27459 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO -E TCTR"G . PERMIT NO. 7 5
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRCSS: .a ; SANITARY NO. APPLICATIONSUBMITTALDATE
2c UNIT1 LOT L
OWNFiRII Ngpp� ,.S PHONE: CONTRACTOR'S NAME: LIC NO: 1 7
NIC CONTROLp
• ARCHITECT/ENGINEER: LIC NO: ADDRI
CONTACT: PHONE: ❑
ELECTRIC,PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB !.TECH
PERMIT ISSUANCE F-1 71 slTplx
\ LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyZ I hereby affirm that i am licensed underpmvisimsefChapter9(comtnencingwith JOB DESCRIPTION
POO Section 7")of Division 3 of the Business arm Professions;Code,and my license is in PANELS
full force and effect.
<Z License Class Lin,It IIP T0200AMP5
r~n GaZito Date Contractor 201-1000 AMPS
Z8y3 ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.PT.
OZ—GGGG]]]] I understand my plans shJl be used apublic records.
C^ SIGNS ELECTRICAL
CgiY G3 Licensed Professional
K� art Ino-exemptE..the CRATION SPECIAL CIRCIRT/MISC.
,,ten I hereby n.(Se Nat 1 um exempt from the Conines Ca License Law for the
W 3 on¢I Which req uirson.(Sretim 7031.&Business end improve.
caiam Code:My city or rounty TEMP.METER OR POLE WST.
tgJOyM which mquirtsa permit to construct,alter,Improve,demolish,file
repair smy igned
Wment
B�00 thtemiacensedIssuance.pursuant
surequires the o the Provisions
of
fthsuch Permit fileaai La statement POWER DEVICES
y)�apK 9(o. islicensedwith
Sectio 7")of
Division
3 of dontnnors License Law(Chapter
a Oo0. 9(catr he is exempt therefrmandthe Division Sof do,Businessixemand.Any vons Code) SWIMMING POOL ELECTRIC VALUATION
orthat y_y
Section 7031.5
by myapl'romandthe bvsiafmthects decd exemption. civil plationof OUTLETS-SWITCHES-FIXTURES
F3Q
not
than fivehundred
cantfor.$500).taubjaa the applicantmecivilpenalty of
not mortownuofhepm dollarmyem). NEWRFSTDENTIALELECIR _SQ.FT. STORIES TYPECONSTRUCTION
❑ I,aawnuofthepropeny,ormyemployttswithwagesastheirsalemmpmsetion.
d will dmhe work,C d e:The Cum atot is License
Law does not
apply.9044,Business
and Dofessipv Code:The Contrmtols License law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through Na
employees,provided that such improvcmemsme notimendedoroffered forsale.If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yemof<omplaim,theowner. TOTAL:
builder will have the burden of proving had he did not build or improve for purpose of
a❑)1,as ownerofthe propertsen tr
y, exclusively contracting with licensed conectursto Q, ,,' .tpi - 'PLUMBING PERMIT FEE FLOOD ZONE "Nanswct the project(Sm.7044,Business and Preparations Calc:)The Contmctola '
License Lawders not apply tom ownerol'property whobuildamimprovestio cem,and PERMIT ISSUANCE
who commas for such projects with acommaor(s)licensed pursuant satin Cmrmcmra
License Law. ALTER-DRAIN&V[WT-WATER(EA) FEE SUMMARY
OUTSIDE FEIIS
❑ I am exempt under Sm. ,B&P C for this reason BACK FLOW PROTECT.DP.V SANITARY Y N
Owner Dee INS-FAR . RFCEIP #
WORKMAN COMPENSATION DECLARATION
SCHOOLTAX Y N_
❑ Thereby affirm thatlhnve acertificate of coneentm self-insurt,orecmi0cete of FlXTU .PER TRAP RECEIPT#
Workers Compensation Insurance or a mrtifieimpy thereof(Sce.3800.LmCJ which PARK FEE Y N
covers all employee's under this permit. PAS-EA.SYSTEM- INC.4 OUTLETS RECEIPT#
Policy p BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(RA) PLANCHECK FEE
❑ Certiiedcopyishmebyfumished.
