27364APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELF,C OUCAL PERMIT NO,
APPLICATION/PERMIT PLUMBING -MECHANICAL, n A
4
BUILDING DIVISION RVILDNGPNQIECI' IDENTIFICATION G
I1100u14
LICENSED CONTRACTORS DECLARATION
CKZ I hereby affirm that l am licensed under provisions ofCTapter 9(commencing with
n100 Section 7") of Division 3 of the Business and Professions Cade, and my license is in
4: F full force ane ,frac 40 `
FZuI License—Cyt. l.ic.k
to Qy I.o Date
L L's'. toI ua!
7ONZ ARCHITECTS DECLARATION
FNF0I�gYjfy Ina y=1 be used as public records.
Z X Licensed Pmfessionul
OWNER -BUILDER DECLARATION
XOaF I hereby oillrm that 1 on eacmpt from the Contractor's License Law for the
WLLO'36y following reassin.(Section 7031.5, Business and Profosiom Code: Anycitymemmy
i...j which requires a permit re ronswm, alter, improve, demolish, fi repair uny suuauln
,=<0 that he is
iemoved pu anti requires meapplicant fmsuch ine CotractoroLiclt,ese La statement
,=<0 ed mat he is ncia, w pars Section
the provision of me Contractor's and Pon Law (Chapter
0.0.oLL 9(commencingwit therefrom
and 000) of
Division Sof the ed exImpva Professions Code)
Way on tionhat 70.3exempt t y applicant
nt f the basisPerm for alleged exemant to civil Penalty
tyation of
[..ZQa.,
Section 703 by anyapplicamforapermit subjats me epplicannoacivil penalty of
not mom than Bat hundred dollars (y employees
❑ Las oche wrk. and[Ile prrrperly,nrmrentended withwages
orsafeiSec.compensation,
63— will dothewor, unde: he Coeianotimm�crea, Lffiamd wlov, s1 apply or a4.n Business
and property
wh professor, builds
or The improves
tmctm's License taw does not apply lf an owntt
property who builh or improvca thereon, and who rices such work himself onhrough his
tl employers,providedrimprovemimprovements hin ne earof doroffered
on, for me canle. r-
however,thebse ialerderia improvement haduinoneyamofcnproveion,theowner-
blle.). ill nave the Horden of proving mm rte did not bailsmimprove for purpose of
alae).
❑ I, as owner of the property, an, exclusively contracting with licensed connprn?
construct the project (Sm. 7034, Business and Professions Cedc:) The Comm
Licen.ac Luwdoes not apply to nn owner of prnpeny who huddsorimpmveaTliereon, an
who contracts forsuch projects with a contractotts) licensed pumuant to the Contractor',
License Law.
❑ I am eamm' under Sec. , B & P C for this reason
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ Increny affirm matt M1ave acenifcate of consenun self in ... a. nr a canmeate of
Workers' Compensation Insurance or aaycertified copy mereuf(Sec. 3800. Lab CJ which
covers allemplgyrT,'a ytpat y4r/Sn —/T
".)It" Till:!' o�
Cnmwny_� `tee ,fmrr
❑ Ccmfied copy a hcrtby fumificd.
❑ crnifiea rory La ilea wim the chr inspection aiviannn.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Qbis section need not be completed tithe Permit is for one hundred dollars ($1 00)
or less.)
I certify that in the performance of the work for which this permit is iss l I shall
not employ any Person in any mannor so as un, m n barmasubject the Workers
2 Compenstion
aLawsof California. Date
Applicant
OQ NOTICF.I'O APPLICANT:If. after making m
this Cifcac of Exemption, you should
F ` become so bjecnn the Worker's Compensation provisions of the labor Code, you must
forthwith comply wim such provisions or his pemdt shall be deemed revoked.
pal_, Z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a comvuctim lending agency for the performance of
V C)�-+ me work for which this permit is issued (Ser. 3097, Civ. Cd
W. t•^ Lender's Name
O L.i Leader's Address
I certify mat I have mal mix application and sate hat me .lave information is
0. correa.l.greemcomply with all city dna county ordinance.. and smmlawsrelaingm
fn building conduction, and hereby authoria representatives ofthis city to enter upon me
U Z ab ve-mentioned pmpeny for Insp atian paryoses.
(We) agree to save, -indemnify and keep harmless he City of Cupertino against
liuhilities,judgments, crisis and expenses which may in any way accrue ag ' st Haid City
it cnnseyuenceoftheg ting f-
�Ili,,,m� 2 ^tis Data SlgnawrenMpplirnnUC Do
tractor m
HAZARDOUS MATERIALS DISCLOSURE
Wil I the applicant or future building occupant store or handle hruurdous material
ua defined by the Cupertino Municipal Code. Chapter 9.12, and the Healon and Safety
Code, Section 25532(u)?
❑ Yea ❑ No
Will the applicant or(mum building oecupantnow c,quirem or devices which emit
hazardous air contaminants as defined by the Bay Area Air Quality Management
District,
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code. Sections 25505.25533 and 25534. I understand that
if the building dons not currently have a meant, that it is my responsibility to notify the
ccupeal of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG/ 17 ECT PLUMB MECII
PERMIT ISSUANCE Ill ❑
APPLIANCES -RESIDENTIAL LLLLLL LOB DESCRIPTION /��5
PANELS rG�Q�(` (-j/ploey Rb i
UP TO 200 AMPS ocuol +�'f ce
201 - 1000 AMPS `� J
SIGNS ELECTRICAL
SPECIAL CIRCUI DMISC.
TEMP, METER OR POLE INST,
POWER DEVICES
SWIMMING POOL ELECTRIC
//lfffVALUATION
OUTLETS - SWITCHFS-FI TURFS
NEW RESID 'IAL ELECTR SQ. FT.
STORIES
OCCLGROUP
FLOODZONE
IYPECONST
RffUD
APN
11 a
MBING PeMjjj FEE
FIX URIS-PER TRAP
GAS -NA. SYSn-M-I INC 4 OUTLETS
GAS -E SYSTEM- O 'R4TA)
GREASET USI' ,WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 2110FT.
WATER BEAM WNEST ELECI'R
WATER SYSTEM TREATING
NEW RESIDENTIAL PLMB. SQ. ET.
TOTAL:
MECHANICAL PERMIT
PERMITISSUANCE
ALTER OR ADD TO MECII.
AIR HANDLING UNIT (TO 10.000 CFM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXHAUST HOOD(W/DUCU
HEATING UNIT (TO 100,080 BTU)
HEATING UNIT(OVER 100,000 BTU)
VENTILATION PAN (SINGLE REBID)
BOILER - COMP CHP OR 100.000 BTU)
BOILER - COMP (OVER 100.000 BTU)
NEW RESIDENTIAL. MECH. SQ. IT.
FEE SUMMARY
PLANCHECK FEE
GRADING FEE
SOILS FEE
ENERGY FEE
PAID
Date Receipt#
TOTAL:
BUILDING FEE
SEISMIC FEE
ELECTRIC FEE
FEE PLUMBING FEE
MECHANICAL FEE
CONSTRUCTION TAX
PAID
Date
011 flu/_ 11019S
ry��NG
TOTAL: I I ISSUED BY: