26149 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOInIlSINi:'ELECTRICAI. PERMITNO,
APPLICATION/PERMIT PLUMBING,-MECHANICAL. nL+ q qn
BUILDING DIVISION RUILDINO PROJRCI'MEN'I'IFICA'r[ON G O 1 °1 J
BUILDING ADDRLSS: -//k) SANITARY NO. APFLICA'1'IOONSUBBMIIIAL DATE
111qV y UNITN LO'I'a, 16 �1
OWNERS NAME: P ON : CONTR R'S NAME: - NO: N/C CUNfROI.a l
L
ARCHITECTILNGINECR: LIC NO: ADDRF,$5. z
CONTACT: PHONE:
' Q'I'Y. ELECTRIC PERMIT PEE BUILDING PERMITINFO
BLDG ELECT PLUMB MRCH
PERMIT ISSUANCE 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DGSCRIPI'ION
OmZ Ihereby affirm that l am licensed under provisionsidChapter9(commencing with
0)00 Section 7030)of Division 3 of the Bmincssand Professions Cnds,and my license is in PANELS
W W full farce and effect.
Y
Fa,y LiccnseC — Lic.a�J( �� UP T0200AMPS
y 44=y Data Convector JC - 201-Vok AMPS
ZOr"ir'� ARCHITF.CI'S DECLARATION OVER Boal AMPS SQ.FT.F1.00R AREA 8/SQ.FT.
O Z_❑ I understand my plans shall h,used as public records.
Py3J SIGNS ELECTRICAL
C"1 Licensed l'rmfaswmnal
OWNER-BUILDER DECLARATION SPECIAL CBtCUIT/MISC, 4= LED IN
tt----��
WW 0 a F 1 hcrtby affrn shot I am exempt from the Contractor's License Law for the
W3mw RJlawing«uson (Section 9031.5,Business and Pimessa ms Codes Any city mcouII nty TEMP.METERORPOLEINST. v ,'v / YY
0 which¢yuirca a permit to construct,alcor.improve.demolish,or repair any.kn oma a� q.
��>� priormittissuance,alsnrequires the npplicant forsuch permitlm files signedsmtement POWER DEVICES �i
p�j,<0m that he is licensed pummnt to the provisions of the Contractor's Lieense Law(Chapter
IDATE
Lge4 9(commencing with Section 700Uaf Division 3 of Ne Business and Professions Cade) SWIMMING PoOL FIPCTRIC VALUATION
7d_m .1(hot he isexentpnhenefmm and the basis for lbcmleged exanption.Any violation of OUTLETS-SWITCHES-P1%TERES
IG Section 7011.5 by any npplicont torn permit sublecN the epplicannoecivil penehy of
not more than five hundred dollars S5 W). NEW RESIDENTIAL F.LECTR _SQ.FT.
CI1,osnwncrnfthepropeny,ormy cmployeeswith wageses theireolecnmpensa(ion, STORIES TYPECONS'I'RUCTION
4322 willdo tbework,andthe structure intim intended oroffend forsule(Sec.70a4,Business
and Prgfcssiona Code:'Ihe Comment's License Law rices not apply to an owner of
property whobuilds orimproveslhercon,and whodeassuchwork himselforthrdugh his OCC.GROUP RES.UNITS
own employees,provided that each impmvemenu arc not intended oroffcmd far Sala.If,
however,the buddingor improvement Is sold within one yearofcampletion,the owner- 'TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
❑ Las ownerof the Dropeny,amexclasively convecting with licensed comracmrsm QTY. PLUMBING PERMIT FEE FLOOD ZONIi APN
construct the project(Sec.7(344,Business and professions Code:)The Convaam, PERMIT ISSUANCE
License Law does notapply to an ownermfpropeny who builds mimproves thereon,and
who contracts for such projects with a convador(s)licensed pursuant to the Conradoes ALTER [.V
License Law. (' FLEE SUMMARY
❑ 1 em exempt under Sec. tl&P C for this reoson BACK FLOW PROTECT.DEIVICH 0UTSI DF.FEES
-- SANITARY Y N
Owner Dune - RFCEIPTs
POND
AREA., .
, WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR, SCHOOLTA% YN
❑ Ihacby affmm(hatlhvvc ucenifcare of consent to self-insure,arecenifcme of PIXTURES-PER TRAP - RECEIPTp
Workerx'Compenvtian lnsumnce orecmifed copy(M1eremf(Sec.3gOp,Luh CJ which PARK FEE Y N
Povers all employee's under this parmif GAS-EA.SYSTEM-I INC. OUTLETS RECEIPT#
licy a BUILDING DIVISION IBES
Company r GAS-FA,SYSTEM-OVER 4(HAI PLANCHECK FEE
❑ Cenifedcopyiaherebyfumished.
❑ Certified copy is fled with the city inspection division. GREASEANDUSTRI.WASTE INTERCEPT OR GRADING FEE.
CHRTIPICATE OF EXEMPTION FROM WORKERS' GNEASETRAI' SOILS IF,F.
COMPENSATION INSURANCE '
This so.mariecdint he completed tithe permit is forms,hundred dollars(SIM) SEWER-SANITARY-STORM FA.200FT, ENERGY FEE
or less.)
I unify that in the performance of me walk for which this permit is issued,Ishall WATER HEATER W/VENT/ELECTR
not employ any person in any manner so as to become subject to the Workers' PAID
Comprmationlawsof Celifomia. Date WATER SYSIHMJJREATING Data Ree,ipta
O z Applicant
z 0 NOTICE TO APPLICANT:If.after making this Cenifcote of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
becmnesubject to me WarkdS Compensation pmvisiansofthe labor Cade,you must
forma,no comply with such provisions or this permit shall be directed revoked. HUILDING FET;
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
V z 1 hereby affirm Nut them is o construction lending agency far the performance of -
the work for which this .it is issued(Set,300,Civ.CJ L: / IiLECIRIC FEE
Lender's Name
a,0 U Landers Address Q'IY. MECHANICAL PERMIT FEE PLUMBING FEE 2
U L certify that have read th' applicatiof.d., n the above information iscorrect.IaGee to m that left droMECHANICALFE-E
g o pdh yon Jsmtelowsr upon the PF;RMITISSUANCI:al,ovengmtioned mond here amhovenofthis citymrnter upon theuMve-mcntioncd r6pccy for' speaion purALTBR OR ADU TO MECIi. CONSTRUCTIONTA%
( e. agree av ,inde mfy and keee City of Caperton against
iebilii ,j dgme ts,ens an expenxs whiwoyaccruengainst said Ciry AIR HANDLING UNI'I'(TO10.000CFM)
in am.¢In c o the gra tin of Nis permit _
�r AIR HANDLING ON]'I-(OVER i 0.000 CFM)
Si amre an vchihot5ioV Dom I EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MAT RIALS DISCLOSURE HEATING UNIT(TO 100,0(1(1 BTU) Dore Receipts
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 1W,000 NIT])
as defned by the Cuperino Municipal Code,Chapter 9.12,and the Health and Safety
Crile,Section 25532(u)9
0Yes 11 No VENTILATION FAN(SINGLE RESID)
Will iheopDlicontorfu(urcbuilJingwcupant use Wuipmentnr Devices whichemit
BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
hazardu s air Camami0anls as defned by the Bay Arca Air Quality Management BOILER-COMP(OVER 1110,000 BTI)
District?
❑Yes i 01. #0
NEW RESIDENTIAL-MECH. SQ.IcE ey_ 41 AD
1 have read the ha menus mmerid,m oremems under Chapter 6.95 of the I"'1
Califamia Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
i ll he hoilding Jaes ran eurrannly hava ateount.told is my respansibfli(y wnail,tha �t1v
scupam of be rtyoiremema which must be mer print m issuance of a Cenifeme of
Ownerormuninzsittu t - Date TOTAL: ISSUED BY: ��
OFFICE