27771APPLICANT
TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BDMBING-RfECHA
CI'BU OF CUPERTINO APPLICATION/PERMIT PLUMBING.
BUILDING DIVISION BUILDING PROJECT IDNN'1'IFICA'I'IUN
PERMIT NO.
27771 7 7 7 1
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SANITARY NO. APPLICATION SUBMI'I'I'AI, DA'IF.
BUILDING
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R MF.: A P H: COMI'RACfOR'S NAME: ^ LIC NO:
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CONTACT: PHONE:
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PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
APPLIANCES. RESIDENTIAL
JOB DESCRIPTION
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I hereby affirm that l am licensed umderprovisionsofChapter9 (commencing with
Section 711(1(1) of Division 3 of the Business and Professions Cade, and my license is in
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full force and effect.
Liwnse LIc.It
Date Counsel.,
UPT02MAMPS
T,,VVV%
201 - 1000 AMPS
SQ, PT. FLOOR AREA
$/SQ. PL
ARCHITECTS DECLARATION
I understund my plans shall be used i s public records.
OVER IWAMPS
SIGNS ELECTRICAL
--jj
f
licensed Rofciommal
OWNInd DECLARATION
SPECIAL CIRC JIT/MISC.
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I hereby ofOmr that I am exempt from the Coronation's License 1rw for the
exempt an din,
following reason.(Section 7031.5, Business and Professions Code: Any city or county
which requires a permit m construct, alter, improve, demolish, or «Pair any srunme
poorn.]such
thin he is issuancpormantaso stheprovisrcs the i nsocant ftheCminn,mmsLiceseLuvstatement
that heisa,im, dpursuant mtheprovisionsof theflieBscmrs and Pre Lew(Chapter
and Professions Cod e)
9(rennheis ixempth Section7andthe Division Sof theed exemption.
onM1m he is rxempnherefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by anyspplicam fm a poink.uldects thcappliesnt ma civil penalty of
no more than five hundred dollars ($500)
❑ 1,asownerofthepmperty.ormyemployecswithwagesmtheirsolecompensation,
willdo the work, and thesimnurcis not lmendedo,offeted forsale(Sm. 70W. Business
and Professions Code: The C.ntm,,ex License Law dears not apply 0 an owner Of
property who builds or improves thereorrand who does such workhimselforlhroughhis
cmployms,providedthatxuchimpmvements=notimendedoroffered(.,sale. If,
however. thebuilding ear improvement is sold within one ycarofcompletion, the owner-
builJer will have the hurdcn of proving that he did not build or improve fur Propose of
sale.).
(to
❑ I,usownerofthepropeny,ttmexclusivelyrnmractingwi#licensed eommars
embabuet the project (Sec. 7044, Business and preboarce, Cale:) The Contractor's
w ho bu ilds m improves thcreOn, and
,TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
l//
OUTLETS -SWITCHES-FIXTURES
NEW RESIDENTIAL ELECfR _SQ. IT.
STORIES
OCC GROUP
Iq.00DZONE
TYPE CONS'fRUCf10N
RES. UNITS
APN
QTY. PLUMBING PERMIT FEE
+ .1
PERMIT IS ANCE
License Law dues not apply m an owner of properry
who contract, forauch projects with a comracmrts) licensed pursuant tothe Contractors
AL' . -DRAIN&VENT-TER(EA)
N
FEE SUMMARY -
.
License Law.
❑ I em exempt under Sec. . B & P C for this ,anon
BACK FLOW PROTECT. DEVI
OUTSIDE 'EE
SANITARY Y _N
RECEIPT#
Owner Date
DECLARA
DRAINS-FLOOR. ROOF, AREA COND,
SCHOOL TAX YN
WORKMAN COMPENSATION
c
❑ Thereby affirm thmlhavm ceni0cme of cansennn self' sure,.racmificate.f
Worker ifi W copy Hereof cc. 3800, Lab C.l which
FI VRES-PF.R TRAP
RECIeIPTp
PARK PIiE YN
RECF.I
S EA. SVSTF.M-I INC.40 LTS �
ION
BUILDING DIVISION FLES
Permit.
covers all employee's under Nis permit.
