27936 -I APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
r. ,,. A.
CITY OF CUPESION PERMIT No.
APPLICATION/PERMIT PLUMBING�MECHANICAL. 279361
"BUILDING DIVISION Fry�:_;fi;:.v+„BUILDING PROJECT IDFNTIFICATWN -
BUILDING ADDRESS: SANITARY NO. i APPLICAnON SUBMrITAL DATE
UNIT# LOT
OW'E S ME: PITO E: CONTRACTOR'S N %IC NU:
' NIC CONTROL#
�RCHI'I ECT/ENGINEER: L INCN A DftEI ^ I / I
11
CONTACT: PHONE: lir I., •.;�. -.:`^ BUILDING PERMIT INFOi-`.•y
Q ';��u.''tPnap'ELECIRIC PERMIT`" �' PEE -BCUG [CECT PLUMB MCCH
PERMIT ISSUANCE ❑ ❑
LICENSED hanImlCONdundcr CONTRACTOR RaTION APPLIANCES-RPSIDENTIAL tlN �l JON DESCRIPTION
I hertbyaffitm BCONTRAC ORSD CLAIZApmr9(commencing with 11 IJOBDES R v(,�sC'A,.Te,'1
OCF.) E¢tihn]0001 of Division J of me Business end Profesxio Code,anJ my license is in PANELS
YZW Lill force andccnx Claz `C 33 Lic.p610151,9 UP T02(q AMPS
o=y Date Contras 201-1000 AMPS SQ.FT.FLOOR REA Et1Q.FT.
J=Z ARCHITECTS DECLARATION OVER Im AMPS
I understand my plans shall be used as public rccmds. w
IL W SIGNS ELECTRICAL
f J Licensed Profeeaio ad
mQ OWNER-BUILDER DECLARATION SPECIAL CIRCUILMISC.
J6U 1 heaby affirm that I am exempt from the Contractor's Licenx raw for the
_Go, following reascn(Smon 7031.5,Business and Professions Cod c:Anyciry or county TEMP.METER OR POLE INST.
which requires a pemdt to container.alt",improve.demolish,m repair any nrvetuor
3}5 Pont to its issuance.alsorequims the applicant for such Permit to Ne a signed smmmem POWER DEVICES
y O that he is licensed pursuam io the provisions of the Contractor's License Law(Chap c
9(mmmenciag with Section]0001nf Division 3ofine Business and Profess ions Code? SWIMMING POOL[IECTRIC VALUATION
torous mthat he is caemptthaefoxnard the basis for Nedleledesemption.Any violationof
Y Section 1031.5h OUTLETS-SWRCHESFlXTURES L V
-ZQ by doltrs($50nnit mbjena me epPlicanuaacivil Penalty of
_...0Oil
ox manfivchuMrtd dollars($500). NEW RESIDENTIAL ELECfR _SQ.FT. STORIES TYPE CONSTRUCTION
f_m ❑ml,mownerafmc7ro M.ormyemploymswimwagmwmeirsolemmpcmmion.
3., will do the work.and the structure isnot intendedoroffned for sale(See.]I110,Business
and Professions Cade The Contractors License Law does not apply to an owner of
propenywhobuildsorimpmvesmemon,andwhodoessuehwmkhimxlformroughlds OCC.GROUP RES.UNITS
own Cmplayten,providedthat such lmprovementsart not lntendedaf offcmlfors0e.If,
however.the building orimproverm nt is cold within one yearo!completion.me owner- L'
builder rill have the burden of proving that he did not build or improve for purpose of
._ ..ay,r...n ; "s FLOOD ZONE APN
L as owncrofthc n tlusmd voctin mikcnsed cono-acmrsto Qom= PLUMBAIG.PERMITyti's`Frt .' FEE'i
❑ pmpc y.amcx Ycon gwl u. :./a[L'.K,2kasrrcexxw.tmezw+itsxfl.S#..$x:.:i=Ges�_t_
comvuct the Project(See.70!1,Business and Professions Code:)TM Convectors PERMR ISSUANCE
ontm
Licenx Laved«snotapplytoanownerofpropmywhobuildsmimproves do" and
whocetsforsuch Projects with aconwetar(s)licensed Promem tothe Convectors ALTER-DRAM&VENT-WATEREA) w=F.f%SE e 'P� .t
License law. ( y,tT_.r, ..+gFEE SUMMARYis
❑ [me.seraph under Sec. ,B&P C for Nu reason BACK FLOW PROTECT.DEVICE
SANITARY Y_N
RECEIPT x
Owner Date
. WORKMAN COMPENSATION DECLARATION DRAP'S-FLOOR.ROOF.AREA.COND. SCHOOL TAX Y N
AT
I hereby affirm that I have o certificate of cmnaem m self-insom.ora certificate of FlJ-MIRES-PER TRAP RECEIPT#
Worked Compensation Insurance ora cenified copy thereof(Sm3800.Lab CJ which PARK FEE Y N
CEIPI'
covers all e 'YI, TE�Wyq:SondvrAflyelm"ty.� -/ GAS-EA.SYSM-1 INC,d OUTLETS BUILPJIG�X- VIS161,1 FLFS
Poficy0 �wSS TT�J 4��-II YY ``
Comfort 'I�{. a GAS-EA.SYSTEM-OVER a(EA) PLANCHECK FEE
Cenifted copy is hereby furnished.