❑ Certified copy is Glut with the city inspection division. GREASFJIN TRL WASTE INTERCE OR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WOR S' G P SOILS FEE
COMPENSATION INSURANCE
(Thissectimneednothecomplet ifthepmitisforonehun Adoan(1lW)) E SANITARY-STORM EA.200 ENERGY FEE
m less)
I certify that in the performaxame of the work for which this pc it isiss WATER HEATER W/VE ICTR
not employ my person in my manner m as so become eubja 'to tl PAID
Z
Compensation laws of California. Dem WATER SYB Date Receiptp
Applicant
z� 0 NOTICE TO APPLICANT:If.after making this Certificate of Exe prion,you o to NEWR SIDE AL PLMB. SQ.FF. TOTAL:
t-I (q become subject to the Workers Compensation Provisions of the Leb rCmde,yo ua
Ix > forthwith comply with such provisions or this permit shall be deem drev.14 BUILDING FEE
0. [� CONSTRUCTION LENDING AGENCY SEISMIC FEE
U z I hereby affirm that there is a cone aim lending agency fm .Pa .
of
O the work for which Ws Permit is issued(See.3099,Civ,C.) TOTAL: ELECTRIC FEE
Lender's Name
0 F� Lender's Add.. QTY.-ii MECHANICAL PERMIT FEE PLUMBING FEE
LUI I certify thst 1 have teed Ws agri iestian anti some slat the a ve information is MECHANICAL FEE
correct.Its".he cmmply with all ci ceumy ordinances ends elawsrclmingto ERMIT ISSUANCE ��
�-' buildingeonstruction,earth It th erepmacnadvea of this ci tommr upon the CONSTRUCfIONTAX
U Z above-mentioned pmperty fm' span puryoua. ALTER OR ADD TO MECH,
(We) m ave.in m d keep mm�lea the city of Ca um.,an
linbilities,judgm e,cos sea sghich may in an a8ui ity AIR HANDLING UNIT(TO 10.000 CFM)
inconsequence of ng a
AIR HANDLING UNIT(OVER 10,1100 CFM)
grata U "we're Dam EXHAUST HOOD(W/DUCD PAID
H RI M TERIALSDISCLOSURE HEATING UNIT(TO IOO,WO BTIf) Dnre Raeiptp
Will the applicant turn buil ngmecupmt is
or handle havammus materiel HEATING UNIT(OVER IW,IXp BILL) OT
as defined by the Ceperti Municipal Code,Chapter 9.12,and the Iledth and Safety
Code,Savu.25532(x)? VENTILATION PAN(SINGLE RMID)
❑Yes ❑No
ISSUANCE DATE
Will the applicant refuturebaildingnecupmt useequipmentordevicawhichemit BOILER-COMP CHIP OR 100,000 BTU)
hicandom air contaminants a defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU)
imict? ❑ P A 1 D
Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. I1
I have mad the hasardous materials requirements under Chapter 6.95 of the
California Healsh&Safety Code,Section 25505,25533 and 25534.1 undersand that JAN 0c:
1995
if the building does not currenthave a Mount.that it is my responsibility to notify the -
occupant of the requirements which must be met prior to issuance of a Certificate of
u,Pancy' CITY ur
Owner miniaturized agent Date ISSUED BY:
OFFICE
e
®� 10300 Torre Avenue
Cupertino,CA 95014
taperti-no Building Division
(408)777-3228
(408)777-3333 (fax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--I have and will maintain a certificate of consent to self insure for worker's compensation,
as provided for
--I have and will maintain workers' compensation, as required by section 3700 of the
Labor Code, for the performance of the work for which this permit issued. My workers'
compensation insurance carrier and policy number are:
(this section need not be completed if 0w permit is for$100.00 or less)
--I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at to become subj c o t rkers' compensation
provisions of Section 3700 of the Labor Code, I shall fort c n I w, ose
provisions. Date Applicant:
by Section 3700 of the Labor Code for the performan t e f c 1 this permit
is issued.
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN
SECTION 3706 OF THE LABOR CODE, IN'T'EREST AND ATTORNEY'S FEES.
0