30313 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-ELECTRICAL - - PERMITNO. �O
BUILDING DIVISION- .. APPLICATION/PERMIT PLOMRING.YDICHANICAI.
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA'L'E
-.
OWNER' ihlE: PHONE: CONT R'SNAME: 1.1 'O:
NIC CONTROLp
ARCHITECT/ENGINEER; LIC NO: DROSS: ❑ '
CONTACT. - PHONE.: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH,
1:1 El ElLICENSED CONTRACTOR'SDEQTY • ELECTRIC PERMIT FEE
1h by mrmmtY I dad ,ompi
p ofm Chapter
pt 9(ommencmg JOB DESCRIPTION
WOO wih5 t' 70W)of Div: 3 fah Buni JPot :mn.0 Je IJ sy licenucis - RESIDENTIAL:
WOO PERMIT ISSUANCE
E m full f rc eRmt. ❑SFDWL [I KITCHEN REMODEL.
F.UU Lca.n:e CP: Lm.k APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE
F.d 6 Dam Com man
ARCHITECTS DECLARATION []MULTI-UNIT ❑STRUCTURAL
FF. PANELS
'ZOy^ Imhdcrsmnd my plant shall he axed as public retards - MODIFICATION
OZ—0 UP102MANIPS I Ll INTERIOR [I CHIMNEY REPAIR
Iqq'W Licensed Professional 201-IWAMPS IMPROVEMENT
d 2_1 OWNER-BUTLD17R DECLARATION
y-t OVER 1000AMPS ❑BATH REMODEUREPAIR El DEMOLITION
Q 'I hereby affirm that I am exempt tram the Contractor's License Law for the _
'3 d Ufollowing reason(Section 70315.Business and Professions Code:Any city or county SIGNS ELECTRICAL C3 OTHER
IL ' which requires a permit to construct,dmr,imprnac,droomi,n or repair any swmurc
F-�O�' print tons issuance, hitoquires tbeapplicrm far.mch pcmam file a sigrcdsummem SPECIAL CIRCUIT/MISC. ,
Itat he is licensed parsuumto me provisionsaf the Comruemr's License Law(Chnpier9
(commencing with Section 7")of Division Sof the Business and l'iokxainns Code)or TEMP.METE OR POLE INST. COMMERCIAL: r
Edeq that he in exempt th arftom and the basis far the alleged exemption.Any violatiod of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmO. Section 703 IS by any applicant fart a permit subjects the applicant to.civil Penalty of POWER DEVICES
W^nl ❑T77I:ANT ❑FOODSERVICE
not more than five hundred Dollars($500).
i IMPROVEMENT .
Sd MLothe work,the pesucconnyemntended orowugesmthei(Sole 044.Business
SWIMMING POLL GLECI'ft1C
�b 1 wtl dohe,ime,ands he Com actut hmided or Law
red dos not apply 1.0 a,Business ❑OTHER _
W 3 m ahJ Professions Coder The Contr:utors License Law fishes mai apply to if owner of OUTLETS-SWITCHES-PIXTURF•S
his o ny who built,or improves thuch i and who does such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ BE
sale.If,however,the building Or inhpmvcmem is sold within one yemol completion,the SQ.FT:FLOORAREA r 5/SQ.FT.
mer-builder will have the burden of proving that he did not build or improve for par- +
pose of salt.).
