27440 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
^ CITY OF CUPERTINO BUILDING TRICAI. PERMIT NO,
APPLICATION/PERMIT PLUMBING-MECHANICAL n�, /I /I 0
BUILDING DIVISION BUILDING PROJECT IDEN'TIFICAT'ION L [ALF
BUILDINGADDRESS: SANITARYNO. AM'LICA'nONSUBMHTM.DATH
70/ 7 UNIT# LOT of
OWNERS NAME r r 1� 1 /�vPHON CONTRACTOR'S NAME: W ICNO:6/�l N/C COMHOLN
1RCHHECT/INGINEER:I_ .1'l` LIC NO: ADDRESS:\ ❑
CONTACT: PHONE: BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
Mlc�n�t 1`�iwORi�4 q pBI.DC ELECT PLUMB MECII
PC;RMII'ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p�Z I hereby affirm that l am licensed under provisions of Chaphr9(commencing with li
LW00 Section 70(11 Division Sof the Bvariev d Professions Code,and my license is in PANELS L./Rvai�) �efr
a F fall Ona anJ eflee �e,. 21? i/l K�.[i/ lam' •I
f,,,Zup fall RcGass Li0.# cJWG UPT02W AMPS
y6y Dme Connacmr 201-1000 AMPS
F-,0s'L ARCI HTECES DECLARATIONSQ.FT.FLOOR AREA VSQ.FL
>_0 m^— I understand my plans shall be used as public records.
OVER 1000 AMPS
0Z C rd
SIGNS ELECTRICAL
4¢yY LicenuJ Professional
Yy WU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
KOi V 1 hereby affirm that 1 am exempt from the Commuters License Law for the
yea i Iidluwing revsvn(Scrik,7031.5,Business and Prafresiuns Code:Any city or county TEMP.METER OR POLE INST.
which rcyuims a permit to ennalmer,elm,,improve,demolish,or repair any structure
to its issuance,also the applicant for such no file a signedstatement POWER DEVICES
prior requires pp prava
yCpO that he 9(comisncing with Stant tofirro7 ).MiProvis,kiuons of the Contractors License Ww(Chapterarts Code) SWIMMING POOL ELECTRIC
2ao�G 9or t that
he is ixemitherrifrn=it the Division Sof theed exemption.
.Any iolaCode) .L ATION
t,Zj Scotia 7031. byanpt applicant for
the lasPermit subjects thedeaemptt to rivilPnalty of OUTLETS-SWITCHES- I'1
F E Ya Satin..]031.5 by any dr d do]]rut a permit subjects the applicant to a civil penalty of Fl%TURES
not more Ihw five hundred Dollars(.S$OB).
�Sp NEW RISIDINTIAL ELECfR SQ.Ff. STORIES TYPE CONSTRUCTION
~m ❑ Lonewrk.arohcp,limea,urs notanoyeawifleredecomei(See compensation,
a3— will dnthcwork.Crat:ne Corusnolmmndese law,dos become(See
1.so, asmar of
send Profcssinns Code:The Cnnrmnor's License law,does not apply to vn owner of
property who buildsorimpmve.s thereon,and who dues such work hint%elfor through his
employes,Movidcdthatsuchimpmvernenlsuenmintendedoroffemdfurule.IL OCC.GROUP RES.UNITS
however,the buildingor improvement is.anld witbin one yearofcompletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
QTY. PLUM GP WIT FEE FLOOD ZONH APN
❑ Las the Project
(See.
ny.7(ofLm Business
and Professions
g s C licensed Conacmrsm
construct the projet(See Rano Business and ywhasinns Coude:)The Contractor's
License law Jesnot apply toanowncrofpmpenY whohuildaanimproves tM1erron,and PERM]'1'ISSU E
who aanmety for such pmje'uwah acontrvcmra)Reenxdpunuant muse Comracior's N.TE
License Law. #ALN&VGNT-WATER ) FEE SUMMARY
❑ I Inn exempt under See. ,B&P C four this rtason ACK FLOW PROI'ECr.DEVICE
OUTSIDE MES
SANITARY Y N
Owner Done RECEIPTp
DRAINS-FLOOR.ROOF,AREA,GOND.
