27495- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PERMUr NO
CITVOR CUPF_RTINO PLUMBING-MECHANICAL27495
BUILDING DIVISION APPLICATION/PERMIT ;BUILDING PROJECT IDENTIFICATION'
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O UNIT# LOT t �2
OWNERS Me: n =yWJs:� CONTE C� T{y�y`IA LIC NO: NIC CONTE
RCHUI'ECT/F.NGINEER: —f LTC_/NO:!^iY/i ADDRESS:LTIV\lV►I\ w� El
CONTACT: PHONE: I«'� fig'm*' "* (• a x v�BUILDING PERMIT.INFO
QTY.I ELECTRIC PERMIT, .FEE'
x` ffi f 1 �.V:'?k"4 Y5. - BLDG ELECT PLUMB MECH
PERMIT ISSUANCE I�{LEj
LI CHNSEDCONdunderOR'SDECLARATION APPLIANCES-RESIDENTIAL W�„ JOB Fp gCgl¢UION
tyZ Thereby off rtnthat I CHNSEDCONT uACTOR'S DECLARATION
with `LL1]`N^l ,-.I�/gT1A
00 Secuorceandaf Division 3oRhe Rosiness and Professions Cade,end my license is in PANELS
y W full lane and effect. - A
¢,ZVz, License CLes Lic.If UP TO 200 AMPS
H 6 ot Date Contractor 201-1000 AMPS
ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O L'"C I undersand my plans shall ba osed as public records.
r 4�W SIGNS ELECTRICAL
Q a� Licensed Pmfesslonal -
C OWNER-BUILDER DECLARATION SPECIALCIRCUILMISC.
°fit O a U I hereby affirm that I Am exempt from the Contrivances License Law for the
W 3 W ti but lowing remon.(Section 7031.5,Business end Professions Code:Any city or county TEMP.METER OR POLE MST.
oeO which termites a permit It,construct,alcor.improve,demolish,or repair any structure
r',i:� pdomn its issoance,also requires the applicant for such permh to file a signed statement POWER DEVICES
W 4 p Mm he is licensed pursuant to the provisions of the Cnntrecmts License Law(Chapter
SWIMMING POOL ELECTRIC
Xp[v. 9 that be is(commencing Section he Division Sof the Business and Professional VALUATION
onhm h7031.5 by any a from and the basis Por thects shed exemppplipm ion.A i,d)psn0on of
Q
Section LS by any applicant l'nrapermit subjects the applicemmacivil penalty of OUTLETS-SWITCHES-PIXTURES
not more than five hundred dollars(5500).
04 A .
� ❑ Lasownernf[hepropeny,ormyemployees with wagesestheirsolecompenNEW RESIDENTIAL ELECTR Ssetion, Q PI'. STORIES i'YPH CONSTRUCTION
y will do the work,and theeomenno isnot immndedoroffsend missile(See,70 ,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property whabnilds orimproves thereon,and whodoessuch work himselfor thrnughlok
own employees,provided thatsuch improvements amnotichusbdorofferedmrsde.If, OCC.GROUP RES.UNITS
however,the building or improvement is sold within oneyear of completion,the owner- TOTAL:
builder will have the burden ofproving that he did not build or improve for purpose of
❑ I.asownerofthepmpeny,amoxclusivelyconm.enngwiMl'censedconnact at QTV Z,If PLUM BINO PERMIT; -;PEE: HLOOD ZONE APN
construct the project(Sec.7044,Business and Professions Code:)The Contractor's
License Lawdoes notapply to an nwnerofproporrywhobuilds orimprovesthereon,and PERMIT ISSUANCE
who commits musuch projects with.coimsestods)licunsedpomuant to the Contractor's PETER-DRAIN&VENT-WATER(EA)
License Law. FEE SUMMARY
❑ 1 tun exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT. OUT FEES
SANITARY YN
Owner Dote DRAINS-FL, OOF,AREA,CONE. RECEIPT%
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ I hereby affirm that i have a certificate ofconsent 0 self-insure,or a certificate of ES-PER TRAP RECEIPT#
Workers'Compensation insurance or a certified copy thereof(Sec.3800,Leh C.)which I PARK FEE YN
