27765 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
DING-ELEC MMA PERMIT No.
CITY OF CUPERTINO PLUMBING-MRCIIANICAL 27765
BUILDING DIVISION APPLICATION/PERMIT
HUILUINI:PROJECT IUENfIFICAT'ION
BUILDING ADDRESS: y� s� /k a1 ff�� SANITARY NO. APPLICATION SUBMITTAL DATE
104 ,15-Z,'ba, ANZA 6`VgJUNIT# LOT.
OWNERS NAME: PHONE: CONTRACTOR'S NAME LIC NO: NIC COMTROL#
I.VC,bc S+o4.es T_A+l j,"0 0ti* N EL¢eT Io
�ARCHIIECT/FNGINEER: LIC NO: ADDRESS:
3. o 3 tD - �• 941to
CONTACT: PHONE: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DF45CRIP190N F
amz IherebyaffrmthatIamlicensedunderprovisimsofatipter9(commencingwnb :CK S44(I `/�(I\ Z,p A
P100 Section?Wdq of Division 3 ofthe Business and Pmfessiom Code,and my license is in PANELS
y W' full fore and effc
<U Licen=rclar Lie.a �IOI G`ll uPTo 20oAMP5 GI QCV(FS �Od ATh I110sIf
v~ Date /D came. "4 AVO 201.1000 AMPS
F.y Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA I/SQ.FT.
Z O ver— I understand my plans shall be used as public records.
OZ 0 SIGNS ELECTRICAL
<4� Licensed Professional
ecy=< OWNER-BUILDER DECLARATION SPECIALCIRCIBTAMISC.
Diu I herehy affirm dem I nm exempt from the Contractors License Law for the
'3 W rFja following reason.(Station 7031.5,Business and Professions Code:Any city or county TEMP,METER OR POLE INST.
t,�-o which requires a permit to consumer,alter,improve,demolish,or repair my structure
T� priorto its iswance,also requires the applicant forsuch permit to rile o signed statement POWER DEVICES
a0 that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
aao� 9(c.mmencing with Section 7")of Division 3 of the Business and Endicott...Code) SWIMMING POOL ELECTRIC VALUATION
,-y onhm he is esompa therefrom and rhe basis for the ellcged esemption.Any violation of OUTLETS-SWITCHES-FIXTURES
r 4 Section 9031.5 by any applicant for a permit subjects applicant the applicano u civil penalty,of
r more than five hundred dollars($50(b.
eS❑ NEW RESIDENTIALELECIR _SQ,PIP. STORIES TYPE CONSTRUCTION
K m n❑ oma .,,.hdth stanch.rmyemtended withwagesasaleiSee.70mpnwness
will dothewons andthe sumaureisnm's License
Law dhoal forsdupplytoan Business
and property
who
hiobu builds
Coale:The Convectors License law doe.not apply f rt owner of
propenywyees,pdvidedtmvnNimprovrJwh.dmssuchwoh himulfm through his OCC GROUP RES.UNITS
own employers,provided that such improvements son,not in¢ndedoroffered for safe.IL
however,the building ormaprovement is sold within one yearofcompleion.theowner- T TAL:
builder will have the burden of proving that he did not build or improve for purpose of
sale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[3I,us owner nftneproperty,ameaclusively commcting with licensed convacmrs to
construct the project(Sec.7044.Bminaa and Professions Codc:)The Contractors PERMIT ISSUANCE
license Lew docs not appl y ro m owner of progeny who bui Ids or improves Neu.n,and
wh.convnex forsuch projects with ncomrectot(s)licensed pumuantto the Contractor's ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
License Luw.
❑ 1 am exempt under Sec. ,B&P C for dna reman BACK FLOW PROTECT".DEVICE UTSI
SANITARY YN
Owner —Dans— URAINS-FLOOR.ROOP,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
�. Ihemby afdrtn thmihaveettnificem ofconsmn.self-insure,ora aenificme of FIXTURES-PER TRAP RECEIPfp
Workers'Com tion Insurance ora certified copy thchan(See.3800,Lab C.)which RK FEE Y_N PA
pense RECEIPT#
covers ullemployec�'s1u.dST tLii O, GAS-EASYGGTLETS
Polity# l •((yyV _ ,... BUILDING DIVISION FEES
Company L•MLr� jv � S-RA.SYSTEMOVER4(EA TLANCHECK FEE
Certified copy is hereby furnished.
