30561APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY-OF'tCUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. NIP'CHANICAL
BUILDING PROJEC'P IDENTIFICATION
PERMIT NO, 30561
BUILDING ADDRESS:
3 414 5 � Sal
SANITARY NO.
APPLI /StIN SUBMITTAL DAI
q l'l q�
0WNER'SN it�E: PHONE:
g7r�J L�.L/n(J
CONTRACfOR'SNAME: LIC NO:
r �x 32 �—
NIC
❑
CONTROL
'4HC TELT 'GINEER: LIC NO:
AD ESA- - 0 4LXe 1
CD ACT: PHONE:
❑ Consultant Fecs Paid by Applicant (initial)ELECT
BUILDING PERMIT INFO
PLUMB MECH
C] 13 ElLICENSED
CONTRACTOR'S DECLARATION
I hued, amrm that I an, licensedander ran�Nioa, of chapter 9 mnm
aaenang
with St 70 RDA Division 3 of the Bminensand Professions Cale, and my lice ,r i,
in full forceand cele f�.e 7'3L--PERMI'FISSUANCP.
Liccnu Cl s• �Lic.p
Dam Contractor
SOAR
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL
❑NFDWL C]KITCHT:N REMODEL
❑ADDITION ❑ PLUMBING REPIPE
❑ MULTI -UNIT C STRUCTURAL
MODIFICATION
❑INTERIOR ]CHIMNEY REPAIR
IMPROVEMENT
�F"n�
BATH REMO/D�E�IJREP ��� /(TION
OTHER L'tNk I 1 `—
APPLIANCES - RESIDENTIAL
CHOD CPS DECLARATION
1 underswnd my plans shall be mcil as public records
PANELS
UNTO 2W AMPS
Licensed Professional
OWNER -BUILDER amexempt fie DE Ce Contractors
I hereby affirm that 1 am exempt from the Comraaors License taw for the
following reason. (Section "1031.5, nosiness and Professions Ctdc Any city or county
which requires a permit to con,nuct, altar, improve, demolish. or mpair any structure
primm asissunner..1,un,ane, the applicant lin such Permit to rile a signed statement
that he is licensed pursuant to the provisions of the Commerce, License Low (Chapter 9
to rooming with Section 90g)(DofDivision 3 mme Business and Professio®Cale)m
that he in axe., therefrom and the basis Ratio alleged exemption. Any violation of
Setlion 9031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
nm morethan five hundred dollars(E5IXry.
C] I. as owner of me Property, or my employees with wages as their sole compensation,
will donde work, and Iheamnnre is not mlunded or Offered fur sale (Sec. 9044. Business
and Professions Cale: The Contractors Liccnse Law dee, not apply Ir an Owner of
property who builds or improves mercon. and who aloes such work himself or through
his own employees, provided that such improvements am not imcmled or offered for
sale If. however, the building or improvement is sold within one year ofeimidedon,lhe
oar -builder will have the burden of proving that he did not build or improve for pur-
pn.a of ea1e.).
C] 1, as owner of the property, am exclusively contracting with licensed contractors to
soma me' 'he project (Sec. 70,14, Business and Professions Cale:) The Com ucbr's Li-
cLaw does not apply to an owner ofpropcnywho builds orimproves immon,and
who contracts for such projects with a conlranons) licensed parsoentto the Contractor',
License Law.
El I a pl
❑mexamunder Stt. ,B&YCfor this reazon
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL /
SPECIAL CIRCUITMISC.
TEMP. METER OR POLE INST.
-DMM R -IA
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT FOOD SERVICE
IMPROVEMENT _
[]OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECTS SQ FT.
SQ. FL FLOOR AREA
J�
J
VSQ. Er.
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE.
- DRAIN &VENT- WATER (EA)
OwnerALTER
Dae
-VALUATION
I 1 hereby atlirm under penalty of perjury one of me following Jedamtions:
Wnunder SCOMPENSATION DE Ce following
❑ I have and will maintain a Certificate afCon.wnuo self -insure for Workers Camper-
,union, a% provided for by Slain. 3700 oldie labor Code, for the performance of the
weak for which this permit is issued.
