29663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MF.CHASHCAI,
BUILDING PROJECT IDENTIFICATION 29663
ILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL ONE
0220 insula AIll. Cuer-hilo. CA `Isola¢ ')-- I�
4WNE SNAME: PHONE: CONTRACTOR'S NAME: LIC NO.
I S\ l—/ W NIC CONTROL#
•ARCHITECf/ENGINEER: /� LIC NO: 00 ADDRESS: ❑
Fit
PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B EL5CT PLUMB MFA.
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
of@m hal I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OWZ01)of Division 3 ofhe Business and Professions Code,and my license is RESIDENTIAL:
.ta100 PERMIT ISSUANCESCE
I-ty_ d cffcm. ❑SFDWL ❑KITCHEN REMODEL,
ULic.W
6 U APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPITP 4 WalC Cha rletu!
at�GG ARCHITF.CTNECLARATION ❑MULTI"UNIT ❑STRUCTURAL.
FH Z l i ndersmnd mrimmed,y plans be used as public med, PANELS
Z O MODIFICATION
5240 UP T0200 AMPS [I INTERIOR ❑C IMNEY REPAIR
-III Licensed Professional 201-IMAMPS IMPROVEMENT
C C C Q 1 hereby affirm OWNER-BUILDER
am a e1mDERpt oDECLARATION
he Co muctors License Law for the OVER Ica AMPS ❑BATH REMODEVREPAB EMOLITION
aU following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
4+13 4 y which requires a Femel In construct,slid,,improve,demolish,nr repair any sr...In In.
prior in its issuance,also requires the applicant for such Froniuol'M a signed oammanl SPECIAL CIRCUIT/MISC.
,g} that he is licensed......it m the....P nsofdm Conbamors Licene Law(Chapter 9
2 (commencing with Section 9000)of Division 3 ofhe Business and Professions Code)or TEMP.MIiTIiR ON POLE INST. �� COMMERCIAL:
Q.d oO C that he is exempt Iherefmm and the basis for he alleged exemption.Any violation of
x lNL F1 NEW)LUG/AUDITION ❑OFiMOLITION
41 Section 7031.5 by any applicant for a permit subjects the,applicant m a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more man five hundred dollars(S500). IMPROVEMENT
=0 ❑1,as owner ofthe proper,or my employees with wages as heirsole compensation, SWIMMING POOL ELECTRIC
F. will do the work,and thc,amcmreis not intended oroffered for sale(Sec.7044,Business ❑OTHER
W w and Professions Cudm Die Curnmemr's Licenw Law does not apply to an owner of OUTLETS-SWI"MILES-FIXTURES
6 property who builds or improves thereon,and who does such work himself or through
his awn employees,provided hat.such improvements arc not intended or offered for NEW RESIDENT[A],ELECIR SQ ET.
sola If.however,the building or improvement is said within nneycar ofeumpletion.the SO.IM FLOORAREA VSQ,FT,
owner-builder will have the burden of proving that he did not build or improve for put- e
ofsale.). L. �a
❑T.as owner of the properith tm
,am exclusively contracting wlicensed conctan to a 6 19gC
ane
msmuct he project(Sec.7(144,Business and Professit h
ons Code:) e contractor's Li-
claw docs net apply to an owner of property who but Ids or ilnpmves thereon.and QTY, PLUMBING PERMIT s F'Lf Cjj 19
who contracts forech projects with acunnnctugs)licensed pursuant m the Contractor's r V/- L
License Law. PERMIT ISSUANCE Ur lt'I f/f�U
]1 am exempt under Sec. B&P C fee this reaam
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION
. WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVI
1 hereby affirm under penalty of perjury one odeclarations f the following declations:
I have and will Parnmina Cenffica¢uf Cenent msalf-in...efnr Workers Common- DRAINS-I1.001i,RO(IP:ARBA,CO GTORIES TYPE CONST111 UC'I ION
smion,as provided or by Scotian 390 of the Lehi Cade,lin the perfopnaned of the
work for which this permit is issued. - FIXTURES-PE.R TRAP
1 have and will maintain Worker',Compensation Insumnm,as required by Section
3700ofhc labra Coda,for the performance.fhe work for which his .it is issued. GAS-E.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cenicc Policy Nu: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEM PION FROM WOR KERSGRASUINDUS'I'RI,WASTE INTERCI?PIOR
COMPENSATION INSURANCE. R I BUILDING DIVISION RTS
(This secllonnccd not he,completed if the pi is for one hundred dnlle.(U(0) GREASB TRAP
or less.) PLANCIIECK PEE
leviifyhst inhe prumamancedhework farwhichthis permit i,00rtilf1hall SEWER-SANITARY-STORM EA.200 FT.
person not employ any peon in any manner so as to become subject m the Workers'Coni ENERGY FEE
Z section laws of California.Date WATER HEATER WNENETLECTR
Z 2 Applicant GRADING FEE
sr cG NOTICE TO APPLICANT:IF aaer making his Certificate of Excmpdon,you should WATER SYS'1'EMITREATING SOILS FELT
1-� 5+ hecomo subject to ted WadersCmn.cr.ation provisions of the Lubur Craft,you must
forthwith comply with such provisions or this permit shall R deemed revoked. WATER SERVICH
UO ereCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM). SQ.FT PAID
I hbyaffrm that hem iso consuril lerdingagency finhe peAm
omnce of Date Receipt p
the work for which'his permit is issued(So..3197.Ci¢C.) TOTAL:
0 U Lenders Name
{L1 Isnder's Address TOTAL:
1 certify that I have rend this spplicatinn and ahem that the above infurmation is BUILDING FEE b�r
Ncurvet.i agree m comply with all enyand a,army e dinence,and late laws relating m QTY. MECHANICAL PERMIT FEE
U Z building consfircinn,and hereby nuhorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree m save,indemnify and keep bsmtlesa rine City of Cupertino against ELECTRIC PER
Iiabilitito.judgments.cosh and expenses which may in any way accme against said City AUERORADDTOMECH.
PLUMBING ItE
in consequence of he granting of htis permi
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNI'I(OVER I0,000 CFM) CONSTRUCTIONTAX
Signature ofAMlican✓Contracmr Dam EXHAUST FOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lhezpplicant nr future building oeeupantsmreor handle haanNous m.tenal HEATING Drift'T(TO am."BTU)
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Section 25532(.)7 HEATING UNIT(OVER 100.000 BTU)
❑Yes ❑No VE.NTILA'I'ION FANS INGLE RESID) PAID
Doh ReccLIM
Will the applicant or furore balding occupant use Aior devices which BOILER-COMP(3IIP OR 100000 BTU)
emit M1auNous air<onmminants as defined by the Bay Arcae.Air r Quality Management , TOTAL:
Dlstiin7 BOILER-COMP(OVER 101j"BTU)
Cl Yes []No
I have read he hazardous mammals requirements under Chapter 6.95 of the Calm AIR CONDTL'IONER ISS UA NCE DATE
forma Health&Safety Code,Section 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ff.
building dots not currently have alanant[hilt it is my re,nisibilry to notify lheoce.pam
of the requhemmns which must be mel prior m issuance of a Corti Gane of Occupancy.
Uwn<r or authon¢cl agent Date TOTAL: ISSUED BY:
OFFICE