27638 APPLICAIIT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFsCUPERTINO B II.DING-BI.FCI RICAL PERMIT NO.
APPLICATION/PERMIT PING PROD-MF;CIIANIFIC 2 7 6 3 8
�.RllllwUl!1G DIVISION BUILDING PROJECT If1FN'TIFICAI'ION
B CUING AIIIIRF.SS: Ar4rol SANITARY NO. APPLICATION SUBMETAL DAT
-..._ UNIT# LOT# 1�� �
O ERS NA E: PEON O 'S NAME: LIC NO:
A 1 � NIC CONTROL#
1RC111'1'I;CI' :N EER: LI NU, DRE S:
r `+y ❑
I aSr� ry
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECIRI ERMIT FEE
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB OFSCRIPf1ON
psrz, I hereby affirm that l am licensed under pmvisionsofatapter9bummencing with
WOO Station 7000)of Division 3 of the Business and Professions CWe.amd my license is in PANELS w �
full force and effect.
W License Class Lic.# UP TO 200 AMPS
rFiaQy Dom Contraetar 20I-1000 AMPS `
7
r-so ARCHITECTS DECLARATION OVER 1000 AMPS
SQ.FT.FLOOR AREA $/SQ.FT.
O_so 1 undersand my plans shall be Wood as public records.
[_vs b-- SIGNS ELECTRICAL
Q>:f Licensed professional
as L'Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KO W U 1 hereby affirm that I nm exempt Bunt the Contractor's License Law Bt the
m3 ay following mason.(Section 7031.5,Business unit Professions Cade:Any city or roam; TEMP.METER OR POLE INST.
F"a ON which requires a permit to construct,eller,improve,demolish,or repair any structure
,WYn prior 1W its issuance,also requires the applicant forsuon pemul 9. asignW saremenl POWER DEVICES
K G O that he is licensed pursuant to the Provisions of the Commoner's License Law(Chapter
aaa� 9(comSWIMMING PoOL ELECTRIC
with Section 3 o(lhe Business and Professions Code) VALUATION
=m ser thin he is excn,urancl'mmund the basis for the alleged exemption.Any violation of
1: Section 7031.5 by my affiliation for a permit subjects the applicant to u civil penalty of OUTLETS-SWITCHES-FIXTURES
not tome than five hundred dollars(5500).
C o ❑ I,asownerofthepmpeny,ormyemploymswithwag"utheirsolecompensation, NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCI'IOD
williothe work,and the structure ism:intendcdoroffered for vide(Sec.J0a6.Business
and Professions Cade:The Contractor's License Law does not apply no an owner of
comedy whobullds)rimpruves thereon,and whodoessuch work himselfortho ugh his
own employees,provided that such imendedorofferedfonale.If, OCC.GROUP RES.UNITS
M1ow'eveq the building orimProvement is soAdid
eyear o!<omplenion,the owner-
'a"
wner- A
builder will have the burden of provipg d mbld or improve far purposeofsale.).I,asownerofd pmpcny, xclu 'ingwithimen it trucarsm QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
r tmlmalrofirojS slit Th,Contrncmre PERMIT ISSUANCE'
LicensclawJmon ran net fp perry wh)bnld f pro sthereon,und
L cense laws fo h jecawilhac lice he Comrnclors ALItJi-DRAIN&VENT-WATER(Eq)
FEE SUMMARY
❑ 1 am exempt under Sec. `� ,B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Data SANITARY YN
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
❑ Ihcrcby affirm nM1mlhave eccnificam of coram muff-insure,oraanifcaa)f SCHOOLTAX Y__N
Workcro Com FIXTURES-PER TRAP RECEIPT#
Compensation Wumncermit. ifiW copy thercof(Sce.3go0,Lab CJwhi<h PARK FEB Y_N
_ mall employee's under this permit GAS-EA.SYSTEM-I INC.A OUTLETS RECEIPT-
Company DIVISION FEES
Policy#
Company
❑ C<rfilicA copy is hcrchy lumishcJ. GASFA SYSTIiM-OVER4(CA1 PLANCHECK FEE
❑ Certified copy is filed with the city inspection division. GRGSMNDUSTRL WASTE INTERCEPTOR GRADING FRE
CERTIFICATE OF EXFMPDON PROM WORKERSORGSETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not bC completed ifthe permit is for one hundred dollars($100) SEWER-SANITARY-STORM BA.2WFF.
orENERGY FET?
f s)
I certify than in the performance ofthe work forwhich this permit is issued,l shall 75ijin
ECfR
not employ any person in my manner sou to become subject to the Workers PAID
z Compensation Lawsof Califomm. Date Date Receipt#
Q O Applicant
z NOTICE TO APPLICANT:If,after making'his Comficale of Exemption,you should SQ.FT. 'TOTAL:
C become subjectto the Workers Compensation provisions of the labor Cods,you mus'
forthwith comply with such provisions or this permit shall be deemed revoked.
(Y �_ BUILDING I}F.
UJ CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 z 1 hereby affirm that them is a construction lending agency for the performance of
U Q the work for which this Penni'is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC ITiC
U. Lenders Name
ULenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
W 1 ccnify that I have ou d Nis application and sem thud the above information is
f--' correct. I agree ha comply with all city and county ordinances and sate laws calming to PERMIT ISSUANCE MECHANICAL FEE
_ (n building construction,and hereby authorize reprosanativesa(this city to enter open the
U z above-mentioned propcny for inspection surfaces. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)agree to save,indemnify and keep harmless the City of Capsicin)again'
Iiabili'ies,judgmenes,costs and expenses which may in any way accrue against said City ATR HANDLING UNIT(TO IQW(I CFM)
or.[,he tingof1h perm'.
� /F AIR HANDLING UNIT(OVER 10,000 CFM)
Vp
Signature of ApplicanVCommcmr Done EXHAUST HOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT 100,000 BTU) Date Raeipd p
Will the applicant or future building occupant share or handle hazardous material
m defined by the Cupertino Municipal Cede.Chapter 9.12,and the Health end Safety HEATING UNIT(OVER 100.000 tl..) TOTAL.
Code,Section 25532nd?
El yes 13 No VENTILATION FAN(SINGLE RESID)
DO11.13R-COMP(JHP OR I W,IX1f1 BTU) ISSUANCE DATE
Will Ihcapplicanmrl"alum building occupant meequipmenmr devices which*L�
vrdoua air conaminanls ss defined by the Bey Area Air Quality ManagementBOILER-COMP(QVF,R IOO.Boo BTU)sura? ❑Yes ❑No NEW RESIDENTIAL.MECH. SQ.FT. o read the hm.ardouc materials on uiraccom,under Chapter 6.95 of ohsleubh&Safety GNe,genions 255(15,25533 wit 25534.1 undersandthat `s "• -Qg does not currently have a tarred,that it is my responsibility to notify thev �/y�the rtpuiremen's which masa M reed poor nW iasuance)f a CeniEcaa)f Vr "lbnrfzcd agcm Date TOTAL: ISSUED BY: - Y
OFFICE
®" 10300 Torre Avenue
(,i i_ Cupertino, CA 95014
vaperth,.1.n 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`mt be completed if the permit is for$l 0000 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 shall forthwith comply with those
provisions. Date �—��—�j+� Applicant: r--!a V. M �
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.
Pnn(rxl nn I fecvdrd Pep2i