Certified copy is fled with the city inspection division. I 0RU"Q&SXRLjk16IR gRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' j GRdrr, A Rov ) S hS FEE
COMPENSATION INSURANCE 11
This aemion need nm be compleed Bass permit is forom hundred dollen($100) •y EW )ANITARY .2 GY FEE
or less)
I certify than in the performance of the work for which this permit is issued,Ishall 1 ATERIIIATF.R .E= j
not employ my person in my mourner so u to became subject to Ne Workers y - `PAID
Compenmtitioaw.of Celii'mit. Dam TEES EATING .:'>✓ Dae Rmeiprp
O z Applicant s T • .....n;::
z NOTICE TO APPLICANT:IL after muking this Cerdfucme of Exemption,you should 4 N RBSIDEMIIAI}PI Y9 SQ 1-7. TOTAL:
F f/1 become sunjeet m the WmArra Compcnsadm provi.iom of the labor Code,you must gassy„•..
foMwith comply with such provision.or Nis pemdt shall be domed revoked. BUILDING IEE
0. (,� CONSTRUCTION LENDING AGENCY SEISMIC FEF.
I hereby affirm that the.I,.consmrction lending agency for the perfomtmtt of
U z civ.c.>
TOTAL: ELECTRIC FEE
U O me work rte which this pert..is issued(s«.709],
Lmdm's N. PLUMBING FEE
0l- Lenders Address QTY. MECHANICALPCRMIT FEE
U I certify that I have read this application and move than the above information ix MECHANICAL FEE
>. correct. Iagree to comply with all city and county ordinances and male laws misting to PERMIT ISSUANCE
fn buildingconswcrion,and hereby authodu reprucnudva orthiscity lumber upon the CONSTRUCTIONTAX
U .hove-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,com.and expenses wNch may in my way mems,against mid City AIR HANDLING UNIT(TO 10.000 CFM)
in consequeYYYpceee� fthu.grmd.gofthispemeit.
-nos _ '3—I —p� AIR HANDLING UNIT(OVER 10.0110CFM)
Signature of ApplicanJContmctor/�/� Da. EXHAUST HOOD(WIDUCI') PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IN."BTU) Date Receipt#
Will the applicant or future building occupant stem or handle h¢mdous material TOTAL
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety lIEATING UNIT(OVER 100,000 BTU) L:
Code.Section 25532m)? VENTILATION PAN(SINGLE RFSID)
❑Yes gNo ISSUANCE DATE
Willtheapplicunmrfum.buildingoccupant mwegminummordevicenwhichemh BOILER-COME(311POR 10,0WRTU) n
bM
uaous air contammw
inas defined by the Bay Area Air Quality Management BOILER-COME(OVER IM."BTU) r A i D
Distinct?
❑Yes 'I No NEW RESIDENTIAL MECH. SQ.IT. MAR I have read the nonetheless materials requirements under Chapter 6.95 of the MA • 1 7995
CJifomio Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that
if the building does am currently have u tenant,that it is my responsibility to notify the co
occupant of the requirements which mum od me prior to issuance of a Certificate of Ur uurtH IIIINC
Occupancy. � #�/I_ _ 3-t- 757C 'iia
Ownernrouthodredagent Data TOTAL: ISSUED BY: �J/kFL_/IM1/11
OFFICE
I
® 10300 Torre Avenue
6 ('ilk nl• Cupertino, CA 95014
IuttpC]'i,'ino 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 worjors'
compensation insurance carrier and policy number are: W C ( C�UtOn
(Wis section need nol Iw rompleled iflhc permit is fur$100.00 or leu)
•� --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 subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shall f rthvYith comply with those
provisions. Date '3 -/— IS— Applicant: I 21j�e. �
by Section 3700 of the Labor Code for the performance of the work for which 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, INTEREST AND ATTORNEY'S FEES.
Planted on Recq chAP:gim