B 0392 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1 PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOO1 6 +00392
BUILDING PROJECT IDENTIFICATION
INILDINGADDRP_SS: SANITARY NO. APPLICATION SUBMI 11AL DAT
1 % -.1 5 Si_ VFX ick , BC, S-- /3-99
OWNER'S NAME: 11 fQ. PHONIi: �+�n C RACTOR'(S NAME: LIC NO:
f `4K'/` �I,.N L .Z. ✓ 7 l�- G�'� Ib ay4o N/C CONTROL#
•ARCI IITI3COLNGINEER: LIC NO: ADI36E'S: ❑
U 97 5. DA tin 0-,rel r
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Cansultant Fees Paid by Applicant(Initial) BLDG ELL
CT PLUMB MECH
�ra.I� a -vG li? ❑ ❑ Cfi ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that[;an licensed under proci.inm of Chapter 9(comlrodng JOB DESCRIPTION
a-s rLZ with Scom.T(gp)of Division 3afthe Businessand Professions Gyle,andmy license is RESIDENTIAL:
W W p PERMIT ISSUANCIi
F�.. in full force and elicit. ❑SFDWI. ❑K19'CHHN REMODEL.
'UU hicenx Class Lic.N APPLIANCES-ftP_SIDF.NTIAL
HZW Dae Conmentr ❑ E3W
ADDITION - d1MBING RE-PIPE
FDm ARCHITECT'S DECf RA'I'[ON PANPIS ❑MULTI-UNIT ❑$TRUCTURAI,
Zpy'z I understand my plans shall W used as public records MODIFICATION
OZ—p UPT0200AMPS [D INTERIOR ❑CHIMNEY RI7PAIR
l-.4LW Licensed Probaioted 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
C C Q 1 hereby affirm that ma exempt Ecom the ConnaOur's License Law for the OVER 1000 AMPS ❑BATH REMODEURF,PAIR El DEMOLITION'
�•p A.U following (Section]131.5,Budness and Professions Cede,An l t ❑OTHER
X3 guiresa emion ymyofcoony SIGNS ELECTRICAL
ID a vFi which requires a permit to um,tmct alms,improve demolish,or repair any,waure
0
6 prier ei it,iwunce.also requires(be applicant for such Permit to file o signed statement SPECIAL CIRCUIT/MISC.
that be i,li omedpursuammthe Frovm...vDWContracmrs.License Law(Chapter 9
se y
100+ C ou rnmencing with Section 70(10)of Division 3 of the Business and Profe,sumv Code)or TEMP.METER OR POLE INST. COMMERCIAL'
a eL oy� 'but he is exempt'hcrefmm and the basis Iia the alleged exnnptinn.Any violetion of ❑NEW BLDG/ADDITION 0 DEMOLITION
KmLLSec'ion](131.5 by any applicant for a permit subject,the applicant to a civil penalty of POWER DEVICES
m ern more Oen Eve hundred Jolles($51X). ❑TENANT ❑FOODSERVICE
i (]I,In nwncr tel the propeny,nnny employees with wages as lhcirsnlc cnmpensatian, SWIMMING POOL ELECTRIC IMPROVEMENT
Wt: will it,,the work.and themosa re is not intendNoroReted fmsale(See Twf.Business El OTHER
Wile
3 m and Pndewian,Gale:The Comments License Law dors not apply to an owner of OUTLETS-SWITCHES-FIXTURES
properly who builds or improves thereon,and who docs such work himself to througM1
his own employees,provided that inch improvements art not intended or offered for NEW RESIDENTIAL ELECfR SQ FT.
sale,If,however the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA S/SQ.FT.
ser-builder will have the burden of proving that he did not build of improve for par- _
pec of sale.).