❑ Ccnificd copy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is for one hundred dollars(SIM) SEWER-SAMTARY-STORM EA.200FT. ENERGY
or leas.)
I certify that in the performance of the work for which this Permit is issued.I shall WATER HEATER WNENT/ELECR
not employ any From in any manner so as to become subject to the Workers PAID
Compensation Lawsof California. Date WATER SYSTEMIrREATING Da¢ Receipt#
� Z Applicant NEW RESIDENTIAL PCMB. SQ.FT. TOTAL:
NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption.you should
r^ become subject to the Worker's Compensation provisions of the Labor Code,you must BUILDING FE
> forthwith comply with such provisions or this Permit shall be deemed.,.kW.
Q [� CONSTRUCTION LENDING AGENCY SEISMIC FE.
z I hereby aff n that them is a convection lending agency for the performsnce of TOTAL ELEMIC prik
Q me work for which this permit is issued(Sec.3097,Co.C.)
lenders Name 'v 1 r :.i h{n l. °yr I PLUMBING FEE
F Lenders Address QT'Y. a13;- lis NICAI'PERMIT w'FEE„
U 1 cattily mut 1 neve mad this a Ronan and state mat the above information is - ` ' ' "'' '
- Y PP MECHANICAL FEE
6.
correct.legxe to comply with all city and county ordinances and sum laws relating to P,^11T ISSUANCE
Vy building comrrucdon.and hereby eamonarreptvsemativo ofmisciry theater upon me CONSTRUCTIONTAX
Z ahuvcmcmioncd property for inspection pumosca. A RORADDTOME
+�
(We)ague m cave,indcmn keep harmless he City of Cupertino against
Infln es.judgmentaents and pen swhichmoymanywayaccrvea 'tilt said City AIR HANDLING UNIT fT01 (RO CFM)
inc equenceofthegmming m' permit.
AIR HANDLING UNIT(OVERT fKKI CFM)
ignatu eof p t C tat ! �{ em EXHAUST HOOD(W/D PAID
HAZARDOUS MATERIALS DISCLOSURE
li NG UNIT(TOI TU) .air Recaip#
Wiilthe applicant or future building hcc.,onst a or handle hmardouaxn0 H UNIT(( E W, X)BTU)
TO AL:
as defined by the Cupenino Municipal Code.Chapter 9.12,and the He. and Safety
Code,Section 25532(0^ 5 LATH .'FANSINGLE RFSLDI
❑Yes ❑No ISSUANCE DATE
BOILER- O 1 'ORIW,gpB )
wusair polka irmamrt bullring by me
a Air Quality Menaghemit �Y A e
• hazardous air contaminants an definW by me Bay. rte Air Quality Managetmn BOILER-C PLOVER IW,00p0 U7 N e D
District?
Cl Yen 11 No N 'R ENTIAL MEC]. SQ.FT. �'{r/1 R 13
I have read the hazardous materials requirements under a 19
or
Califxo i.Health&Safety Code.Sections 25505,25533 and 255M.1 e�atan Clly
if the buildin6 rhea not curtcndY have vcnant.the it is my rtaponsibilitYm if3m
e HJT ;:
«eapam of the regaircmenu which must he met prior to issuance of a Cenifir f Ilf krl J/
Occupancy.
Owner or authorired s"m Dam TOTAL: ISSUED P
OFFI c
10300 Torre Avenue
•, ('ilt of Cupertino, CA 95014
uI �
ttpe till.0 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 it issued. My workers'
compensation insurance carrier and policy number are:
- (this section need not be completed if the pant is for SI00.00 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 sub'eet to the worker ompen ation
provisions of Section 3700 of the La bor Code, I sha I� rthwith �I �h tho
provisions. Date �' �� �/ Applicant:
by Section 3700 of the Labor Code for the performance of the w9K for which thl 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.
•
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