h as owner of the pmy,per ran exclusively contracting with licensed cnmraaors to TOTAL: .h
construct the project(See 7014,Business and Professions Codc:)The Contractor's wLi-
c c Law Jots not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE rhoconctstoreuch �
projectswithacommor(s)licereclproatam me to Gmtmmors AUGU1 ��(�
License Law. PERMIT ISSUANCE. 96
I am exempt eider Ste ,B&PCfnr his reason ,��•ryi
Owner Date ALTER-DRAIN&VENT-WALL ER LEA) ks LH"LVALUA,V N
WORKER S COMPENSAI ION DECLARAI ION RACK FLOW PROTECT.DFVICH
I hereby alTrtn undi penalty of pep ry f h following d I tons:
�7 I have and will maintain a Certificate of Consent to:elfn.uafor Worker.Con,am DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
inion,as provided for by Section 3700 of the Labor Code,forma a foormoon of the -
workfee both his permit is issued. FIXTURES-PER'TRAP
I have and is'll ner000lon Worker sCompensation Insurance, required by Section ,
37W of la o�C�odc.f Me erf nnanc flh Af rwh' hh's permit sued. GAS-EA SYSTEM-1 INC.4 OUTLET'S OCC.CROUP - APN
My W k r L.% I ce c and Policy�fft urej '
L% p y y „ `^'1 GAS EA SYSTEM-OVRR 4(EA)
CERTIFIC EOFEXEMPTIONi ROMWORKERS'
COMPENSATION INSURANCE GRIASE)INDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not ba completed if the permit isfurnne hundred Jollars($lg) GREASE TRAP -
or 1"0PLANCHECK FGF,
Iccrify Mat in the perfoors.,,ol the work for which thispemut is'iswN,Ishdl SEWER-SANITARY-S'IORM lin.200 FT.
nm employ any perms in eny manner w ac m I+ecnme subject m he W'ohers Cumpen. ENERGY FEE
zZ scion Laws of Cdiamiu.Date WATER HEATER WNENTMLECTR
Q Applicant GRADING FEE ,
y NOTICE TO APPLICANLP If,after making this Certificate of Exemption,you should WATER SYSTENU TREATING SOILS FEE
F ; become mbir,r the Workers Compensation pro,mors of the Labor Cate you must
Intlhwith comply wlth.such m,,i.,mp,o;this permit shall M depossi ,stked, WATER SERVICE
Q Q
7z CONSTRUCTION LENDING AGENCY . NEW RESIDENTIAL PCMB. SQ,FT. PAID Date Receipts
L)Q Thereby affirm that here isaconztrvcton lending agency for the Performance of
the work for which this Permit is issued(Sep.3097.Ci¢CJ
UU Lenders Name TOTAL:
C.I Lenders Address TOTAL:
I comity that I have read cis application and otta that rhe above information is BUILDING FEE
iF. N Corea.I agree nh romply with all city end county orJrnances ane sum laws mlahing n+ QTsy. MECHANICAL P17RMIT FEE
U Z building construction.and hereby authorize representatives of this city to enter upon the SEISM IC FEE
,hove-men.inned pmpeny for o"ectiun purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kcep harmless the City of Caperton against ELECTRIC PEE
liobili ) d& entsu-t: d penmsm a'ch may in any way aceme against said City. ALTER ORADD'TO MECH.
in ron.e n dMeg i g this t PLUMBING FEE
APPPEL A,"' NDERSTANDS A ')WILL COMPLY WITH y,Is NONEE
POINT` AIR HANDLING UNIT(TO 10.000 CFM)
S If E I ]ON //�J / MECHANICTIAL ONI
// �/(/�z-tE/- AIR HANDLING UNIT(OVER I0.U0(I CPM) CONSTRUCTION'1'A%
Sh amrC nfApplicanVContrucmn Date, EXHAUST HOOD(WNUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE _
Will theapitemn tar future building occupznt.ameor handle baeudous material HEATING UNIT(TO 100.000 BTU)
as defined by tlet Cugrino Municipal Code.Chapter 9.12,sad live Ilculth and Safety
CWC,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - ,
❑Yet ❑No VENTILAT[ON FAN(SINGLE RESID) PAIL) ,
Date Reoelptk
Will the applicant or future building occuWnt use equipment or devices which
kemit hazardous tar contaminants as deired by he Bay Area Air QualifyMarugemcm BOILER-COMP OHP OR 100.W0 BTU) TOTAL
DisWCT! BOILER-COMB(OVER 100,000 BTU)
-] ❑Yes ❑No
I have mad he hoeardous muarals AIR CONDITIONER I$$UANC° TE
requirements under Chapter 6.95 of the Cali-
feral,Heahb&Safety Coda Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building does not curently have a tenant.that it is my responsibility to ratify me occupant
:a of he requirements which must be met prions issuance of a Certificate of Occupancy. -
s, a
Owner m authadzed egenl Date TOTAL: ISSUED BY:
v OFFICE