27431 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOUUMBlN'- ' PERMIf NO.
APPLICATION/PERMIT PLUMBING-MECHANICALNTs7 431
BUILDING DIVISION BUILDING PROJECT IDEIFICATION
BUILDINNGA/D/DRM SANITARY NO. APPLICATIONSUBMHTALDAT
2716;,/7/(p UNITY LOT# �_G�_QC
O i SHAME: PHONE: r CON ACfOR'S NA r. LIC NO: TbC CONTROL# / ✓
;53- 46-53 l ff Q90/S
�RGIITTELT/ENGINEER: LIC NO: ADOORF$IV '5, -/V�7ti a�JY�Y1 ❑
CONI'ACI': PHONE: Q QTY. ELECTRIC ELECTRIC PERMIT FEE BUILDING PERMIT INFO
S3 -O61 PERMIT ISSUANCE BLDG ELECT P B MI;CH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pyZ I hereby affemthat l am licensed uncierpmvisionsof Chaprer9(comntencing with JOB DESCRIPTION
FOO SeeJailpaeandefDivisi.n3 of the Business Professions Code.and mylicense is in PANELS
CU� full force orad effect. .i1(.Wllun 1
la. or Lmr.xc Class Lac.# UPTO200AMPS
H=y Date Custm er 201-1000 AMPS
'LOyZ ARCHITECTS DECLARATION OVER 10(IpAMPS SQ.FT.FLOOR AREA S(SQ.Ff.
O Z—a I understand my plans shall he axed as public records.
F y H w SIGNS ELECTRICAL
Q YF„"Ij Licensed Professional
�rd�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
kOaO I hereby off.that 1 am exempt from rhe Contract se Law far the
m�Oy¢ following rcasoa(Section]OJLS,Business and Rvfessi Cudc Any city or county MP.METER OR POLE INST.
t.it yJ which requires a Permit to consumer,alter.improve, clish,or repair any structure
f�}� pnonoit issuaneq also requires the applicamfor hpermiv.file aligned slammenp WER DEVICES
tY G Oz chat he is licensed pursmnuo rhe provisions a C.nmacp.i s Llcerte Law(Chapter
'E:Q 9(enmerencing with Secpian 7")of Di ' on3ofthe Bu.sinesssnd torsions Code) S MMING POOL ELECTRIC VALUATION
m_m or that hem exempttherefrom and t a lis fortheallegWen Wn. ny violation of O EI'S-SWITCHES-FlXTURES
t,} Section]03iSbyanyapplican rapermitsubjarsrheappli t 'viI penally of
K�<M nor more Wan live hundred d lars(SSW).
❑ Lasowncrofthe n ,. 1.ceswit NEW 6SIDENTIAL ELECr1t _SQ.FT.
y�q props rmyemp so a compensation, S'PORIIS TYPECONSTRUCf101
_ willJn the work,and thesWct not ina d of asale(See.]014,Busi
and Professions Code:The Co partner 1' se w ars
nm apply to
propenywhobuildsorimpmves aeon,and w ssuchworkNm bon
i
cmployas,pmvided Woe
dons" rimpmvemcn ttnotim5nded prof J rr .l(, FCC.GROUP RES.UNIT'S
however,the building.rimprove cot is sold ani one
.eye
ole fie cr TOTAL:
builder will have the burden of pr ing that he di not builtl V�J_siroe fore se of
C Lueownerofthepropeny,am elusively contracting with licensed comae .to QTY. PLUMBING PERMIT FEE FLOODZONE APN
nntImer the project(Sec.7041,B i and Professions Cade:)The Co anis
License Law do snot applyaan owne ofprepenywhobuilds Orimpon ex a and PERM IT ISSUANCE
whoarntmdsforsuch projectswithac rracter(s)licemnai rsuanuo eC.nnnctor's ALTER Law. WATER(EA) FEE SUMMARY
❑ um nempt under Sec. ,B C for this mason BACK FLOW PROTECT,DEVICE OUTSIDE FEES
Owner SANITARY Y N
arc DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATI LARATION SCHOOLTAX Y N
❑ Iherehy affirm tbmlhaveecenif<aro of comm mselGinsum,orettrtificae of / FIXTURES PTB TRAP RECEIPT'# _
Wofkers'Compenmtion lnsuance orattnifcd copy Wereof(Sec.38W,Lab CJ whicM1 PAkK FEE YcoceN
c til l etnployMs under this permit. GAS-EA.SYSTEM-)INC.4 OUTLETS RECEIPTp
Policy X
Company BUILDING DIVISION FEES
GAS-EA.SYSTEM-OVER EA
ElCCnifW copy is hereby famished. (PAT PLANCIIIiCK PF.F,
C Certified copy is filed with the city inspection division. GREASEUNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMP'T'ION FROM WORKERS' ME.
