27434 - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'PINO "Inuit P.1-El.I RI A, PERMI'I'NO.
APPLICATION/PERMIT PLUMBING-MECRANICAL , -/I �] A
BUILDING DIVISION ' DING PRO 2744
ON J IDENTIFICATION BUIhDIN DRESS: WILSANITARY NO. APPLICATION SUBMITTAL DA'lli
UNITp LOy'N
OWN. . NA PHONEi CONT R ORE: LIC NO:
y T�
NIC CfINTROLq
ARCHTIEcO% N:IIR: ICN ADD L' ❑
JArAe
'oNTACI': PHONE: QTY, ELECTRIC PERMIT flip, � HUILDING PERMIT INFO
T ELECT PLUMB MUCH
PERMIT ISSUANCE 0 ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
ACy l hereby affirm that l am licensed underprovisions of Chapter9 m
(comencingwith 10B DESCRIPTION
POO Seaimn 90001 of Division3of the Business and Professions Code,end ray license is in PANELS
FF full fora L
and effNt WF UP T02110AMP5
F2 W Liccnu Clazs 1.ic.N
m,=y Dated Contractor 201 IOW AMPS
7.Ov`a'i� �"/' ' J ARCHITECT' OVERIIXWAMPS SQ.FT.FLOOR AREA E/SQ.FT.
O'L--❑ lundctstandmyponsshalllwmn spubliene oft.
IGNS ELECTRICAL
< W y :d Licensed Professional
aawQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
XOi I hereby affirm that I sum exempt from the Contrutoes License law for the
W3LLhfollowing reason.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
LL40aJ which requires a Front to construct,alter,improve,demolish,or repair any structure
ago -7 Inform its issuance,also requires the applicant for such Permit o file v signed statement POWER DEVICES
ty eK OO that be is licensed pursmmt no the provisions of the Contractors Limm.law(Chapter
d e� 9(commencing with Section 7")of Division 3 of the Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
p ,_y or that he is exempt therefrom and the basis for alleged exemption Anyviolationnl GUILE'TS-SWI'1'CHIS-
��QSection]n31.5 by any applicant for a permit subjects the applicant to o civil Finely ofFIXTURES _
z not more than five hundred dollars($500).
m ❑ I,mownemftheprt)ir ty,ormyempio mswithwopsu Neirsolccompensution, NEW RESID414TIALELEC R _SQ.FT. STORKS TYPECONSIRUCDON
n3— will do the work,and the structum is not intended or offered for sale(Sm.9014,Business
and Ihafessions Cole:The Contractor's License Law does not apply to an owner of t
_ prnpeny who builds nr intpmves tharcmt;und whadoes such work hirm0forthroughhis v
own employees,provided that such improvements are not imendedorofferadforsals.If. - OCC GROUP RFS.UNITS
however,the building or improvement issold within one year o(completion,theowner- TOTAL:
builder will have the burden of proving that he did not build or improve for puryose of
s`E`')'EI uivcly contracting with licensed contractors to QTY. PLUMBING PERMIT FEE TLOODZONEcommiApN
Licenser thedoes not
(Sec ton
no Business pe Ponywho build or improves
Contractor's PERMIT ISSUANCE
whoe�lawJasnot applyctanownerofprogeny whobuildsarimprovesthereon,end
whornmmnsfmsuch projects with econtmnorls)licensed pursuant mile Con tare
License law. ALTER-GRAIN a VENT-WATER(EA) FEE'rSUMN
❑ In exempt under Sita. I &P C I'oI da mascot
SANITARY .d,YN
Owner - Dau J, sRECEIPTN
DRAINS-FLOOR.ROOF,AREA,COND.
WORKMAN COMI'IlySATION DECLARATION SCI IDOL TAX YN
❑ I hereby affirm that l have accnificatemoonuntta self-irmure, rattnificvte of PIXTIIRES-PER TRAP RECEIPT
Wnrkcrn'Compensminn Insurance orattnifedcopy thereof(Sec.' --ofJwbifa PARK ME Y N
rs all employee's under this permit. GAS-EA.SYS'G?M.I INC.4 OUTLETS =RECEIPT M
Policy g BUILDING DIVISION FEES
Company GAS- 1SYSTVER4(FA) PLANCHF.CK FEF.
