PERMIT ISSUANCEG
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VEND'-WATER(EA) va. �ALUATION
Owner Data GG
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Q
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain aCerliGcam of Consent toself-inmre for Workers Crimper- DRAINS-FLOOR,ROOF.AREA,GOND. - S 5 TYPE CONSTRUCTION
sation,as provided for by Section 37W of the Labor Code,for the pkofmmunce of the -
work for which this permit is issuW. FIXTURES-PER TRAP -
O I have and will maintain Workers Compensation Insurance,a,requirod by Section - -
3900ofthe Labor Code,for the performance orthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS CC.CROUP APN
My Worlekyy Is cc and Policy ier�'7wf eurierPolicy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' OREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section needs.BM completed iflhe permit is Imme hundred chill ars(SINB GREASETRAP - -
nr less.) 'PLANCHECK FEE
Iceniry that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in my manner so as to become subject m the Workers'Compen- - ENERGY PEE
Z
station Laws of Califomiv.Date WATER HEATER W/VENTIELECTR
B Z Applicant ` GRADING FEE
gNOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
abecome subject to the Worker's Compensation provisions or the Labor Cade,you must SOILS FF.F.
R.I forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
.Uti. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.PT. PAID Date eceipt#
VQ I for whaffimithat them isaed(Sec.30lending agency for the performance of
the work for which this permit is issues(Sec.309],Civ.CJ
IT•1 Lenders Name - TOTAL'
W L< sAddress TOTAL:
.
1 certify that 1 have read this application and also hot the above information is 1 BUILDING FEE
W correct.
l agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
V Z building con ctien,and hereby authorize representatives of this city to enter upon the 'SEISMIC
ti above-men[ ofamy for inspection purposed. PERMIT ISSUANCE
(We a to save,indemnify and keep harmless the City of Caperton against ELECTRIC FEL
liahil es,j d e S.costa and expenses which may in any way mems,against said City ALTER OR ADD TO MECH.
equ an f egmatingnftbispermir PLUMBING FEE
APP C T NI ,RS NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,M)CFM) Ne
MBCHANICAL FEE
SOU CE t L, IO
rl I AIR HANDLING UNIT(OVER 10,000CPM) CIONSTRUCTION TAX
Si a t ce i Co to - ll Date EXHAUST HOOD(W/DUCr) HOUSING MITIGATION FEE
Z DOUS MATER LS DISCLOSURE
Will fill n or future building occupant.store or handle hazardous marenal HEATING UNIT TO 100,000 BTU)
as defined by a «into Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 2. 2(a)7 HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID -Dam Receipt It
Will the applieam or future building occupant use equipment or devices which BOILER-COMP(HIP OR 100,000 BTU) -
mit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
D stdct7
E]Y. ON. BOILER-COME(OVER 1(10,011()BTTE
'
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DA E
made Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. �-y 2 ~
building does not currently have a cenant,Nal it is my responsibility ns notify the occupant 1 J 111
of the requirements which must he met prime,Auance of a Certificate of Occupancy. B
Owner or sentenced agent Date TOTAL: ISSUED BY:
OFFICE