27355 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOImusla"on- L ECTRICAL FERMUTNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 27355
]O C C
BUILDING PROJECT IDENTIFICATION / J J J
BUILDING ADDRHSS: y7 SANITARY NO. APPLICVDONSUBMITTALDATE
NIT# ,- LOT# �
O NF.RS A E: PHONE: CO RACf00.'S NAME: LIC NO: - N/C CONTROL
ARCHITF.CT/ENGINEER: LIC NO: ADD S:
�X'•IOl'
CONTACT: PHONE:
QTY. :ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB DESCRI 'ION
Matz I herehyatfinn that l am licensed underpmvisionsof Chapter9(commencing with
t fall fim,..rd
g Seca imt7000).fDivision3of the Business and Professions Code,and my license is in PANELS �5
a License Class Lb.# UP TO 200 AMPS
I'x06y
Data Coommun 201-1000 AMPS
z FOy� ARCHITECTS DECLARATION OVER IOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z—G I unJemm�J my plans shill be used ns ec
public rords.
F 4 SIGNS ELECTRICAL
Y Licensed Professional
yat6 OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOaF I hereby affirm that I Om exempt from the Conommfs Liana law for me
F�Orn followingreasoe(Section7031.5,Businessand Professions Code:Any city orcounty TEMP.METER OR POLE MST.
mm
rn which segpermits.comonct.also,improve,demolish,o mpvir any.wean
�maY� poor to its issuance.also requires be applicant for such peeduo file a signed snsmLnt POWER DEVICES
CO that he is licensed Farmers o the provisions of the Contract U sa Lew(Chapter
yC, 9(commencin8with Sccuon70)of Divisio3ofine Bussand feaxm.Cade) SWIMMING POOL ELECTRIC
VALUATION
or that he is exempt therefrom and me basis for the are exemption. yvioladonoF OUTLETS-SWITCHES-FIXTURES
QSection 7071.5 by any applicant for a permit subjec a applicanteo a vil penilty of
not mom than five hundred dollen($500).
_o props y,ormyemploya ithwagresstheirsolec Notation, NEWRESIDENTIALELECUR S .FT.❑ I,mownero(the t —SQ.FT. TYPE CONSTRUCTION
y3°.: will do the work,end thcswcnreianmtinsn moffmxdforsilelSec.7 ,Business
and Professions Carle:The Contractor's axis Low does not apply to owner of
property who buildsur improves mereo d whodoes such work himselfor rmughhis
ownemployers,provided that such rovenventiamenotionewdedin.ftered rale.If, OCC.GROUP RES.UNITS
however,the building orimprove an a old within oneyearo campletiamt aowner- TOTAL:
buil der,will hevathe burden idea
ving that he did is t build or prove for ryox of
le.).
❑ Lu owneruf theprops excl0sivelymn a al, ed rnscon tanto QTY. PLUMBING PERMIT FEE Fl.00D'lANE APN
construct the project(Sec. a,Business ano 1 p The Cc mecum's
Licenselawdoesnorep ly a nerofp n' uildsoricalowe or .and PERMIT ISSUANCE
m
whoeomeBforseehp I Instead puts. Can
rostra
(CA)
License law. I FEE SUMMARY
❑ I stn exempt under Sec. or th rn! BACK FLAW PROTECT.DEVICE 1
SANITARY YN
Owner D n RCCEIPTp
WORKMAN COM ENSA 1 RATION DRAINS-FLOOR.ROOF,AREA,GOND. SCHOOL TAX Y N
I hereby affmm that l has.a cerci teme. s&I mmlf-insure,or nifcaw.f FIXTURES-PER TRAP RECEIPT0
oh en'Compmaotmilmoranceu a stircopy,mand(See.38 .lab C.)which PARK FEE Y N
coven all employees under thio Permit. GAS-EA.SYSTEM-1 INCA OUTLETS BUILDING
#
Policy p BUILDING DIVISION FEES
Corona JAI 13 GAS-EA.SYSTEM-OVER 4(PLA) PLANCHECK PTE
❑ Certified copy is hereby furnished.
