25816APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OFCUPERTINO
BUIL D;❑(i-h,h6 RI AL
PERMITNO.
58 C
APPLICATION/PERMIT
PING
25816
BUILDING DIVISION
PROJECT IDENTICAL
xull,uiNf: PROJECT IDENTIFICATION'
L J o 1 v
BUILDING ADDRESS:
SANITARY NO. APPLICATION SUBMITTAL DATE
L
UNITp
OTp
OWNERSNANE: PHONE:
CONPAgOR'SNAME:
LIC NO:
N/C CONTROL#
P
RCHITECT N GINGER: LIC NO:
ADDRESS: �}'.
❑
ob e
'ONTACf: ONE
rvaloae7
QTY.
ELECTRIC PERMIT'
r BUILDING PERMIT INFO
EEE
i _X
1
1 G ELECT PLUMB PIECE
e S
PERMII'ISSUANCE
APPLIANCES-RESIDF.YI'IAL
El 1:1
JOB DESCRIPTION
LICENSED CONTRACTOR'S DECLARATION
IherebyafBnn Nal l amlicensed underpmvisionsof CTapter9(commencingwith
Section]00st Division 3 ofthe Business and Professions Cole, and my license is in
PANELS
J,•�•• f +1/.
full force andcfcct.
C/����J
hi ase Class Lic.#
UP TO 200 AMPS
Date Contramor
201 - 10(10 AMPS /
W
OVER IOAMPS
S/SQ. Ff.
ARCHITFCPS DECLARATION
I understand my plans shall be used as public record,.
SIGNS ELECTRICAL )
p II
�` TER
Licensed Professional
OWNER -BUILDER DECLARATION
SPECIAL CIRCUIT/MISC.
Jy
I buefir nOlnn chat I am exempt from he Contractor's License Law for the
following reason. (Section 0031.5, Business and Professions Cale: Any city or county
TEMP. M E' 1' ER OR POLE INS].
D
which mi a permit to construct, alter, improve, demolish. or repair any sweture
L_
prior to its isuance,also rerimmo atipplicaut tinsmith permit lm file. signed statement
POWER DEVICES
that he is licensed pursuant to the provisions of the Convectors License Law (Chapter
9(cotmnencing with Section 7000) of Division 3 of the Business and Professions Code)
SWIMMING POOL ELECTRIC
ygLOpT ,
'.. or that he is exempt herefrom and the basis for the alleged exemption. Any vioutionof
1
Section 7031.5 by any applicant for a permit subjects the applictm m a civil penalty of
OUTLETS - SWITCHES - FIXTURES
not non, than Ove hundred dollars($5110).
❑ I,asownerofthepmp ny,ormyemployeeswithwagesasiheirsolecompensaiion,
NEW RESIDENTIAL ELECfR _SQ. F].
STORIES TYPECONSTRUCTION
will do the work,and the someone is not imended oroffered forsale(Sat.]041,Business
and Professions Code: The Contractors License Law does not apply to an owner of
propertywhnbuild,mimprnves thereoo,and wlmdoessuch work hinmelforthrough his
OCC, GROUP RES. UNITS
1 deed thatsuch int t tmemdedoroffmal forsale. If,
amp oebuildovi prmcmensarenoi
however, the improvement itself within one year of completion, the owner
TOTAL'.
builder will h:rve the htvAcn of proving that he did rat build arimprove for pumace of
have the bur
sole.).
❑ I, as ownerofthe progeny, am exclusively contracting with licensed contractor to
QTY.
PLUMBING PERMIT
FEE FLOOD ZONE APN
construct the project (Sec. 70TU Business and Professions Code:) The Contractor's
License Lawdoes not apply loan ownerefpropeny whobuildsor impmvcsthcreon.and
PERMIT ISSUANCE
whocommuct for such pmjecr with. convactogs) licensed proom a me Contractor's
ALTER - DRAIN&VF.NT - WATER OA) )
FEE SUMMARY
License Law.
❑ 1 am exempt under Scc. , B & PC for this mason
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS- FLOOR. ROOF, AREA, CORD.
