B 0386 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. 1 PERMITN 0 3 8 6
BUILDING DIVISION APPLICATIO MIT PLUMBING-MECHANICAL. SOOOI
6UILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APP IC At ON SUBMITTAI.DXH
INNER'S NAME: ^ PHONE: CONTRP�I I NAM;er4 L1140(
E/ S„t ` l C/ NIC CO
LICCHI"IiCf/13NGINEER: LIC NO: ADDRESS: ❑ C ��
rarksox/ ��laK.r dr 5 r s J
CONTACT: PHONE: BUILDING PEHvGT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
x4vlol .tris*az . '-&5v /ZS -Z1:0 ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 bombs uRrm that 1 am IicenttJ under gnvisions of Chapmr 9(commencing
,nQ zO wi,M1 Seninn 7f100)nf DivixianJof,he Busincsx and Professinnx Code.and cyliccnseis�F RESIDENTIAL:PERMITISSUANCIi
full lorcc undo act ❑SFDWh [I KITCHEN REMODEL��U iter,eClass Yse'3e Lot# a 7 3 bol
ZU tri —ContractorT/y p APPLIANC17S-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
Faty Date
ps ARCHDECT"DECLARATION PANELS [D MULTI-UNIT []STRUCTURALv�Z I understand my glens shall be used as public MOWS MODIFICATION
oz-0 UPI
T0_ AMPS ❑INTERIOR ❑CHIMNEY REPAIR
J Licensed Prafessimal 201-I008AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER ImM AMPS ❑HAITI REMODEIJREPAIR El DEMOLITION
CC 1 hereby M.that 1 am exempt from the Commam's License Law for the
Y 6 U followin Section 7831.5,Business and Professions Cude:An t m mum ❑OTHER
x g reamn.( Y d Y Y SIGNS ELECTRICAL [ p
y.gi
LL y which inquires a permit t.conswct.alcor,improve,demolish,or repair any,structure("' �; Prior to its issuance.also requires the applicant for such permit O file a signed statement SPECIAL CIRCUTUMISC. l
r
but he is licensed put....re mi,the pmvisi.mof the Contractor's License Law(Chapter 9 COMMERCIAL:
OC (commencing with Section 7000)of Division 3 of the Business and profession,Crime, TEM4IM44 P
Nat he is exempt tbembom and the basis for the alleged exemption.An on of- ❑NEW BLDG/ADDITION ❑DEMOLITION
m Section 7031.5 by any applicant for a permit subjects Ne applicant to a c J alts o(. POWER DEVICES ❑TENANT (I FOOD SERVICE.
not more than five hundred dollars($500) •� IMPROVEMENT
p�+< I,as.wner.f the rn norm employee,with woes us their soled o,..la , / SWIMMLNG,P004ELE
ttz� Q ❑ P P< Y Y e P Y 6 M,r ❑OTHER
will da the work,and the,mature i,not intended to offered for cola(Sec.7 '^ R-.1, ss
m and Net,,tore CWe:'ITu Contractors License Law docs not apply to ner.f ,�ty,OUT` T-SWI' E I>IXT
progeny who builds m improves Hereon,and who does such work himac through
his Own employees,provided Nat such improvements are not intended o Dp_ t FSIDIiNI E LTR SQ FT.
sale.If,however one building or improvement is sold within a=sent oleo SQ.Ff.FLOOR AREA S/SQ.fT.
ner-builder will have the burden of proving that he did not build or improve for pur-
pose.f,slay TOTAL.
