27567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO "ERLTRCAI . PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 27567
TITI-DING ADDRESS: SANITARY NO. APPLLTCaATIONSUBMITTALD�ATEE
.R E: UNH: C R'SNWE: LIC NO:
� N CONTROL#
�CHITECf G EER: LIC NO: A DR ❑
CONTACT: PHONE: QTY.?�''. ELECTRIC PERMIT FEE
p BUILDING PERMIT INFO
`U ELECT PLUMB MECH
QF PERMITISSUANCE
LICENSED CONTRACTOR'SDECLARATION APPLIANCES-RESIDENTIAL JOB prS('R�ION
VQWz4 02 I,ereby7")of Divihat i am licenxdun ss and Pifi sof Chapr s 9 and
se with
00 Seca 7")of DivisionJof the Business and Profevians Cade,end my license is in pppfELg
I llfo'co and eif
6y Licenx Class ��) Lic.pUPTO2n0AMPfi
y6� pateaZO—Contmc-� 201-IOW AMPS i)
7 FO v=Ni� ARCHITECTS DECLARATION OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O^—Wp I understand my plans shall be used as public records.
cal SIGNS ELECTRICAL
Q � Licensed Professional
K OWNER-BUILDER DECLARATION SPECIALCMCUITIMISC.
KOn,(J L hereby affirm that I am exempt from the Contractors License Law for the
W 3 LL vFi following main.(Section 7031.5.Business and Professions Cade:Any city or county TEMP.METER OR POLE MST.
(_�OG
N.] which requires a Toro].to conserve,,slier,improve,demolish,or repair any anus um
ata>7 mc,to it,issuance.also retrial.the applicant Teno
for Bach n to file.signed m
swreem POWER DEVICES
,Y�O that he is licensed pursuant Ne provisio r.fthe Contractor's License Law(Chapter
0.101 9(commencing with Section]WO)olTdvision 3 ofthe Business and professions Code) SWIMMING POOL ELECTRIC 9V-ALUAONC tZ
'f�M, a,thea he is exempttberefmm add the basis fmthe allegedexamption.My vioh,ianof OUTLETS-SWITCHES-FIXTURES /Il
❑7Q Section 703 LS by any applicant for n pennit,object,the applicant to a civil pevlty of mow"`--•••e
awnot more than five hundred dollars($500). NEW RESIDENTIAL ELECTRS
L Po ❑ 1,mownerofthe Mro ny.ormyemployeeswiNwagesastheirsolee mpema,ion, Q.PT. STORIES TYPE CONSTRUCTION
will do the work,and the struetu ciamn intcndealm.ffere l forsalo(Sec.7044.Business
and Profmsians Code:The Convectors License law doe.,not apply to an owner of
property who huildso,improve,thereon,and whodoerauch work himselforthroogbhis OUCGROUP RES.UNITS
wnemployas,pmvided that such improvements are no,in¢ndedoroffered forsake.if,
however,the building orimprovement is sold within one yearofcampletion,the owner- TO TAL:
builder will have the burden of proving that he did not build or improve for purpose of
,ale.).
EII,aeownerofthepmpeny,amexclusivelycontmctingwiNlicensedcontmctomto QTY. PLUMBING PERMIT FEF. FLOOD ZONE APN
Y..
eooantet the project(Sec.7044,Business and ProfessionsCode:)The Convector's PERMIT ISSUANCE
Li cenx L aw docs nor appl y m an owner of progeny who builds m improves thereon,and -
whoconuactsforsuchprojectswithacormactohd licensed pursuant tothe Conlmetoes
License Law. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICE S '
SANITARY YN
Owner Data RECEIPT#
DRAINS-FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ l hereby affirm that L have a certificate ofconaantro self-insum,or a certificate of FI%TURFS-PER TRAP RN EIPT#
Workern'Compensetion lnsurancanracmifiedcopy therrof(Sa.JBW,Iab CJ which PARK FEE Y N
covers Alemploycesunderthi,permit. GAS-EA.SYSTEM-IINC.4OUTLETS R CEII'f#
Policy# BUILDING PIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FF.
