30574 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMI"FNO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROjECI'IDENTIFICATION
BUILDING ^ ' C� r��� - SANITARY NO, APPLICATION SUBMITTAL DATE
W�E G� DI t l � C(NTRACTOE% LIC NO:
!C4uli "i �
NIC CONTROLa
\RCHITECT NGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE BUILDING PI?RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLUG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRA CnOR'$DECf CON QTY ELECTRIC PERMIT FEfi
- 1 hereby affirm that I am licensed under provisionsons oof (commencing 9(commcing JOB DESCRIPTION
„�,aZ with Section 011(Il)of Division 3 ofthe Business and Professions Code.and my license is ,,a��
TIAL
in full faceand elfecl. PERMIT ISSUANCE 3
F�U( License Class Lie.#, - SI'DW15EI. KITCHEN RIiMODEL,
NQ Dale Commere APPLIANCES—RESIDENTIAL. []ADDITION ❑PLUMBING RF.-PIPE
ARCHITECTS DECLARATION El []STRUCTURAL
OY iq Z 1 understand my plans shall be mad os public records PANELS MODIFICATION
�.1 UPTO 200 AMPS
Licensed Professional - - _ C1 INTERIOR ❑CHIMNEY REPAIR
••1 OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
sic
1 hereby ammo shut 1 an exempt from the Contmcen's License Law for the OVER I000AMPS D BATH RF.MODEUREP IR [I DEMOLITION
a6i U Allowing reason.(Section 7031.5,Business and Professions Code:Any city or ammy SIGNS IiLEC'RICAL El 01
WaF which requires u permit to construct,alter,improve,demolish,or repair any structureN.] prior to its issuance,also requires the applicant for such Permit o file a signed statement SP A IRCUIT/MISC.
f } that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter l Oe2 AOL
..CO£ (commencing with Section/00ftef Division 3 ofthe Business and Professions Calc)or SER,
OR POLE INS'I'.
d L
that he is exempt themfrom and the basis for the alleged"inflation.Any violation of
LLXl (_1 NEW BLDG/ADDITION El DEMOLITION
y a.,ane 'him111 by hundreany d
($50 permit suM1jens the applic its, civil penalty of ESt mora Than Ove hundred dollmm(§500), 3s, � ❑TIiNANT ❑FOOD SERVICIiD 1,as ownenrfihc Pn�peny,amy nnployeer with wager ns dfieir so le cs3mpenmtion, OI.ELECTRIC IMPROVEMENTwill do the work,and theruucmm is not intended or offered for sale(Sec7Wa,Banner, ❑OTHER
and Professions Code.The Commcmrs Licence Law does not apply to an owner of ES—FIXTURES'`
a 3.. prepeny,who builds or improves thereon,and who does such work himself m through
his awn employees,Provided that .in improvements art not intends d or offered for ENTIAL LECISQ FT.'
sale.ILhowever,the building or impmvemetn is sold within one year ofcompletion,the SQ.FT.FLOOR AREA §/g Q.IIT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
D 1,as owner of the propeny.am cnddnively mmraming with licensed contortions to TOTAL: #
consumer the poesS,(Sec.7044,Basiners and Professions Gxfe:)'Thc Corrosion's Li. Cp
ase Law does not apply m an owner of property who builds or improves thereen,and QTY. PLUM PERMIT FEB SEP 181996,
whocontmeta forsuch pmjeats with a conuactorod Licensed Farman ua rhe Costmctors
License law. PERMIT ISSUANCE
C]I am exempt under Sec. ,B&PC for Nis reason I s s � • • '••`
_ ALTER—DRAIN&VENT—WATER(EA)
Owner Dam VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declamations
I have and will maintain a Cenificate of Commntto self-inmee for Worker's Compton. DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE GONS'IRUCTIGN
ration,as provided far by Section 37M of the Lather Code,for the performance of the
work for which this permit is ismed. FlXTURFS—PCR TRAP
F11 have and will maintain Workers Compensation Insurance,as required by Section
37M of Ne lallo Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AI'N
My Worker's Compensation Insurance carrier and Policy number m'e:
Carver: Policy No.: GAS—EA.SYSTE NFOVER 4(11A)
CERT IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR
('this section need not be completed ifthe permit is torose hundred dollars(§IIX0 BUILDING DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I cenify that in the performance ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FI'.
not employ any person in any manner so as to become subject In the Workers'Compton- - ENERGY FEE
xmmr Laws of Cr1i1!,na .Date
O Applicant WATER HIIAIER WNENT/ELECI'R
PP GRADING FEE
h NOTICE TO APPLICANT.If.after tanking this Certificate of Exemption,you should WATER SYSTESIG"REATING -
a ; become subject to the Workers Compensation provisions of the Labor Cede,you must
forthwith comply with such provisions.,,his SOILS PEC
4 0 permit shall M deemed revoked. WATER SERVICE
UO CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
I hereby uffnn hitt Nere isaconsuuction lending agency fnnhe performuncc of Date Receipts
Lar P the work for which this peroral is issued(Sec.3097,Civ.C.)
0 U Lender's Name _ - TOTAL:
H yLenders Address TOTAL:
1 cattily that I have read this application and state that the above information is BUILDING FEE
TA correct.l agree to comply with all city and county ordinances and state laws hitting In QTY. MECHANICAL PERMIT FEE
V building construction,and hereby audience representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agroa m save,indemnify and keep harmless the City of Capeniso against - ELECTRIC 193E
lohllities,judgmcnts,todamid oxpense,whiehnnymmi,way acme nguina said City ALTER ORAllDTO MECH.
in nugmeuae of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER BLOOD CFM) CONSTRUCTION TAX
Signature of Applicant/Contmcmr Data EXHAUST HOOD(W/DUC'q HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theipplivam or famre huildingnccupant store or handle hncardoes Guiana] HEATING UNI'f(TO 100,0110 RT U)
as defined by the Capetian Municipal Cade,Chapter 9.12,and the Health and Safety '
Code,Section 25532(a)'7 HEATING UNIT(OVER I00,IX10 BTU)
❑Ycs FINo
- VENTILATION FAN(SINGLE RISIII) PAID
Will the applicant nr future building accmlam use equipment air devices which Dae Receipt a
emit hazallous air contaminants as defined by the Bay Area Air Quality Management BOILER—COMP IMP OR 100,000 BTU)
Diarier? TOTAL:
D Yas ONo BOILER—COMP(OVER 100,000 BTI])
I have mad the hnaallous materials mquiremcms under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fomid Health&Safety Cala Snot.25505,ismyand25534.I understand thatif Ne NEW RESIDENfIAI.MECH. SQ.FT.
building does tr iscurrentlych have a tenant,that n is ni responsibility t notify cc nccupum
of the ha7oirtmcndx which must be met pnono issuanceof a Crnificme of Occmpancy.
Owner m-mil nnud ike nt Date TOTAL: ISSUER IIY:
OFFICE