❑ 1,o., r of the property,a Exclusively contracting with licensed connectors to
construct thecpmject[Sec.7044,Business and Professions CWeJ The Contractor's Li-
cenm Law does not apply ro an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commitments)licensed pursuant the Contractors
License Law. PERMIT ISSUANCE
1 um exempt under See. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
137M
wner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2f. D .o p
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure forWmker's Compere DRAINS-FLOOR.ROOF,AREA.COND. STORIES TYPECONSTRUCTIOI
tion,its provided for by Section 3700 of the Labor Calc,for the performance of the
nfit for which this permit is issued. FIXTURES-ITER TRAP
1 have and will maintain Wnrkers Compensation Imsummet,as mluired by Section
of Ne laboryCeode..(a,the performance ufine work for which Nis permit is iss.W. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUT' APN
MY an
mer: at d///CVOP�iL FIeC ePOlcyNn.PolicY nu,t`berOX / GAS-EA.SYS TEM-OVER4IEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASIIINDIISTRL WASTE.INTE BEEPTOR
COMPENSATION INSURANCE UILDING DIVISION FEES
(This section nmin.,bec.mplmWifthepewit is(Drone hundteddnluv11S1001 GREASETRAP 21 U
or less.) PLAN f FEE v
Loy any that in the performance.Tobe work forwrext 1.permit isen'C comas-liquill SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so us m Mcom�sWjem to the Waken'Gtmpen- EN E
,Z sution Laws of Caf rmia D tc 5�_x 1 WATER BEATER W/VEN VRLECTR G 1 r FEE
O O Appllcont ^-
�y NOTICE TO APPLICANT:If,efts making this Certificate of Exemption,you should WATER SYSITIMUREATING
abecame mbject no Ne Workers Counteraction provisions of the labor Cole,you must SOILS RE
{17 fonhwith comply with such provisions m this Pewit shall be decreed revoked. WATER SERVICE
Q PAI
CONSTRUCTION LENDING AGENCY NEW RES[DIiNTlA1.PLMB. SQ.FT. Dam Receipt#
V 0 l hereby affirm that is a con tm lion lending agency for the performance of
Hs �+ the work for which this permit is issued(See.3097,Civ.C.) TO L
O VLender's Name
fbI TOTAL:
LeWer's Address
1yyr G 1 o mfy that I have read this application and slate that the above information is BUILDING FEC
Gw V7J correct.l agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL.PERMIT FEE SKIS FEE
V G building maturation.and hereby aathodzc rcpresenmtivea of this city,.enter upon am n
above.mentionW property for inspection purposes. PERMIT ISSUANCE 4 FILE E
(We)agree to save,indemnify and Kest,hatches,the City of Comedian against
liabilities judgments,costs and expenses which may in any way accme ecinectiend City ALTERORADDTOMECH. PLUMB[ FEE
in consequence of Ne geeing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(In 10,1100 CFM) MEC CAL FEE
f
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 111,000 CFM) C RICTION TAX
J, �( 5/D,L�d s-i3-tis
Si awre of Applica C.m DO Dalc EXHAUST HOOD(W)DUCT) HOUSIN 'MIT[CATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WIII,he applicant no lumra huilJng oecupam.vmrc nr hendlehmaNnm amoral HEATING UNIT(TO IIN),ll[X)B'I'UI
os defined by the Caperton Municipal Code,Chapter 9.12.wd rite Health sad Safety HEATING UNIT(OVER 100,000 BTU)
Cram.Section 25532(x)7
'yes No VENTILATION FAN(SINGLE RESID), PAID Dam Reeeipt#
Will the applicant or future building occupant use equipment of devices which BOILER-COMP(3HP OR 11X1,1100 BTU)
mit hazntdnus air contaminants as defined by the Bay Arca Air Quality Management 'A[
Distrm' BOILER-COMP(OVER 100.000 BTU)
❑Yes ❑No
I have mail the hazardous materials requirements
CONDITIONER ISSUANCE DATE
under Chapter 6.95 of the Cali- n
fomin Health&Safety Code,Sections 2.5511.5,25533 and 2.5534.1 undeend that if the NEW RESIDENTIAL MECIL SQ�FT.
buildingdoe ncmrcntly hav t¢nutn tlia,,qP ismymspnnsimhilitymnmify Nc..p.11
ofth a encsw In I h p' in11 exofa Cmifiegid Oc ,
neon um.dzWu t Dae T ISSUED BY:
OIFFICE