27363 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
-CITY OF CUPERTINO -n'.hUTRIUAL PERMITND, 27363
APPLICATION/PERMIT PLUMBING-MECHANICAL
RU11.131Nf i DIVISION BUILDING PROJEC"I'IDEN'TIF'ICAI HIS
ZR5ING ADORES S: /aSANITARY NO. APPLICATION SUBMITTAL DATE
/9472 ROSC--MARserve]-# " IOTA
OWN SNAM.:� PHO� .77/S CO (T'O�� MAjoyiRY IC NO: N/C CUNTKULN
ITF.CI'/ENGINE R: LIC NO: AD RJ:p3 waen '6 P
ONTACT: PHONE: t�"W, w I-LECTRi X'P-, T I PEE Y'I gilUILDING PERMIT INFO
s f��'I - "a' BLDG ELECT PLUMB MECH
PERMIT ISSUANCE \I��l� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPI'
ay I hereby affirm that l am licensed underprovisions of Chapmr9(commencing with
00 Section 700(dnf Divisinsin
n3ofthe Noess and Professions Code,and my license ism PANELS
y U fall fnroe and effect.
FZa License Class Lie.# UP TO 200 AMPS IAT
O1?m Date Cantrtctm 201-1000 AMPS
ZONZ ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLUOR AREA $/SQ.F7'.
O Z 1 understand my plans shall he used as public records.
SIGNS ELECTRICAL
Licensed Psdussional
�ce6 OWNER-BUILDER DECLARATION SPECIAL CIRCUMIMISC.
MEI hereby alirm that I am exempt tram the Contractors License law for the
tQ following rcmnn.(Smtion 1031.5,Business and Pmfessiona Code:Any city or cowry TEMP.METER OR POLE MST.
ty-OJ whichrequirese
petmino constma,alter impmvc,demolish,or rtpeir any awnure
Y2 prior to its iasusnce,also requires the applicant for such permit to file Deigned statement POWER DEVICES
QO that he is licensed pursuant to the provisions ofine Counsel.,License Low(Chapter
4yo6' 9(commencing with Section T(gtOof Division 3ollhe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
orthat he is exempt therefrom and the basis for me alleged exemption.Any violation of OUTLETS-SWITCHES-FTXTUREs
F Z Q Section 1031.5 by any applicant for u permit subjects the applicant m n civil penally of
t mart than rive hundred dollars($500).
tY 0 n❑ Lasuwncrofthepropeny,orroem 10 des with wa esastheirsolecam NEWRESIDENDALELECfR _SQ.FT.
utu� y p y g ,Business STORIES TYPE CONSTRUCTION
y3, will dothe work,ande:the nommisora Licesearded unalteredLaoes notl apply to an
and Professions Crile:Thr Contractortherco's License Law Joos not apply to an rough of
propertywho s,proorimpmveuthereon,sadwho Joessuchworkhimseched hrough his
oxnempinyces,Movidedthet such impmvementsare not intcnddoroffemd Tarsale.IL OCC.GROUP RES.UNITS
however,the building Orden of patent is sold within one ycu or improve
for Ne owner TOTAL'
builder will have the burden of proving that he did not build m improve for purpose of
sealed. n"�,tt �. . ..
❑ L asownerofthe property,am exclusivelyconmacting withlicersed contractors to 17 x -PLUMBING PER IT--,-, FEE FLOOD ZONE APN
construct the project(Sec.9044,Business and Professions C-v'Thu Convaetods
License Lawdoesnotapplytoanownerofpmpenywhobuildsorimpmvesthereon,end PERMIT ISS E
whocontmets for such pmpols with a comoddods)licensed marmot oche Contractors
License Law. ALTER RAIN&VENT-WATNR Es,) PEESUMMARY
❑ I am exempt under Sec. B&P C for this res»n HACK LOW PROTF,CT.DEVIC SID -E,
Owner Date SA ITARY Y_N
DRAT S-FLOOR, F, ❑ (IND. / RECEIPfp
WORKMAN COMPENSATION DECLARATION ,SCI OOLTAX Y_N.•
❑ Iherehy affimttM1atlhnveu cenifiwm of consenns self-insure,orncenificete of BEC'In set
FIX S-PER 74W
Weakers'Compemation Insurance or acertified copy thereof(Sce.3800,Lab CJ which PARK FEE Y Id
rovers all employee's under this permit. GAS- .SYSTEM-II OI1T1 / RECEIPT
Policy / BUILDING DIVISION FEES
Compann y GAS-EA SYSTEM-OVER 4 CA) PLANCHECK FEE
` ❑ CenifiW copy is hereby famished.
