27676 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO II ILUI G-ELECTRICAL PERMITNO.
APPLICATION/PERMIT PING PROJECT HI MECHANICAL 27676 7 6 7 6
BUILDING DIVISION BUILDING PROJECT IDEN'fIRICAT'IfTN L YNR VM
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
UNIT#is LOT
OWNE NAME
PHONE: CONTRA i LIC NO:
JJ 4 JJJ NC CON ROLM
CHITEC'I dzNGINEFR: LIC NO: ADDRESS: is �r El6 5 4 S'• �ia r0nzti V
CONTACT': PHONE: BUILDING PERMIT'INFO
Ql'Y. I,LECTRIC PERMIT FEE
BI.DG ELECT P UMB MECII
PERMIT ISSUANCE ❑ ❑
LICENSED CONT RAM OR:S DECLARATION APPLIANCES-RESIDFN'I'IAl. TOB OIiSCItIfTION
M=z Ihereby affirm lhat l mer licensed under provisions of Chaprer9(commencing with
P00 Section 7000)of Division 3 ofthe Business and Profbssiom Code.and my license is in PANELS
aVF full force and effect.
GF+z,UUpy License Class Lick UPT02WAMPS
mQy Date Contracmr 201-I00OAMI'S
Z~Oyu ARCHITECTS DECLARATION OVER UX0 AMPS SQ.FT.Fl.00R AREA 5/SQ.Fri.
Oz— luu
ndersnd my,fers shall be asides public retools.
�
_b' SIGNS ELECTRICAL
4Y�J Licensed Pmfessienal
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
aggOaF 1 hereby affirm that 1 am exempt from the Cnm
mcmr'a License Law for the
Wawi following reason.(Section 90315,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
which requires a permit to construct,alter,improve,demolish,or repair any structure
Kw<� prorminissuance,also requites the aWlicantfor such Permit to file a signed statement PDWER DEVICES \
uu115p0 than he is licensed pursuant to the provisions of the Contractors License Law(Chapter
a4o RI 9(commencing with Section 7000)ofDivision 3ofthe Busineasand Professions Code) SWIMMING POOL EL? R `� VALUATION
m L,, or that he is exempuherefvers=it the basis for the alleged exemption.Any violation of OIJTLI - ITCHES-PIXTUR s
�z4 Section 7031,5 by any applicant for a permit subjects the applicant m a civil paternity of
g 0 nntmore than rive It join dollars($500). NEWR SIUENTIALELEC'IR g .P .
t•�i7 . ❑ P,asowneroftheprnpeny,ortnyemployeeswiNwogesustheiraolecompensation, Q STORT17S TYPE CONSTRUCTION
Is.
_ willdothe work,and the svucmrc isnot intended unrefined!forsale(Sce.1044,Business /
and Professions Code:The Contractor s Licenu Law does not apply to an owner of
irevapropenywyees,dsorimphat suchcreon,amdwhodcessucot tende reoffredthrough OCC.GROUP RES.UNITS
however,
thebuildi building
hat suchimprovemeithin neyearndedmoffered theforowner-
builder
the building harden
of potent is hath within of build or improve
for the owner- TOTAL:
builder will have the harden of proving that he did not build m impnwe for purpose of
p)I,mowneroftbe property.am excfusiodycomraNng with licensed to QPY, 'PLD PERMIT f'A FEE I'hOOD'I.ONG APN
construct the purest(Sec.7044,Business and Professions Code:)The Contractor's /
License Law Jcesnot apply torn ownerofpmperty who buildsorimprovesthereou,and PERMIT I UANCE
who conbmets forsuch,mieetaw0,acontrmtor(s)licensed pnoiriatothe Contractors AI:IT?R-DBA &VENT-WATT?R(fAy
License Law, ) I7HE.SUMMARY
❑ 1 ren exempt under Sec. ,B&Y C for this mason BACK FLOW PRO FCL'.DEVICIr. SANITARY O Y E N
Owner Date RECEIPT#
DRAINS-PIAOR,R ,,AREA, ND.