❑ Certified copy is hereby famished.
❑ CmiFied copy is filed with the city impa,ion division. GREASE/NDUMI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Tldssection neednm becompleted lithe permit is faronehundraddallam(V00) SEWER-SANITARY-STORM EA.200FT. ENE
or leu.)
I certify that in the performance of the work for which this permit is issued.I shall WATER HEATER W/VENT/F.LECfR
not employ any penton in any roamer x as to become aubjat to the Workers' PAID
z, Compemmionlawsaf Celifomia. Data WATER SYSTEM/IREATING Dete Receipt#
Applicant
Z 0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
LO) becomembjest to the Wodsers Compensation provisiom of the labor Code,you must
forthwith comply with such provisions or this permit shall be dcamW resulted. BUILDING FFF
PW-i [� CONSTRUCTION LENDING AGENCY SEISMIC
VZ I hereby affirm that hem is a construction lending agency for performance perfounce of
O the wart for which this permit is issued(Sec.3097,Co.CJ TOTAL: ELECTRIC F
Lenders Name
Ixn&ea Address QTY' if._.. MECFIANICAL'"PBRMIT``y, FEE PLUMBING FE
U I cenify that 1 have read this application and state that the above information is MECHANICAL PE
nmeel.Into=to comply withal]city wool county ordinances and slate Is.raladngto" PERMIT ISSUANCE , I�
F" building construction,and hemby authorize mpreaenutivesof Nis city to enter upon the
V] ,1 CONSTRUCTION TAX
es
�J eMve-mentioned p everysave, forindemnify
and keepPurposes. o AFTER OR'A D ME H
(We)agree to save,indemnify and keep I hmmhss the City of Cape oat
inconseajude,oft costs end expenses which may in ywey xemengein�wid try •AIR HAFB)'la G.UNI t� CFM)
conscquentt oft as of .. AI HANDLING NI (OZER 10.(100 CFM7
d
utore of Ag ,cwt/C an Da US •II PAID
HAZARDOUS MATERIALS DISCLOSURE pH r- -H NIT(TO IW,000 BTU) .�(' Darn Raeipr#
Will the applicant or future building occupant store on handle hamrdous�Lmedal TOTAL:
as defined by the Cupertino Municipal Code,Chapter 9.12,wJ the Heed rd Safety HEATING UNIT(OVER,(W,WO B r6f"��
Code,Section 25532(.)?
❑Ym 0N VL FAN(SINGLE RESID)
9
BOILER-COMP(3HPOR IW,WBTU) APJ(7BDATE
Will iheepplicantorfroam buildingacupantuxequipmcmardevimwhichemit LL//
azardous air comaminanB as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 1 W,"B'rU)
istrict, JAN 241995
❑Yea ❑No NEW RESIDENTIAL MECH. SQ.FT.
1 have read the hazardous materials rr,iremema under Chapter 6.95 of the U
Califomie Heahh&Safety Code,Sections 25505,25533 and 25534. 1 understand rest
VV1 f�kilNO
if the building dos not eunently have a mnaa6 that it is my resp.mibiliry I.notify the f
Ocup rm of the requirements which mus,be me,prior to issuance of u Certificate of
Owugwcy.
Owner or authorized agent - Date TOTAL: ISSUED BY:�J
OFFIC /,
®.
10300 Torre Avenue
Cupertino, CA 95014
CiIN. td,
v +tl�:)e x 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. MX workers'
compensation insurance carrier and policy number are: S*C14 4v
^a
(this section need not be completed if the 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 subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shal fort-h/��th corn y wit those
provisions. Date /—,2 4-9S Applicant:
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.
Printed on RP.rpcled P1grm -
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