❑ I have and will maintain Workers Compensation Insamnce, as required by Section
3710 of the labor Code, for the Performance of the work for which this penult is issued.
My Works nn tinyl,nsumn J Policy numhcr
Carrier:�K/�f/6�Poliey Ea:�yL
INN IItAM WO KERS'
C.RI'IFlC COMPENSATION
COMPENSATION INSURANCE.
(This section need not he utmrlutfrom, ifthe fr , is bonne hundred dollars ISI W)
or less)
an er of the work he which It to the W is issued, I shall
1 certify thus in the any manner
not employ any person in any mannerwauo become subject to the Workers Confer-
stolon Laws of California. Dae
Applicant
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR. RODE, AREA, COND.
STORIES
OCC. GROUP
TYPE CONSTRUCTIO
qPN
FIXTURES - PER TRAP
GAS - RA. SYSTEM -1 INC. 4 OUTLET
GAS - EA. SYSTEM -OVER 41EA1
GREASF/INDUSTRL WASTE INTERCEPTOR
GREASE TRAP
BUILDING DIVI ON FEES
PLANCHECK FEE
t
SEWER -SANITARY -STORM EA.2IXI FT.
ENERGY FEE
WATER HEATER WNENTiTLEC It
GRADING FE
NOTICE
subjcttoa Woo -IIT. Co tanking this visions of ofE abort Cm you u muldost
become subject m rhe Wnrkds Coons or shat of the Labor Coda, you must
litnhwilb comply with cash provisions or this permit xhall be deemed revoked.
is Permit
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a ennstm<tian lending agency for the Pc forroo ,o of
the work for which this permit is issued (Sec. 3(97, Civ. C.)
Lenders Name
I<ndm,Address
1 certify that I have read chis arplicalion and stem thus the abase information is
sect. I agree to comply with all city and county ordinances and stale laws relating to
building amvlmctim. and hereby authorize representatives of this city to enter Open the
j abnve-mennioned pmpeny for inspection pu"Oes
(Wc) agree m save, indemnity and keep hmmlea the City of Copernino against
liabilitiesjudgmems, costsand esprames which may in any wuyicemeagaimtsaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI NON- DINT
SOURCE3tEGI,'1J$n
��fE/nn/((!��/////
WATER SYSTEM/I'REATING
SOILS FEE
WATER SERVICE
PAID
Receipt M
NEW RESIDENTIAL PLMB. SQ. FT.
TOTAL.
TOTAL:
BUILDING FEE
QTY. MECHANICAL PERMIT FEE
FEE
PERMIT ISSUANCE
EF.
ALTER OR ADD TO MECH.
E
AIR HANDLING UNIT (TO IO.L00 CFM)
L. EEE
AIR HANDLING INI'f(OVER IO.IXp CPAs)
GO
MFEE
Sae f Appnewe"merac� One
HAZARDOUS MATERIALS DISCLOS E
the applicant Or Bnure building Occupant store or handlehazardous material
defined by rhe Cogent.. Municipal Codc. Chupmr 9.12, and the Health and Safety
C de, Sectin 25532(x)9
❑ Yes I] No
Wll the applicant or future building Occupant use equipment or devices which
t hazardous air contaminants as defined by the Bay Area Air Quality Management
Omen^
❑Yes ❑Nr
I have read the hazardous materials requirements under Chapter 6.95 of the Cali-
farm. Health A, Safety Code. Sections 25505, 25533 and 25534. 1 understand shot if the
building doesnm comically haveatarar, Nm it is my oc,,mibility to notify the mention,
of the requirements which must be "tet prior to issuance of a Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
ITIGATION FEEWill
HEATING UNIT(TO 100,0010 BTU)
HEATING UNIT (OVER 100,000 BTU)
am Receipt N
VENTILATION PAN(SINGLE RESID)
BOILER- COME(3HP OR 101.000 BTU)
TOTAL:
BOILER- COME (OVER 1(100DO BTU)
AIR CONDITIONER
ISSUANCE DAT
ISSUED B V:
NEW RESIDENTIAL MECH. SQ. FT.
Owner nrhmhnvcd agcm Dam
r
TOTAL:
OFFICE