❑ Certified copy is riled with the city inspection division. GREASEANDUSTRLWASTEINTF.RCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nmbe completed ifthepemtit is for one hundred dollars($100) SEWER-SANITARY-STORM EA,200Ff. ENERGY FEE
or less,)
I cenify that in the performance of the work her which this permit is issued,l shell WATER HEATER W/VENDELECTR
not employ my person in my manner so a to bernme subject to the Worker' pplp
Compensetionlaws.f Califomia. Date WATER SYSTEM/TREATING pas Receipt is
Q z Applicant
z 0 NOTICE TO APPLICANT-.If.after making his Cenilkwe of Exemption,you mould NEW RESIDENTIAL MAUI. SQ,FT. TOTAL:
LO) became subject to the Worker's Compensation provisions of the Labor Code,you most
� > forthwith comply with such Provisions or His prrnit shall be deemed revoked. BUILDING FEF.
LkI Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that them is a construction lending agency for the performance of yf L. ELECTRIC FEB
O the work for which this permit is issued(Sec.3097,Civ.CJ
Lkr (r
Lumber.Name
O l^ Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify that 1 have read this application and ante that He above inAnnular.is
4 carted. lmpeeme plywith 011 city and county ordinances and state laws relining n PERMITISSUANCE MECHANICAL FEE
' building continuer n,mdhere emhoou reprexamadves ofthle city 1.enterupon the CONSTRUCTION TAX
L) 7 above-memioneJ mpcty for' spectionpurpm.. ALTER OR ADD TO MP.CH.
rte- (We)agree o Savo,ind unify and kee urmleas the City of CUpenino against
Iiabiles,jud ms,co is cxpenaee whi may in my way accrue against said City AIR HANDLING UNIT(TO 10.0011 CFM)
mcnnsoqucn • fthc ti of thio peon'.
Z-?- 7 '-7 AIR HANDLING UNIT(OVER 10,IXpCFM)
Sig of ¢rot/ carr Due EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT ITO IM."BTU) Das Receipt#
Will the applicant offumm building occupant attire or handle herardons masdil HEATING UNIT(OVER 100,000 BTU) T
m defined by the Cupertino Municipal Code,Chapter 9.12.and the Heehh and Safety
Cade Section 25532(e)T VENTILATION FAN(SINGLE RESID)
❑Yen 1:1 No yy A
Will the a pplicmtorfutumbuildingoccup tunequipmemmdevica whlchemIffy"it BOILER-COMP(JET OR I "BTU) %Upl4gy TE
strict? air contaminants m dcfmcd by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) FEB .
Diau;mT 1' T 1995
11 Yea ❑No NEW RESIDENTIAL MECH. SQ.Ff. /s
I huv.mad the beamMus materials requirements under Chapter 6.95 of the Gil y Vt
California Health @ Safety Code,Sections 25505,25537 and 25534. 1 understand that L(/N'H Flit ru
if the building docs nen omremly have a mnan4 that it is my monme niby to n.rdy me 11#
a:cupum ol'the requirements which must M met prior in issuance of a Certificate of '
Occupancy
Owner nr amhnoecJ egeat Das TOTAL: ISSUED BY:
OFFICE Z
10300 Torre Avenue
pt, ul Cupertino, CA 95014
( tt��erti- 1p 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:T5,/ 13 &
(this section need not be completed if the permit is for$100.00 or I=)
--I certify that in the performance of the work for which t is pe it is issue , I shall not
employ any person in any manner so at to become subje to th workers' co pensation
provisions of Section 3700 of the Labor Code, I shall rth it comply those
provisions. Date —7-- 9 5 Applicant:
by Section 3700 of the Labor Code for the performan a of the wor 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.
4
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