99110095 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C C�Y OF CUPERTINO BUILDING-ELECTRICAL
I
UILDING DIVISION �PPLICATION/PERMIT PLUMBING-MECHANICAL
"m,LDINGADIjjbESS BUILDING PROJEd7F IDENTIFICATION SANITARY 10 MITTTIDATE
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4WITTECT71INGINEER: TIC NO, ADDRESS: ID
CONTACT PHONE BUILDING PERMIT INFO
E:1 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El El R1 1:1
LICENSED COND RACTOR S DECLARATION ELECTRIC PERMIT
M=z I hereby unreal that I am licensed under provisions of Chapter 9(commencing Q:ry FEE JOB DESCRIPTION
WOO with Seat 700I)a!Dickina 3 milli,Bmirlaxamd Predfiessim,Code,and an,ficarnicas PERM] ISSUANCE
F.I— infuliforecand f .
�U'u Liectsecla" SFDWI. C1 KITCHEN REMODEL
F.Z W Datc APPLIANCES-RESIDENTLAL OADDITION Ll PLUMBING RE-PIPE
F, AficUrrECIS Ii PANELS EIMULTI-UNIT El STRUCTURAL
,"'a "a
zoiolz I andersuand my paal�shall It do,. mucoarmid, MODIFICATION
____4-a UP T020nAMPS D INTERIOR C1 CHIMNEY REPAIR
W I-mr.'al Professional
201-1000AMPS IMPROV17MENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
I hereby affirin met am exempt from the Contractors License Law fich, OVE
_2M INSAMPS 1-1 BATH REM
aDELIREPAIR DEM LITION
, t /;,
X0 U following rection.(Section 703 1.5.Business and Professions Cook:Any city or county SIGNS ELECTRICAL OOTHER 341014/" "LAS iiv�
a.I" which requires a Permit in constract,altc�improve,demolish,or repair
0 my smarome Is isil' !+2
Time to its issuance.also requires the applicant for such Permit to file a almost statement SPECIAL CIRCUTUMISC.
that he is licensed paration to the provisions(if the Contractor's License Law(Chapter 9
W.M 7
C) (commencing with Section 71100)of Division 3 ofthe Business and Protectionist Core)or TEMP.M17ER OR TOLE INST. COMMERCIAL
P= that ficus exempt duaref..in ad he basis for the alleged exempron.Any violation of — [I NEW BIDGIADDITION E:j DEMOLITION
Section 7031.5 by any applicant for a pararl subjects the applicant to a civil penalty of POWER[)TV []TENANT [I FOOD SERVICE
nad...thm five Formed!dollars ICES 011,
0 1.ra;owner of the property,or,my employees is it wages as their We compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended vacuumed!for We(Sec.7(vi Business — []OTHER
W and Profics,min Cei The Communities License,Law does not apply to an maxper of OUTLETS-'SWITCHES-FIXTU�
poopeny who builds or irlipmeciv thencon,and who does such work himself or through —
his own employees.provided that such improvements am not intended or offend fin NEW RESIDENT I"TLECTR Ir e
sale,If,hmxcncr�the building or improment is sold wiffifin on,car of completion,the — SQ.FT.FLUOR AREA $?SQ IT.
mvqvrbm1hqwill have the burden of procip,that he did no,Wild or improve for per- IF asa,
posse of sale.).
