S 0455 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING.ELF.CRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONAPERMIT rLUMnwc.MECHANICAL S 0455
BUILDING PH JKCP IBEN'1'IFICATION
NIIILDING ADDI31155: SANITARY NO, APPLICATION SUIIMITI [
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T. PHONE: BUILDING PERMIT INFO
❑ Consultant Fans Paid by Applicant(Initial) BLD ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARA]'ION QTY. ELECTRIC PERMIT FEC JOB DESCRIPTION
oda,affirm that I am licensed under provisions Of Chapter 9(commencing
{O WZ ivision 3 ofthe Business and Professions CMe,and my license is RESIDENTIAL
FOOceundeB'ecl. PERMIT ISSUANCE 0SFDWI ❑KITCHEN REMODEL
ouZ� License Class Lic.11 APPLIANCES-BESIDES I'[At, ❑ADDITION ❑PLUMBING RIiPIPH
Date Contractor El MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
piny PANELS MODIFICATION
OZ—'Z lundermmnd my plans shall be nxalmpuhlic.,a.,an].,nUPTO200AMBS
❑INTERIOR ❑CHIMNIiY REPAIR
Licensed Professional 201d00AMPS IMPROVEMENT C]SWIMMING POOLS
Y2; OWNER-BUILDER DECLARATION OVER I(NNIAMPg ❑BATH REMOD IJREPAIR ❑DE f01ATION
L C Q 1 hereby sffrm its,I um esanpt from the Cnmoemr's License Law for the L1 EATER �`L
x068r fallowingreamO Sopme7031.5,Bmmessand Ponfiroses Code:Any city or mm.ty SIGNSEL13MICAL
F ig t. which n,.ima a permit ut consvuc,,titer,unprowe,demolish or repair tiny xmtemre �"k p�T✓
prior to its issuance,also requires the applicant for such Permian file a signed statement SPECIAL CIRCUIT/MISC.
} that he is l]cemedpunum
dn, ate provisions st ile Commmnrx Licenm Law lChaptcr9 COMMERCIAL'
W (commencing with Section 7000)of Division 3ofthe Businessund Professions Cwld or TIME MITER OR POLE]MST.
6 o K that he is exempt demount and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y
Section 7D3 1.56yany applicant nor ape.it,nhjlll the oppliconuoa civil penalty of POWER DEVICES ❑TENANT El FOOD SI?RVICP.
F m mire Nan five hundred dollars(5500). IMPROVEMENT
p I,as owner of the propeny.mmy empinycex with wages as their sole compenstion, SWIMMING POOL ELECTRIC
F1 OTHER
will d0 the wink,and the sbuetum is not intended oroRered for sale(Sm.]OW,Business
and Professions Cn It,The Convucmr's License Low does not apply m an owner of OUTLETS-SWI'(CIII?S-ITXTU RES
a' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or(offerd efar NEW RESIDENTIAL IiLF.CI'R SQ FF.
sale.IL however the building or improvement is sold within one year of completion,the SQ. A - so PT.
ser-huider will have Ne hdNen of proving thou he did notional or improve for psr-
[D 1,a sowne SEP 5 ECI
1,a.s owner stile pmpeny,sun exclusively contracting with licensed cnmrvctors to TOTAL: Il' ssk.v
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE pr CUPERZINO
who contracts forsechprojects with ecentra taro Iicensedpursuanuntbe ContractorCITY's V I I
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this reason
ALTER-TRAIN&VENT-WATER(EA) d VALUATION
Owner ❑am iq AlLD , Q
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CI'.DEVICE LL/1 C ULD'
')r-
1 hereby off rat undo pe^nhy of perjury one of the following declarations:
❑I have and will maintain a Cerificata of Consent to sdf-insure for Workers Camped- DRAINS-FLU OR,RODE,AREA,CONE. STORIES TYPH CONSTRUCTION
nation,n,provided for by Scclinn 3101 of he LtiMr Colo,for the perfom ore of the
work for which flux penin is issued. FIXTURES-PER TRAP
❑ I have and will motion.Workers Compensation Insurance,os required by Senior
3000of the[.be,Co e,f0rfhepcdomat <(the workfor wIt lithole if sissuen. GAS-EA.SYSTEM-1 INC.4 OUTLETS (OCC.GROUP APN
My Wor}+is ff. satin mncee 'er anJynlicy nu
Came folic No. GAS-EA.SYSI EM-(OVER 4(EA)
CERTIFICAMOPEXRMPI'ION FROM WORKERS' GREASIJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING OrvisioN FEES
(This section need not becnmpleted if the pomtit isfimone hundrtdd(oIlars 15100) GREASETRAP
or less.) PLANCI{f:CK IliE
I certify that in the Performance ofthe work ferahich his Permit iso,4lshall SEWER-SANITARY-STORM EA.201 Fr.