SANITARY YN
RECEIPTis
SCHOOLTAX Y N
Owner Date
WORKMAN COMPENSATION DECLARATION
I ❑ Ihereby affirm that l hzveacertilicmcofcomem toself-insure, oracartificateof
FlXTURFS - PER TRAP.
RECEIPT# '
n lnsacea certified copythm.f(Sm. 3g W, lab C.) which
Woo Compearreaorenor
ts'
PARK FEE Y N
covers tllundermis permit
GAS - En. SYSTEM -I INC. 4OUTLETS
RECEIPTN
Policy #
BUILDING DIVISION FEES
bErYCatifiN
GAS - EA. SYSTEM -OVER 4 (EA)
PLANCHECK FEE
conn is hereby W.
GRGA5171NUU$TRI. WASTE INTERCEPTOR
GRADING IB?E
❑ ertificd copy is fled withll the city inspection division.
the
CER'I'IFICATEOG EXEMPf10NFROMWORKERS'
GREASETRAP
SOILS ITE
COMPENSATION INSURANCE
SEWER - SANITARY - STORM EA. 20fFT.
ENERGY FEE
(Ibis section need not be completed ifthe Permit is for one hundred dollars(SIW)
or less.)
WATER HEATER WNENT/ELECTR
I certify that in the performance of the work for which this permit is issued, )shall
net employ ;at, person in any mammr .cot as an become nuhject to the Worker,'
- PAID
Compensation Lawsof Califomia. Dote
WATER SYSI'HNIGREATING
Date Recciptis
Applicant
NOTICE TO APPLICANT:If, after making this Ceraficam of Exemption, you should
NEW RFSI DENTIAL PLMIL SQ, FT.
TOTAL:
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
BUILDING IEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agorcy for the performance of
TOTAL:
ELECTRIC FEF.
the work for which this permit is mand(Sec. 3091, Civ. C.)
QTY.
MECHANICAL PERMIT
FEC PLUMBING EEE
MECHANICAL FEE
Lenders Name
Lenders Address
I modify that 1 have read this application and state that Ne above iNormation is
correct I agree to comply with all city and county oNinutc<s snit state laws relating to
PERMIT ISSUANCE
building construction, and hereby authurize repmsentativesof this city to enter upon the
CONSTRUCTION TAX
above-mentioned propcny for inspection purposes.
ALT ER OR ADD TO MECH. \
(We.) agree to save, indemnify and keep harmless the Cay of Ci pcnino against
liabilities,judgments, costs and expenses which may in any way accrue against said City
AIR HANDLE NO UNIT (TO 10,000 CFM)
in consequence of the gmnling of this permit.
AIR HANDLING UNIT (OVER 10.000 CFM)
I EXHAUST HOOD(W/DUC)
PAID
Signature of Applicent/Co muctor Date.
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100i I BTU)
Date Receipt #
Will the applicant or Poore building occupant store or handle hazardous material
HEATING UNI'1'(OVER 100,000 BTU)
'TOT
as defined by the Cuperino Municipal Cade. Chapter 9.12, and the Health and Safety
Cade, Section 25532(a)?
❑ Ycs ❑ No
VENTILATION FAN (SINGLL RESID)
ISSUANCE DAT
BOIIPR -COMP AHP Oft 109.000 B'N)
Will the applicator(urebuildingoompaat usectimpmemordevicessvhichemlt
m
jbizandous air contaminants as defined by the Bay Amu Air Quality Management
BOILER -COMP (OVER frightful BTU)
strito?
ry D A
❑Ycs ❑ No
NEW RESIUI?N'TIAL MECH. SQ. t•1'.
tr Ii
1 have read the hazardous materials braim emem5 under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25513 and 2s534. I undcrstand that
_
DEC 1993
if the building docs not curendy have o tenant, that it is my responsibility m notify the
occupant of the requirement/ which must be met prior to issuance of a Cenlficate of
Occupency.^
- A..
TOT Al.
/.
ClIY VI --r ch I IINU
ISSUIiU BY:
Owner ora horiac agent Date
orrlGt