❑ Ceniful copy is Bled with the city inspection divieium GREASED USTRL WASTE INT-RCEPTORX GRADING FEE
CERTIFICATE OP EXEMPTION FROM WORKERS' GRFASETRA
SOILS FEE
COMPENSATION INSURANCE
f'Dtis section need not be completed Rile Permit is torose humbeddollars($100) SEWER-SANTI' Y-STORM .200FT. ENERGY FEE
or less.)
Icenifythol in the petiormnnee of the work fm which his permit is issued,l shell WATER HEATER WNENT/ELECfR
not employ any person in nay rammer so as m become subject to the WorkersPAID
Compensation Laweof Califomia. Dote WATER SYS'1'EMlfREATING Date Receipt#
O ,Z Applicant
z NOTICE TO APPLICANT:If,after making this Certificates of Exemption. ou should NEW RESIDENTIAL PLMB. 'SQ.FT. T 'A
forthwith
comply
the Worker's Compensation ermisio all be themed
revoked.u must
a 7 forthwith comply with such provisions or permit shall be deemed revoked. BUILDING FEE
Z CONST RUCTION LENDING AGENCY SEISMICFEE
1 hereby affirm that there is a construction lending agency for the performance of
V C) the work far which this perMt is issued(See 3097,Ci,C.) TOTAL: ELECT FE
Lenders Name - PLUMBIN E
F Ianaera Add.. Q'TYY ' - bdEC11ANICAL PERMI11 T ± PEE
V 1 cenily that I have reed this application and state that she above information is '
acorrect l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MIiCIANIC �H
Lp) building construction,and hereby authorise representativeamiddis city to error upon the
L) Z above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONS NTA
(We)agree to save,indemnify and keep harmless the City of Cupcnino against
liabiln a'uJgmdind.costsandexive swHchmayinanywaye meagainsimid Ciry AIR HANDLING UNIT(TO 10,000 CFM)
iac �enceafthcgr ungofthiapennr.
lO,l-✓ n Q AIR HANDLING UNI'((OVRR IO,WOCPM)
Signaurecf Ap nt/ van J rYP Alaxc,D�om— 1i- HAUSI'HOOD W/DUCT)
PAID
II ' RDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) On Receipt a
Will the npplic orfumm building occupant store or haddle heamdaus material HEATING UNII'(OVER 100,000 BTU) TOTAL:
as defined by the Current..Mmticidd Code.Chapter 9.12,and the Health end Safety
Code,Seoti ID You ❑No
25532(e]]
❑ VENTILATION PAN(SINGLE RBSID)
BOILER COMP(JHP OR 100,01X1 BTU) AHC)DATE
AOL Will OeapplicmtorfuturchuilJingwcupam useequipmenmrtlevices which emit WW D
ous air roataminints m defined by the Bay Arca Air Quality Management BOILER-COMP(OVER IW,IXq 81V) r
Istoct] 7�r^
❑Ya ❑No NEW RESIDENTIAL MECH.—SQ.Ff. G(� O
1 have read the havaMous materials requirements under Chapter 6.95 of the !'s �
California Health&Safety Cock,Sections 25505,25533 and 25534. I understand that f
Blue building does not currently have a tenant that it is my responsibility to notify the kill
cupant of the requirements which must be met poor to issuance of a Certificate of I
Occupancy. I -
Owner or anthsomd agent Dole TOTAI; ISS TIED BY:
OFFICE
t
PI
10300 Torre Avenue
Cupertino, CA, 95014
ul'
0 Building Division
(408)777-3228
(408) 777-3333 (far)
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: SJPc2/oQ 1J(AT/oNAL W CA9a30
(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 sliI forthwith mply with those
provisions. Date 1- 8—F Applicant: v cf 4sar/ec�
by Section 3700 of the Labor Code for the performance the ork 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.
Primed orr I Pncyrlud I';por