0 1,as owner of the poTafty,am exclusively emanating with licensed contractors to TOTAL. 41!_" L,3y=N11 7 19 �9
construct the project(Sec.7oTL Ifivincts and Professions Cm1a)The Contractor's Li-
ecrove Law does oul apply to an owner of property w W Im Ids or i mproves domon,and QTY. PI.UMBINOPEPmrr',.; FEE
who contracts for'nah"odee,,f,a ciontruclons)licensed Function to the Contractor's I
Licee'a Low. I PERMIT ISSUANCE
1 11111 exampa allual Sal. —,IT&P C]or this ra...... —
ALT17R-TRAIN&VENT-WATER UIA)
Date— — VALUATION
WORKER'S COMPENSATION DECLARXI[ON BACK FLOW PROTECT DEVICE
I hereby attain kinder Penalty of perjory one ot the following declamations: —
I haveand wi I I maintain a Cendievate of Consent it)valf-insure for Worker's Coaqen- DRAINS-FLOOR.ROOF,AREA.COND. I STORIPq
sation,as provided lot by Section 3700 of the"hot Coste,for the performance of the — TYPE CONSTRUCTION
weak far whi,liflus Fmout I,issiad. VIXI ORES-PER TRAP
0 1 have ad vvdI mainland Worker,Coarderectican Train....al as required by Secom —
37M of the Lataor Code,for the farpormance of the work for which this pervall is issued GAS-EA,SYSTEM-I INC.4 OUTLETS OCC,GROUP
st"Workers C4i��mon Ins arraccefixamilPidic,conadval-cure: I
fic, _ . a' I cc Is.ficyN.AdOtf- R12 GAS-PA.SYSTEM OVER 4 PAT sv
"CAII k11n71'EMPT[ON FROM WORKERS�
COMPENSATION INSURANCE GREASEqNDUSTRL WASTE INTERCEPTOR
Chi,casum remain Ive riontrEad ifthe pecrit I,fortune hundred do[].pi UK) BUILDING DIVOTO
or Ic,T GREASETRAP PLANCHECK HE
I sanity that in the Performance ofthe wark for which thispernmi is ismad.I shall
not employ any parent in any mareser so as to Ivecome subject to the Worke".Cmeoper- — SEWER-SAN]TARY-STORM EA.200 FT, ENCROYFEE
C) Z sation Laws of California.Date
z 0 pplinal I WATER HEATER WNENTIELEM GRADING FEE
Ela� NOTICE 10 APPLICAN'p If, fic,oulkintitflux Canifi,,cle of E,amplim.you should WATER SYSTE1,19REATING
5 become subject it)the WoToc's Compensation provisions afthe Labor Code,you most — SOILS FEE
forhexull comply w ith such provisions or this permit shall be deemsed mccLed. WATER SERVICE
z CONS I RUCTION LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.IF PAID
U 0 fluarelfilimfinualatt... Date Receipt If
lon work f which hi,Peanuil is "and(Ser.3097,Cie.C.)
Leader's Name TOTAL
U Truck, Addei, TOTAL
I verfify,forl I have rand hi,application ad late man[be above immucali'm is BUILDING FEE
r (Z) comact.I it,.a,comply all idl any and.,.my duarce,and sude laws reining in QTY MECHANICAL PERMIT
) Z buildfic'elmonactilm,sualkench'anuhloile 1 . 1 - I sEISMIC FEE
move-onsectiorad prolverdy tarmopelim porpoxal. PERMIT ISSUANCE
(We)agma In...a,indemnify md keep harralle,sda City of Caperton agairst ELECTRIC FEE
liabilitict.judgments,costs and expenses which may in my way averve against said City
in consequence of the granting of this Permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO to."CFM) MECHANICAL,[TIE
SOD
go, AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
6lifiature ii/Applicamocontractor Lane EXHA UST HOOD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE — HOUSING MITIGATION FEE
Will the,lificter,or too..building oce.pern some or handle fiscrarmils material HEATING UNIT(TO 100,000 BTU)
as defined by the Culverfirm Municipal Code,Chapter 9.12,and the Health and Safety —
Code,Section 25532LO? HEATING ON]T(OVER 100,000 BTU)
E]Yc, rjNa — VElH1LAHON PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or device which Date ip,
Out Taormina air cont....mare,a,defintal by he Bay A.Air Quality Management RUH'ER-COM POHP OR 1 I'Lood RT1D
District' TOTAL xvi
Fl Yes Ej No BOILER-COMP(OVER 100,001)BTU)
I have mail do,he...lot — AIRCONDIIIONER ISSUANCE DATE
famic Health&,Safety Cadc.Sceiiims 25505.25531 and 2.5534.1 underviand thatut he NEW RHSIDENG Al.MECH. SQ.FF.
building fices ran mrantly have a comn,Ill.,,it is myne......biliq mnamu"Inc.coqual —
of,hem,airannem,vehicanmi,hunnal Prior 1.ivannea cf,i Caftifieste or Oexa,me, 1" -7
Owra,.ram1um,ad again Dole TOTAL: ISSUED BY,
OFFICE