erwor,all employee's under this permit. GAS-EA.SYSTEM-1 INCA OUTLETS RECHIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy Is hereby famished
❑ Certified copy is filed with the city Inspection division. GREASE/INDUSTRL11STE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION PROM WORKERS' GREASE TRA SOILS FEE
COMPENSATION INSURANCE
IT his section need not be completed ifthe pernitis for one hundred dollars( 100) SEWS RY-STORM, 2 ENERGY FEE
or less. JJ
I certify that in the Performance ofthe work for which this Permit is littlest, hall A 11 TERW/V T/IIZFATR
not employ any ponsur in ponsany manner so as to become subject m the Wore PAID
Comsation
penLawsof Culifomia. Dale rs RSY E NO Date Receipt
Z Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of8xemption,you shr IdN W ESIDP, AL PLMB. Q.FT. TOTAL:
L� Vj became subject to the Worker's Compensation provaim.,ifthe Labor Code,you ust
forthwith comply with such provisions or this permit shall b,rimmed revoked. BUILDING FEE (64
Q CONSTRUCTION LENDING AGENCY SEISMIC PEE
I hereby effinm that there is a construction lending agency for the of
U O TOTAL ELECTRIC ME
the work for which this pertains issued(Sec 3099,Cis.C)
Lenders Namerpt- # 6 r.. + r z
W F Lendus Address QTY` 4-"t *MECHANICAL PERMIT , :PEP PLUMBING ME
U 1 cart fy that I have and this application and stunt that Ma above mformenon i a -$f ` ''" °
correct,l agree to comply with all city and county ordinances entlsam Laws relatingm PERMIT ISSUANCE MECHANICAL FEE
building construction,and hereby authorize representatives ofthiscity to coloration the - CONSTRUCTION TAX
U above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree in save,indemnify and keep harmless He City of Cupertino against
liabilities,judgments,costs and expenses which may many wayamcrua agairposaid City AIR HANDLING UNIT(TO IIk000 CPM)
In eo equerat. I egrwtilll��g of this emit. -
\�#PN /—?—) AIR HANDLING UNIT(OVER FLOW CFM)
Si In IfApplicant/Conwmor Dam EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATHRIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Date Roempt#
Will the applicant orfuture building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) T
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25532(x)'!
Yes 11 No VENTILATION PAN(SINGLE RP,SID) I
❑
BOILER-COMP CHP OR 100,000 RTU) ISSUANCE DATE
Will lair contaminants
a in rots as building by the
en n.Air tQualit Massuachemit I"�'q
bmardous dr conmminams as dcOned by mo Bay Ante Air Quality Management BOILER-COMP(OVER 100,000 BTU)
Distant? - A
❑Yes ❑No NEW RP.SIDENTIAI.MECH. SQ.FI'. Ir
ee
1 love mad he hazardous materials requirements under Chapter 6.95 of the
CWifami.IleaOh&Safety Code,Sections 25505,25533 end 25534. 1 undersand that W 'I
if the building does not currently have a tenant,that it is my responsibility 0 notify the UNr ,S
occupant of the requirements which must he met prior to issuance of a Certificate of
Occupancy.
Owner or aulhodzed agent Data TOTAL: ISSUED BY:
OFFICE
of
x,® � 10300 Torre Avenue
Cupertino, CA 95014
(',il��
Cupertino Building Division
IJ (408)777-3228
(408)777-3333 (fax) (7
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: /,;.5-7 ;) Q r1— ? y
(this section need not be 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 s 1 forthwith comply ith those
provisions. Date ;—Z7— �l S' Applicant��
by Section 3700 of the Labor Code for the performannc"Je f he 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.
Ponlod an Roeyrinrl Pape,