❑1,as owner M the property,am exclusively contracting with licensed conlmcan9 In TOTAL:
instruct the project(Sec.](W.Business and Profeasims CWe:)The Cmdracmr's Li-
wlaw does notapplym an ownerof pro,amy who bulrd,or improves thereon.and QTY. PLUMBING PERMIT FEE
who contractsfor such p'njects with a convanm(s)licensed pursuant to the Combat
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for do,sena
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW Plt( IFC`E DEVICE
1 hereby uffinn under Penally of perjury one of the following declambons:
I have and will maintain uCcr'ificam of Conscnuoself-insure for Workcts Campcn- DRAINS-FLOOR.BOOP.AREA.GOND.
satins,a,provided for by Section 3700 of the Labor Cede,for the pe llmormecc of the STORIES l'YPE CONS'rRUC11C
work fm which Ibis permit is issued FIXTURES-PER TRAP
❑ 1 have and will maintain Workers ComPcnsation Insurance,as lcquimd by Section
3700 of the labor Cede.for the performance ofthe work for which this Permit is issued. GAS-Ek.SYSTEM.)INC.i OUTETS
OCC CROUP AYN
My War- 'eC nmpcnxa�i In. ruseca IPnlicy.nu '
Came - CHI cPolicy No.:�9Go1 GAS-EA.SYSTEM-OVER
CERL'1 CATE OF ATION INN FROM ORKERS'
COMPENSATION INSURANCIiGREASFIINDUSTRI.WASTE IN'I F.RCF.PTOR
(This section need no'krour letN iDhe permit n furor hundred dollars(5100) BUILDING DIVISION F
ter Ij GREASE l'BF,E9
"' AP PLANCHECK FFE
I cenifythat in the performance ofthe work for which this Permit is issued,I shall SEWER-SANITARY-STORM EA.200 FIE
not employ any Item s,in any manner m a,to became subjea'o the Workeri Compen- ENERGY ITE
OZ .anon Laws of California.Date NATER HEATER WNEN AI.LECTR
Z Applicant GRADING FEET.
NOTICE IU APPLICANT:L after making this Certificate of Exemption,you should WATER SYSTEM/TRIATIRG
a , become subject to the Worker'.,Compensation provisions of the Labor Cod,you sed SOILS FEE
W forthwith comply with such provisions or this permit shall W deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.FI'. PAID
V Q k11 which his
that ieaconslri.30 leading agency for it,rtormance of Data
U the work fur which thio pannit is issued(See.3f19],Civ.C.)
O F' Lender's Name
r Lender's AJdrcm A f
F y 1 reify that I have uJ this application and dale thvuhc above informvtion is BUILDING FEE
Ln correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U 7- building emomiclion.and hereby umhorlu repfexn'a'ivevofthis city lumaerupun the SEISMIC FEE
abmmc-mentioned property for inspection p.,,.,. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Caperton against FLECfRIC FEE
liabilities.judgments.costs and expenses which may in anyway an:nc against said City ALTER ORADDTOMECH.
in n,equence of the granting of t 's#Beds PLUMBING FEL
APPLICANT UNDERS ' NI AND s' ,COMPLY WI'I'if ALL NON-POINT AIR HANDLING UNITr010,003 CFM)
SOURCE RED / ^ MECHANICAL 12EL
S-f ��) O AIR HANDLING ON]'1'(OVER 10.00hCFM) CONSTRUCTION TA
NN
Signet pplicanrCommctnr /Dam EXHAUST HOOD(W/DUCT) ROUSING MITIGATION .E
HAZARDOUS MATERIALS DISCLOSURE
Will'hcapplicant or too i building occupum.dorc or handle haaardou,Inamnol HEN1 ING UNIT(TO IFTUI,I1TU)
as defined by the CuPcrtino Municipal Cede,Chapter 9.12,and the Health and Safety
Cole,Secliun 25532(.)'1 HEATING UNIT(OVER 100,000 BTU)
p Yes QN7—
VENTILATION FAN(SINGLE RESID) PAID
Will thea lica'n or future huildin 'use u 'or device,which Data Romp,#
pp gby then Area
BOILER-COMP(3HPOR 100.BIX)BTU)
it hasallous air mnmminant,a,dcfineJ by the Bay Arev Air Qualiry Management
Ui4rictp TOTAL:
0Yce rl No BOILER-COMPfOVER IINI.gp BTU)
1 hauc read[lie haeuNo¢,materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER
ISSUANCE.DATE
Tonto Health&Sofa Cod✓Scuio' 05,25533 and 25536.1 understand than if the NEW RESIDENTIAL MUCH. SQ.FT. r S�
buildingdocs y Fj have ,Ihmnn sibility m notify the occupant 3
miehi
m mel prii Ierxsuunee ofu Ce nificatenfO,aypune,
Ow uu Date TOTAL:
I ISSUED BY.
OFFICE