❑ Cerified copy is hereby fumishd.
❑ CeniEd copy it Bled with the city inspution division. p Bll ,WASTE INTERCEPTO GRADING FEE
CERTIFICATE OF EXEMPTION FROM WO ERS' �GREASBTRAP SOILS FEE
COMPENSATION INSURANCE
('ILis section need not be complemdifthe Permit is(Drone undid doll ( W) WJFR-S T 200Ff. ENERGY FEE
or less.)
I andy that in the performance of the work for which this mut is issue .'shall AAWR EATER W/VENT/ELECTR
am employ any person in any enamor m as to hecnme sul'ect to the Worker.' PAID
Camp e...lionlawsof Califinot DateWATER SYSTEMTREATIN Data Raman
Z Applicant
� Q NOTICE TO APPLICANT:If,after makingthis Cerifictte of Ext,ninon,you should NEWRESFDIN , LMR. SQ,FT. - TTAL:
y become subject to the Worker's Compensation provisions of the Lab r Cole,you must
� ; forthwith comply wilt such provisinnx 11,this permit sblJl he deems evoked. BUILDING FEE
reiii
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Uz Ihereby affirm that than is a construction leading agency for the performance of
O the work for which this Permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
Lenders Name
0 s
Leaders Address QTY. MECHANICAL PERMIT FEE PLUMBING ME
I certify th ve read bit,epplimtion and sum that the above information is
�" Da cast lag roc aply with ity and county ordinances and stem laws relating toPERMIT ISSUANCE MECHANICALPER
buildings true u,and hereby authorize representatives ofthisciry to enter upon the CONSTRUCHON'I'AX
V 7 above.,, ninn ProPatY tion purposes. AMUR OR ADD TO MF,CI I.
Gl l c)agree m s nify end keep harmless the City of Cupertino against
If. ries,judgmenu av candexpemex which may in anyway aecrueagaion said City AIR HANDLING UNIT(TO 10,000 CFM)
ounce of gran ofthispcmtit.
AIR HANDLING UNIT(OVER I0,000 CFM)
Sigamane of cant/Cnmmnor are EXHAUST HOOII(W/UUCI) PAID
HAZARDOUSMA . IAM DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data ReminIf
a plicant or future buil g occupant store or handle hazardous material
aide sed by the Cuperino Munici Cofe,Chapur 9.12,and the Ikalth and Safety 14PATING UNIT(OVER 100,0(1(1 BTU) T
Cr ,Section 25532(a)1
El Yes ❑No VENTILATION FAN(SINGLE RISID) P
POILER-COMPOHPOR 1M.00 BTU) ISSUANCE
Nrz
Will air conicanmrfuorebuilding by the
no onBay Ana Air Duality Management Md
' hazardous air conaminunts ns defn<d by the Bay Area Air Quality Management
District? BOILER:COMP(OVER 10i BTU) ^� 3 1'vY
q��ga5a�a
❑Yes ❑No NEW RESIDENTIAL M[CH. SQ,ff. y�
Ur
1 have read the hazardous materials requirements unaur
der Chp6.95 of the LVrCKI/
California Health&Safety Care,Sections 25505,25533 and 25534. 1 underswnd fl or
if cupam atuand Jing does not currently hate a mnamJbm it is my responsihility ro nmify the
al'0e requirements which must he met prior m issuance of u Cmificau of
Occupancy.
Ooomoraathodaedagert Date TOTAL: ISSUED BY:
OFFICE
I
®.`.
10300 Torre Avenue
(:ilk• Ilf Cupertino, CA 95014
�t17�Cj'i]]1 O Building Division
I (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: 4E 94 /
tr�Ts
Oris section need not he wun Ieted if the r
( p permit is for S 100.00 or less)
-I certify that in the performance of thework for which"m it is '
d, I shall not
• employ any person in any manner so at to become subje to� e w rs' compensation
provisions of Section 700 of the Labor Code, I shall o with p with those
provisions. Date Applicant
by Section 3700 of he Code for the perf&enance of o or which Is p
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 nn 17ecpr.Lal I':q nlr