31339APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING- ELECTRICAL PERMIT No. 31339
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL.
4Cf: PHONE:�S� /-
1 hereby affirm that 1 mu licensed under provisions of Chapter 9 (commencing
with Section ]000)af Division 3 of the Business and Prnfeasions Code; and .,I ec.se is
in full tome ane effec
Littnw Cla. Lic. #
Dam Counselor
ARCHITECTS DECLARATION
I undentund at, ilium shall be used as public more,
Licensed Prz hesslonul
OWNER -BUILDER DECLARA'T'ION
1 hereby affirm that 1 no, exempt from the Commdar's License Law for the
following reamer (Section 7031.5, Business and Professions Code: Any city or county
which roguires a permit to construct. alter, improve demolish, or repair any structure
prior to its issuance, also requires the applicant for such Permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section ]000) of Division 3 of the Business and Professions Cecil or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not mare than Five hundred dollars ($508.
❑ do
the work,
property,err myemntend x wioffemd xasthei(Sec. 0LI.B sines.
will dothework, and the structureontisnotintended Law
sale(Sec.9044, weer of
and Professions Code: The oyes themr's License law saes not apply s if owner of
his o ny, who builds or improves thereon and who nts such work himself or through
his own employeese provided that such improvements are not intended of completion,
or plered for
sale. ILhowever, thebuilding or improvement is sold Within one yearofmrovetior the
owner -milder will have the burden of proving thin he did not build or improve for pur-
pne of sole.).
I, as owner of the property, um exclusively com met ing with licensed conmmmrs to
om met the project (Sec. 70Li. Business and Professions Code) The Contractor's U.
cense Law does not apply to an owner of property who build, or improves thereon, and
who contracts for such projects with a contmaogs) licensed pursuant to the Comracmr's
License law.
❑ I am exempt under Sea .B&P C for this reason
❑ Consultant Fees Paid by Applicant (Initial)
I QTY.I (ELECTRIC PERMIT I FEE I
.owner D
WORKERS COMPENSATION DECLARATION
1 hereby affnn under
penalty of perjury one til the following Winwr''s C
El I have andwild maintainby een 37am of he Labor Code lorcfer Worker's Cnmpcm
endue, us provided for by Section 39W of the Luka Code I'or the perfonnonce ol'thc
wo k have and this permit is orke.
1 have end will rat.maintain Worker's Compensation work
fornce, li required t i Section
4100 of the Labor Crde, for the pedommnce of the wink for which this permit is issued.
My Work{ ��Cog as i' � "cumuumc carrier anal Policy quylye�me /idT.t�q
Cartier. //!y [,pLd�Policy No(Mg(OKI OIXJ
CERTIFICATE PEXEh1YTION FROM WORKERS'
COMPENSATION INSURANCE
(This wei ion used not be completed if thepennit is or one hundred dallam'($1 W )
or less)
I certify that In the performance of the work lin which this permit is issued 1 shall
not employ any Person in any manner sa as tit heennm subject to the Worken' Contpem
O Z ration Laws of California. Dale
Z O Applicant
y NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply withmch provisions on his permit shall N deemed revoked.
0
CONSem is ac ONLENDING AGENCY
L)Q khereby
whic affirm that Nercissue(See.3nlend ingagency for the performance of
tr, H me work rte which mispernm is iaaaw (see. J89l, cisc.)
p V 1<nder's Name
} LIJ lenders Address
0. I certify that l have read this application amt state that the above information is
f' N coned. 1 agree in comply with all city and county ordinances and state laws relating to QTY.
U building construction, and hereby authorize mpremamoves of Nis city to enrar upon the
wev -imm cad property for inspection purposes.
(We) agme to save, indemnify and keep harmless the Chy n[Cupeninu uguina
liabil'niev, judgments, coa.s and expenses which may in any way accrue against said City
in
asequence of the gmnti ag of this permit.
APPLICANT U6DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
IIAEARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare tar handle hazardous material
tax defined by the Ca,nit Municipal Code, Chapter 9.12 and the Health and Safety
Cade, Section 255320)?
e
Will the applicant or future building occupant use equipment or devices which
emit hazardaus air contaminants as defined by the Bay Area Air Quality Management
District?
Yes No
ia,
1 have read the hamnlous materials requirements under Chapter 6.95 of the Cali.
fam I I�&Saode, Salions 25505. 25533 Imd 25534. I anderstetd thus tl'the
Idi ag y have atenanL Not itis my responsiblity m pouf thetmcupita,
ry t riorto issuance of a Coo t
0.4r.,a omsd agent t ere
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 200 AMPS
201- Beat AMPS
OVER light AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. MEI ER OR POLE INST.
POWER DEVICES
SWIMMING ['001. ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTR I SQ FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF. AREA, COND.
FIXTURES -PER TRAP
GAS - EA. SYSTEM.I INC. 4 OUTLETS
GAS - CA. SYSTEM -OVER 4 (EA)
GREASMNDUSTRL WASTE INTERCEPTOR
GREASE 'I RAI'
SEWER -SANITARY -STORM EA. 201 PI'.
WATER HEATER WNENT/ELECIR
WATER SYSTENMEATING
WATER SERVICE
NEW RESIDEN'I[A[, PLMB. SO. FT.
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MFCH.
AIR HANDLING UNIT (TO 10,000 CFM)
AIR HANDLING UNIT (OVER I0,000 CFM)
EXHAUST HOOD (WMUC )
HEATING UNIT (T0 100,000 BTU)
HHATINC. UNIT (OVER 100AX) If'I U)
VENTILATION INN (SINGLE RESID)
BOILER - COMP (3HP OR 100," BTU)
BOILER - COMP (OVER 1 W.000 BTU)
AIR CONDITIONER
NEW RESIDEM'IAl. MECH, SQ. PT.
OFFICE
Fm-
❑ ❑ ❑
JOB DESCRIPIION
RESIDENTIAL:
SEISMIC FEE
❑SFDWL
❑ KITCHEN REMODEL
❑ADDITION
❑PLUMBING RF. -PIPE
❑MULTI -UNIT
❑STRUCTURAL
MODIFICATION
❑ INTERIOR
❑ CHIMNEY REPAIR
' IMPROVEMENT
❑ BATH REMODEUREPAIR ❑DEMOLITION
❑ OTHER
Pl
J
T/
COMMERCIAL:
❑NEW BLDG/ADDITION
/l
❑DEMOLITION
❑l'F,NANT
❑ FOOD SERVICE
IMPROVF,MEN'r
C OTHER
ESQ. FTFLOOR
V
OR AREA
P
W
IC E
FEE JAN 16 RECTI
STORIES
BUILDING DIVISION FEES
PLANCHECK FEE
ENERGY FEE
GRADING FEE
SOILS FEE
PAID
Dam Receipt#
FEE
BUILDING FEE
SEISMIC FEE
.✓ll-,`
ELECTRIC FEE
PLUMBING FEE
MECHANICAL FCL:
CONSTRUCTIONTAX
I HOUSING MI HGAT10N FEE I
PAID
Dote Receipt#
ISSUED BY:
LSQ, FT.