WORKMAN COMPENSATION ofco DEC6ARATIOName. SCfI00LTAX Y_N
❑ Iherehy affirm thatlhawecenificem ofcomem to xlf-insutt,mattnifee¢of pr FIXTURES-PERTRAP RECEIPT,
Wmkers'Com,dmmimnlnsumnce or aceniricd copy thereof(Sec.3800,Lab C.)which O PARK FEE Y N
covers all enmloyeck under this permit GAS-EA.SYS'T'EM-1 INC. OU'11.,,S RECEIPT p
Pulicy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK IEE
❑ Cetiried copy is hereby famished.
❑ CenilicA ropy is tiled with the city inspection division. GRCASE/INDUSTRLWAS'THINTI;RCEPIOR GRADING EEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thisnectionneednot be completed iDhe permit is for one hundred dollars($100) SEWER-SANITARY-STORM HA.200Ff. ENERGY FEE
or less.)
I citify that in the performance of Ne work for which this permit is issued,l shall WATER HEATER W/VEM'/ELECI'R
not employ any person in any manner ha as to become subject to the WorkersPAID
z Compen.amiom Lawsof Califomia. Date WATER SYST'1?MTRP'T'ING Date Receipt#
Applicant
zOzQ NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should NEW RESIDENTIAL PI.MB. SQ,FT, TOTAL:
De, become subject to the Worker's Compensation provisions of the Lahr Code,you must
� ; Ibrthwitb comply withsuch proskinns or this permit sound be,deemed revoked. BUILDING FEE
W Q CONSTRUCT ION LENDING AGENCY 1120 SEISMIC FEE
z Iherehy affirm that there is u construction lending agency for the performance of
the work for which this permit is issuext(See.3099,Civ.G) L: ELECTRIC FEE
pP Lenders Name PLUMBING PEE
F Lenders Address QTY: MECHANICAL PERMIT FEE
U I ceeify rent I have rend dii,v uPPllc.lion nod sure that the above information i.a
correct. lugrec mcom,ly with all city snit county ordinances and stmt levee relining to PHRMITISSUANCE MSCI IANICAL FEE
F-' N building ronsvuction,and hereby auienu«preacremses ofthis city to enter upon the CONSTRUCTION TAX
U z ohne-mentioned property for inspection purposes. ALTERORADDTOMECII.
(We)agree to save,indemnify keep harmless the City of Cupertino against
Iiabilities,juit men ,rostsonde ns hie eyinanyway accrue egainsteaid City AIR HANDLING UNIT(TO 10,"CFM)
e gmn1n f t ' perrid
2 AIR HANDLING UNII'(OVER 10,000 CFM))
gnn of PI ic and/colauss<0or EXHAUST HOOD(W/DUCTj
PAID
I IAZARDOUS MATERIAIS DISCLOSURE HEATINGUNIT(TO I0B000BTU) Date Hmc,,,#
Will the applicant or future building occupant store or handle hamrdoux material HEATING UNIT(OVER 100.000 B1'U)
as define)by the Cupertino Municipal Cole.Chapter 9.12,and the Ilcalth and Safety
Cale,Section 25572(e)?
❑Yes ❑No VENTILATION PAN(SINGLE RESID)
BOILER-COMP(THP OR 100,0)BTU) ISSUANCE DATE
Will the aImumnincidsd or o building by the
nBay equipment ..1ay Marml meat PAID p I D
hnesrdous air contaminants as defined by the Bay Arta Air Queliry Management BOILER-COMP(OVER 100,000 BTU) P' PY
District?
119 Yes ❑No NP,W REEN
SID9'IAL MRCH. SQ.Ff. FEB i
1 have read the hnmolous materials requirements under Chapter 6.95 of N �9e 1999951
California llwlth&Safety Cale,Sections 25505,25337 and 25534. 1underamnd that 17v^
if the building does not currently have a tenant that it is my responsibility to notify or, l# l V
Occupant of the requirements which must h met prior m issuvse of a Cenificme of I+Ut• )
Occupancy,
Owner or amhadud ugenl Date TOTAL: ISSUED BY:
OFFICE
x!® 10300 Torre Avenue
Cupertino, CA 95014
Cupertino Building Division
C (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:
(this section need not be completed if the permit is for$100.00 or less) J
:• --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 ff rthwith comply with those
provisions. Date ;? 0- 55 Applicant: p2 eta
by Section 3700 of the Labor Code for the performance of Ihe work fo hich 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.
Pnnlerl on I?ecyclerl Pepin