27784 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEU rRIAL PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PR OJECTIDENTINICATION 27784
BUILDING AUDRHSS: SANITARYNO. A/PPLICA'I ION SUBMI I9'AL DA'H1
jTT— UNIT# LOT#
0 NERSiNAMF.: P1rfl: CONTRACTOR'S NAME: LIC NO: •/
/!`� N/C COY]'ROLp
.ARCHITE-C'DEN NITER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT LU N MECIi
PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
OZZ I herebyaffrmthat l am licensed under pmvisionsofOrapter9(commencing with
00
m Section 7000)of Division
s n 3 of Nand
e Rosiness d Professions Code,and my license is in PANELS
WOO
form
<W License Class 1.1,.# Gyno/ UP TO 200 AMPS
.<o- Date Coda., 201-1000 AMPS
F yZ ARCIIITF.CTS DECLARATION SQ.Ff.BOOR AREA S/SQ.IT.
Oz—O
1 understand my plans shall be used as public words.
OVER 1000 AMPS
Py=� I SIGNS ELECTRICAL
G Y f J Licensed Professional
ry,cd< OWNER-BUILDER DECLARATION SPECIAL CIRCUTDMISC.
KOyO 1 hereby affirm that 1 am exempt from the Contractors License Law for the
uJ3t+.v followingreason.(Section 7031.5.Business and Professions Code:Any city orcounty TEMP.METER OR MILE INST.
,—:O< which requires a Permit to construct.alter,improve,demalish,or repair any stmcture
=WT2 prior to its issuance,also requires the applicant for such permit o file a signed statement POWER DEVICES
'=<O that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter
c-Xos 9(commencing with Section 7")of Division 3 ofthe Business and Pram,aions Code) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt therefrom and the basis for the alleged exemption.An I tion of
m_m p gAny OUTLETS-SWITCHES-Fl%TURES
(—Z> Section than byanrive ndred applicant
rs($50rnit subjects the applicant tosci ' pen of
not mom thanrofthera,mr,lordayerpl NEW RESIDENTIALELECR SQ.Ff. STORIES TYPE CONSTRUCT ION
�F� ❑ 1,thewrk,anhepmpucture myempinded orofwugeor awle(S cnmpnnsure
p,3. will dothewons and the structure knotintendedLa a does not
.7044,Business
prefer,
Professions Code:The Comrudon.and
License Law does not ap y If sn owner of
pmpenywyces,provi imprvvexth imprandwho doessuch ime mmoedthrough his
employees.provided than mcM1 improvements me natimcnd oroffercJ tarsale.If, OCC GROUP HES.UNITS
however,the buildingor improvement is sold within one yen +mpletion,theowner- TOTAL:
builder will have the burden ofproving that he did not b ' or Improve for purpose of
sale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Las owner ofthe proven,am exclusively c trusting with licensed comfemoran,
construct the project(Sec.7044,Business Prolession.Calc:)The Caters.....',
License[.so doesont apply to an owner u,"yolumildxor in+pm sIhercon,und PCR ISSUANCE /
Limmse Lew.oternms fncsuchprnjvO a ,nacto,P)liccmcd pursuanw mumamrs AI 0R-DRAIN&VENT-WATER(EA) FEE SUMMARY
Licen
❑ lam exempt um .See. & ❑is I Ol1TS1
ACK PLOW PROTECT.DEVICE DL II.S
SANITARY YN
Owner De RIiCFIPI'#
DRAINS-PLOOR,ROOF,AREA,GOND. 1
WOR AN COMPHNSA'1'I(JN UEC BION SCfI00L'I'AX YN
❑ I hereby affirm than ave ucenificute nfams'm t s nsure.nr nbemeof Fl%TURF.$-PER TRAP RIdCH1P1'#
WnrLen'Cnmpcnsmionlm acxarumdi cop the 1(Sce 3g' .)whicM1 PARK PEE YN
rs all employee's ummd'npenniL 1 GAS-HA.SYSTEM-I INC.40UTLETS R[CIi1Pl'#
Paltry N BUILDING DIVISION THUS
Cntepeny GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FTiH
❑ C,m Fvdv+pyisherebyfumi, I,
❑ Cenifvdv.,yisfiledwithth,,61 'nspeaian ivishm. GREASI91NDUSTRL WASTE INTERCEPTOR GRADING ME
CER FIFICATEOF EXEMP NFROM WORKERSGREASETRAP SOILS FEE
COMPENSATION 1 : RANCH
(ibis section need not Is,completed ifthe peon forome M1un dollars,H 00) SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or heo..)