WORKMAN COMPIiNSAT10N DECLARATION SCf1OOL TAX Y N
(p�I hereby affirm that l have a certificate o!consent to rel f-insum,or acertf eof FIXTURES-PE RECEIPT#
Worker'Compensulionlnsurancemaceniri Jco ythereof(Sec.3g0U.l.0 .)which PARK FEE Y N
Pors nll em uyceI nit th's pe i GAS S -I INC. 5 RECEIPT#
licyM BUILDING DIVISION FEES
Company A
GAS-PA.5 . EM-OV PLANCHECK FEL:
_@Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division. Gft . DUST W,A'TE INTER EPfOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G TWIskovSOILS FEL'
COMPENSATION INSURANCE
(Ihls section mend not be completed ifthe Permit is fm one hundrddull ($100) WE R- 17G -STORM - .200M. ENERGY FEE
or less.)
I erdify that in the serformarcow7the work for which this per mit isissuedl all I2R t1EAT. WNENT .ECTR
not employ any person in any manner so as to become subject to the worki WAT - PAID
Cumpenmtionlani fCoobfomia. Dam ER SYSTEMJIRF NG Date Receipt#
O z Applicant
ZD NOTICE TO APPLICANT:If.ntwo making IS,Cerdifismeof Exemption,....bund NEWRESIDEN'HA I.MB, SQ.FT. TOTAL:
f•-' . hecomesubjecunthe Workers Cumpensmion provisions of the Labor Code,youmust
� > hmhwith comply with such provisions or this permit shall be deemedrevoked. BUILDING FEE
IJ.ISEISMIC FEE
0. Q CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
U O the work fur whelm this permit is ivaved Xrv.3097,Civ.C.) TOTAL: ELECTRIC FEE
Leader,,Name
D" F Lconer's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
0 U 1 tardily that I have most this application and sum that the above information is MECHANICAL.FEE
>. Ll� correct.I agree us comply withdl city andeotmy ordinances and state laws relating to PERMIT ISSUANCE
CL building building construction, hereby aothonse representatives ofthiscity m enter upon the CONSTRUCTION TAX
U z above mentioned property far inspection purposes. ALTER OR ADD TO MECH.
(We)ogres to save,indemnify sad keep humless the City of Capenin.against
lubllitics,judgmenu,enws and txpcnv,s which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in curs"uence of the gmming of Nis permit.
AIR HANDLING UNIT(OVER 10.000 CIM)
Signature of Applicant/Contractor Dale EXHAUST HOOD(WNUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,001 BTU) Date Remold#
Will the applicant or future building occupant store or handle hea sous material 'f01'AL
as defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 BTU)
Six Code,Sectio 255320)1 .� VBM'ILAI'ION FAN(SINGLE RISID)
❑Yes IE No
ISSUANg DATE:
Will theapplicantorfummbuildingmcup nI usersqum
ipmenrdevices whichemil
BOILIiR-COMP(311P OR 100.000 RTU)
i
isardim,air contmiwms os dtlined by the Bay Area Air Quality Management BOILER-COMP(OVER It10,Of1f1BTU)
mrie° ❑Yes �Nn NEW RESIDENTIALMECII. SQ.FT.I have real the M1avtfdous materials micturemtnts under Chapter 6.95 of thealifornia Health&Safety Code.Setons 25505.25533 and 25534.I understand Warff thchudding dors not t amently havealcnanl,that it is my responsibilily to notify the GII� Vccupvm of the rtquimmena whir met poor m issuance of e''C��en``ifcppm�e of
Oa p C 3•L7'7�
OwIter or authorized ggcnf Dere TAL:TOE�]]ISSUED DY:
OFFICE
A
® 10300 Torre Avenue
• Cupertino, CA 95014
('.ilk of
supe ti-no Building Division
(408)777-3228
(408)777-3333 (tax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--1 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,221?—9'S UeAi A' as 7"/*O
(this section need not he completed if the permit is for$100.00 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 subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shall forthwith compIv with those
provisions. Date 3 ' 29 %5— Applicant: /jGC{di�
'- 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.
r,6r„r„ r a,.r.s,•r r..r.,.