INSURANCE GRFASGTRAP SOILS
('Phis section need not be completed ifthe permit is forone hundred dollaes;DIB) SEWER-SANITARY-STORMEA.2WFT, ENERGY FEE
.,Jr..)
I certify In.,in lhepefforrmmceofthe work forwMch this permit isissued,Ishall WATER HEATER W/VEFDLLECIR
of employ any person in say mamar so as to become scbjw to the Workers' PAID
z Compensationlawsof Culifomia. Date WATER SYSTEM/T'RFATING Dae Receipt
OC) NOTICE To APPLICANT:TL after making this Certificate of Exemption,you should NEW RESIDENTIAL rnaliPLMB. SQ.FT.
,r V) became subject 1.the Worknes Compson provisions ofdre Labor Code,you must TOTAL:
� ; forthwith comply with such provisions or this pe 1.shall be deemed revoked. BUILDING FEE
paw, Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z Ihereby affirm don here is a combated.lending agency,for the performance of
U O The work for which this permit is issued(Sm.3097,Civ.CJ ELECTRIC ME
Lenders Name
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
I certify that I have read this application and stale That the above information is
FRWi correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
_ building consructiaq and hereby tooll mpmsentativeso(this city to enter upon the
U Z above-mcmioned property for inspection purpmes. ALTER OR ADD TO MECH. CONSTRUCTIONTAX
(We)agree to save,indemnify and kap hamdess The Cary of Capron.against
Iaabilipics.judgmems,costs and expenses which may in any way accrue against said City AIR HANDLING UNIT(TO 10,000 CFM)
in cmcgop ente of We gaming of this ceearn
ATR HANDLING UNIT(OVER I(LOW CFM)
Signature of ApplicantICommdnr Darc EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,(100 BTU) Dae Receipt
Will he a11licanp.1 future building occupant store or handle haaerdous ma¢n d
as defined by The Cupertino Municipal COR,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IWLWO BTU) TOTAL:
Cale,Section 25512(a)? y
❑Yes ❑No VENTILATION PAN(SINGRFSTD) U
Will de applicator future huildingoccupanmseequipmentordeviceswhichemit BOILER-COMP TRIP OR I00,11W BTU) ISSUANCE DATE
hass�Drdous air contaminant as defined by the Bay Area Air Quality Management BOILER-COMP(OVER HM0W BTU)
❑YLW �agCat
s ❑No NEW RESIDEN'T'IAL MECH. SQ.FT. PAID
read the hamrdom mammals requirements under Chapter 6.95.[,he
alth&Safely Code.Sections 25505,25533 and 25534. 1 understand that /I D
g does nm currently haves tenant,Wat it is my responsibility 1.notify rhe g'11j •^ '..
he regWremcros which muss Is;met pnor w issuance Of.Cenificam of
hov agent Date TO'T'AL: ISSUED BY: I/NO
OFFICE _
�r4.a�Y
t`®' 10300 Torre Avenue
T (,it, oI' Cupertino, CA 95014
l Lper illo Building Division
L (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: y'-1 Ll 7 o q-z
(this section need not be completed if the permit is f"$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 comply with those
provisions. Date 3:-;;?- 95 Applicant: ` ,-- j�(toG
by Section 3700 of the Labor Code for the performance of th6 work for which t is 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.
•
1"inWJ on H,N 11,,Lx:Papel