sol employ mry pe m i any man a as to become suhlem to 1 ,ttp�- ENERGY 17EE
z porion Laws of Uam WATER HEATER WNGNT/IiLECTR
z Applirm, GRADING FEE
NOTICC TO APPLICANT:If,after sun ung thix Ceni of Exemption,you sh(ovld WATER SYSTEMYTREATING
a ; become subject to the Worker's Cumpcnxalinn. sof he L.Nor Code,you mu.n SOILS FEE
W forthwith comply with such provisions m Nis pecian shall he doomed revoked. WATER SERVICE,
z CONSTRUCTION LENDING AG17NCY NEW RESIDENTIAL PLM9. SQ.Fg PAID
L) Q 1herehy affirm that is acon.sductinnlending agency for the performance of Date Receipt no
I, f" the work for which this Permit is issued(Sec.3097,Civ.C.)
O U lamiName - TOTAL:
Lender's Address TOTAL:
Uy I certify that 1 have read this application and state thin the above connotation is BUILDING FEE
h amen.l a gree m comply with all city and county ordinances and smte lows relating n+ QTY. MECHANICAL PERMIT FEE 5
(,) building construction.and hereby vmhoriu tepseaedtadves ofthis city to enter upon the SEISMIC FEE
above-intentioned pmpeny for inspection purposes. PERMIT ISSUANCE
(we)agree to save,indemnify and keep hamtlew the City of Capenino against ELECTRIC FEE.
Pralines,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH, PLUMBING FEE
in consequence oft granting of this permit.
APPLICANT UN 1,,kI N AND WIhL C(�(dPLY WITH ALL NOv-P INT AIR HANDLING GotI(TO 10,(00(CPM) MECIIANICALPEE
SOURCL .IU .TIOIJR. ! ,I
YAIR HANDLING UNI'T(OVER 10,000CFM) CONSTRUCTION TAX
Signature of APPlicen1lCommcmr te EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MA DISCLOSUR,
Will the applicant or future buil supan,smre or handle ha ardour material HEATING UNIT CFO 100.00(1 BTU)
as delined by,he Cupeninn Municipal Cad,Chapter 9,12,and the Health and Salety -
Cole,Section 25532(a)? HEATING UNIT(OVER 101.001 I{'rU)
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID
Dam Receipts
Will the appllcanl or future building(occupant use equipmcm rF devices which BOILER-COMP(OHP OR 100,(X10 BTU)
emit haeurdrdx air contaminants as defined by the Be,Area Air Quality Management TOTAL: 177,60
Dvamm�'
❑Yex ❑Nn BOILER-COMP fOV ERR 101,001 BTU)
I have rend the hvundeus materia,rryuiremems under Chapter 6.95of the Cull- AIR CONDII OON ER ISSUANCE DATE
fomite Health&Safety Cale,Sections 25505,25533 and 25534.1 understand that drop NEW RF.SIDENIIAL MECIL SQ.IT.
building docs not currently have a report,that it is my rtxptmsibilify,to n nify the occupant
of the qm
uireems which must beater m et Prior issuance of u Cedificm¢of Occupancy.
Owner or aroloored ages, Dale TOTAL:
rcISSUIiD BY: q�5�g7
OFFICE