11 roupSycetion der this
Policy It
pS- .SYS ER4(EA)
PLANCHECK FEE
Company
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
GRE NI W 'rEl . CEPTOR
GRADING FEE
AP
SOILS FEE
CERTIFICATE OF EXEMPTION FROM WOR S'
COMPENSATION INSURANCE
(This section need not becomplaed iftbe permit is for be he heti dol $1001
SEWER -SANIT Y -STORM EA. 20017.
ENERGY FEE
WATER . TERW/VENT/ELECTR
PAID
Dae Receipt#
0 Z
or less)
lcertify that in the performance Ofthe work for which this pe lis issu Ishan
not employ any person in any mummer so as to become subject o the Workers'
Compensationixwsof California. Date
W SYSTEMTS RATING
Applicant
NOTICE TO APPLICANT: If, after making this Cmificate Of Eaemplio ,youshould
EW RESIDENTIAL PLMB. SQ. FT.
T At,:
BUILDING HE
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fq
aforthwith
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become subjm tO the WOhers Compensation provisions of the lsbor Co ,younned
comply with such provisions or this permit shall be deemed revolt d.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that is u eme,hummn lending agency for the performance of
the work for which this pe,mit is issued (Sec. 31197, Civ. C.)
Lenders Name
S[ISMIC FF£
*�7
,
ELECTRIC P
Q7YL. (. MECflANICAI. PERMIT FEE
-
a '"
PLU P E
Undms Addross
MECHANICAL. FE
1 certify Nat 1 have read this applicanon end sure that the above information is
correct.Iit'... comply with al city and catty ordinances end state laws I.d.9 in
builAing construction, and hereby euth.nee«pmsondivm mNis city to soler upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap batmiess the City of Cupertino against
liabilitits, judgments, costs and expenses which may in any way accrue against said City
PERMIT ISSUANCE
AL LER ADD TO MECII.
CONSTRUCI'10 TAX
ING UNIT TI'O tg000 CFM)
LING UNIT(OVER 10,000CFM)
n conscq noOf the gruntin ((this man.
in
PAID
Dam Receipt #
�'
1100D(W/DUCT)
Of Appla,amcOntrac r Date
HAZARDOUS MATERIALS DISCLOSURE
NIT ITIOO.000 BTU)
NTT(OVERIM."BTU)as
Will the applicant or future building occupant store or handle hatardOus materiel
defined by the Cupertino Municipal Cade, Chapter 9.12, and the 11.10a and Safety Code, Section 25532(u)7
❑ Yes ❑ No
�1$$UA B
'ION 17AN (SINGLE REM D)
BOILER - COMP (3HP OR I0(t. BTU)
BOILER- COMP(OVER I110,000 BTU)
Airl Quality anagM1 a it
Will tai, co icumordunes s defined by the Bay Arm
harardous air cnnmminunts as defined by the Bay Arca Air Quality Management
R
�aw
istnctl
❑ Yes ❑ N.
1 have read the hazardous materials rcyvimmems under Chopper 6.95 of the
California Ilcubb & Snfcty Cod., Sections 255115.25533 and 25534. 1 understand that
if the building does not currently have a mount. that it is my respsmsibility to not the
occupant of the requirements which must be met prior to issuance of a Certificate of
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NEW ftESIDRNTIAI. MECII. SQ. FT.
Occupancy.
TOTAL:
SUED BY
Owner or amhon>.M agent Date
o 1,
O
.1.
10300 Torre Avenue
Cupertino, CA 95014
WORKER'S COMPENSATION DECLARATION
Building Division
(408)777-3228
(408) 777-3333 (fax)
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)
•-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 shay forthwith comply with those
provisions. Date Applicant: 4f
by Section 3700 of the Labor Code for the performance of the work for which this permit
is issued.
0
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.
PrinfeJ un 17oUVcL,MI / thpm