I cerif don in performance oflhe workh+rwhlchlhupennitisismaLlshnll W ' TERW/VENT/ELECR
not employ any person in any manner so as to become subject to the Workers' PAID
Compensatioulawsof Califomia. Dam WATER SY M/TREATING ;cyDam Receipt
ZApplicant L( t
NOTICE TO APPLICANT:If.one,ranking this Ccnificme of Exemption.youshould Rf•SIOENTIAL PLMB. SQ.FT. 'I'O'FAL:
` become subject to the Workers Compensation provisions of the Labor Code,you must BUILDING RTE
a - forthwith comply with such provisions nnhis Permit shall lx deemed revoked.
[A Q SEISMIC FEE
6. CONSTRUCTION LENDING AGENCY
1 herehy affirm bar them is a cnnstrumian lending agency for the perocommic of
U Z. ELECTRIC FEE
U Q the work for which this Permit is issued(ga.3097.Civ.CJ �-
Lender s Name PLUMBING FEE
O' F Lender's Address QTY. MECHANICAL PERMIT FEE
0 U I modify that 1 have read this application and state that no above information is MECHANICAL FEE
>. W correct. Iagree m comply with all city and county ordinances and state laws miming to PERMIT ISSUANCE
building construction.and hereby auNorim representatives ofthis city menter upon the CONSTRUCTION TAX
U Z above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,indemnify and kap hamdeas the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way stem,against mid City AIR HANDLING UNIT(TO IRM CFM)
roman,enceafthegrwting o,((f�tth()' Knout.
[
AIR HANDLING UNIT(OVER HL000 CFM)
Signal u of ApplicanUCu actor Dam EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,00(l BTU) Dane Receipt p
Willtheapplicant or forum building..pact store or handle hazardous material HEATING UNIT(OVER IW.WO BTU) TOTAL:
as defined by the Cu,mm Municipal Cod,Chapter 9.12,and the Health and Safety p�
❑Yes ❑No
Code,Section 25532(n)^ VEM'ILATION FAN(SINGLE RESID) r
ISSUANCE DATE
Will the applicant or future buildingoecupant cemcquipmentordeviceswhich emit BOILER-COMP QHP OR FOR"BTU) MAR
hvardous air contamts inanas defined by the Bey Amu Air Quality Management BOILER-COMP(OVER 1x1,000 BTU) r�/I/ 8 1995
D,enciB
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. CII YUf-
1 have read the hazardous meterials requirements under Chapter 6.95 of the l,UrtH f/
Calif orm.I Iullh&Saluty Cndo,Sermons 25505,25533 end 25534. 1 understand that
ifthebuildingdoneenot currently Laveastnam,et itla mysmame of
e"ifiefy the __////A����
acupnm al the requirements which muse M met pilar ser Lsummee of v CcrtiOwrc of
Occupancy.
Owner,.anthadmd agent Umc TOTAL: ISSUED BY:
OFFICE
1
PC,
10300 Torre Avenue
Cupertino, CA 95014
of
cupert -w 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: 1' -3576/
(This scaion need not be completed if the peril is for$100.00 or less) -
• --1 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 :3- Y — 9S Applicant: c�
by Section 3700 of the Labor Code for the performan e of the work f r hich this his 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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