27889 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOuamNG-EcxaraTc PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 27889
BUILDING DIVISION BUILDING"PROJEC"IADEN'I'IFICA'I']ON
BUILDING ADDRESS � •v w SANITARY NO, APPLICATION SUHMITI'AL DATE
12
k UNIT IT [.OTY
CONTRACTOR'S NA li: LICr'O:
N/C CONTROI.M
.xRCI11TEC1'/ENGINEIiR: LIC NO: ADDRHI
CONTACT: PHONE:
QTY. ELECTRIC PER IT REE BUILDING PERMIT INFO
BLDG ELECT PLUMB MHCH
PERMITISSUANCE E] 13 El
LthaNSEDCONTRACTOR'SionsDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Wyz Ihercby of
misionat I 3 ofth Business
sed nder ssand previsions Comr9(commencing with
m0O Bntinn]OUO)of UlvisionJ of the Business and Professions Code,and my license is In pprypy5
WF. full force and effect.
FZW La"aw,C Li..N U1`TO20OAMPS
L,6 H Da��te Convenor 201-IWO AMPS
Z O=� \ ARCIIITECTS DECLARATION SQ.her.FLOOR AREA $/SQ.F1'.
I JcrstanA my plans shell be used as public records. OVER I WO AMPS
_ W - SIGNS ELECTRICAL
y
Q J I.iccnud
Professional
OWNIiR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
Ra('0yU 1 hereby affirm lost I um event from the Convenor.Limme Lew for the
41'3 WrF following...son.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
C which requires a permit to construct.alter,improve,demolish,or repair any structure
0�� prior In its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
00 that he is licensed pursuant to the provisions of the Contractors license Law(Chapter
d op, 9(commencing with Session
]")ofErivision 3 of the Business and Professions Code) SWIMMING POOL ELECIAIC VALUATION
to or that he is exempnherefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
F- G Section 7031.5 by any applicam for a permilaubjapplicant alty
aots the applicano a civil penof
not more than live hundred duller.($500), .
W m ❑ I,as Ownernftheprop ny,ormyemployeeswiNwagcsastheirsulecompen,.tiNEW RESIDENTIAL ELECT Son, Q ET. STORIES 'I'Y PE CONSTRUC'T'ION
W will du the work.and[he structure is not intended or offered for sale(Set.7044,Business
and Professions Code:'fhe Contractors License Law does not apply to an owner of
pmpmy who builds or improves themon,und who does such work himselforthrough his
employees,provided that such improvements rc notimende4 oroffcred forsale.If, OCC.GROAT' RCS.UNITS
a
however,The building or improvement is sold within one yearofcompletion,the owner- TOTAL:
builder will have the burdea of proving that he did not build or improve for purpose of
le.).
❑ I,azowner0frhe progeny,emexdusivelyconbecHngwithlimned cmnwetorslm QTY. PLUMBING PER FEE PLO DZONE APN
coma uct the project(Sea 7044,Business and Professions Codc:)lbe Commetor's
Lickselawdoesnm apply to an owneroffampeny who builds or improves thereon.and PERMIT ISSUANCE
thonmort eo forsuch projects with a cormactons)licensed pursuant to the Contractor's gL'ITR-DRAIN&VE -W TIiR(FA)License Low. FEE SUMMARY
❑ I am exempt under Seo. ,B&P C for This mason BACK FLOW PROTE -VICE OUTSIDII FEES
SANITARY Y N
Owner Date DRAINS-FL R F,AREA, D. RECEIPfM
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
C1Ihercby uffrm lheG have ecenificnu of conscano Self-ins......mni0camuf RECEIPTp
Workers Compensation Insurance or a certified copy thereof(Sea FlXTURES-P'3800,Lab C.)which P PARK FRE Y N
covers all employee's under this permit. GAS-EA.SYSTEM- .4 OUTLETS RECEIPTp
Policy k BUILDING DIVISION FEES
Company GAS-EA.SYSTEM.OVER 4(EA) PLANCHECK FEE
❑ Cenifed copy is hereby famished. -
❑ Ceniftedcopy is filed with the city inspection division. GREASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATEOPEXEMPf10NFROM WORKERS' GREASETRAP SOILS FHE
COMPENSATION INSURANCE
Oris section need not becompleted ifrhe permit is forme hundred dollms($R)U) SEWER-SANITARY-STORM P.A.200TH'. ENERGY FEE
orless I
I certify that in the performnce oflhe work for which this Permit is issued,I shell WATER WATER W/VENT/ELECfR
not employ any person in any manner so as to became subject to the Worker' PAID
Compemmionlawsof California. Date WA'T'ER SYST81,19RHATING Date Recmiptk
0 z Applicant
"z C) NOTICE T'O APPLICANT:If.after making this Certificate of Exemption.you should NEW RES]DENTAL PLMB. SQ,FT. TOTAL:
CI) become subjectto the Workers Compensation provisions of the Labor Code,you must
� > fonhwith comply wi]h such provisions or this formal shelf be deemed revoked. BUILDING FEE'
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm Net there is a construction lending agency for the pcRmmenm of
the work for which this t is issued(Sec.307,Civ.C.) TOTAL: ELECTRIC IEE
U 0 p n,d
Leader's Name
O H Lender's Address QTY. MECHANICAL PERMIT REE
PLUMBING FEE
U 1 certify that 1 have read this application and stale that the above information is
correct. conte mon,and withalll city and countyordinancesoft is site laws r upon the PERMITISSUANCP. MECHANICAL ME w
h Z rhol.ngcmnmmcdoome" herebyuutho famprosenutivu oflhis city roamer upon the CONSTRUCDONTAX
U z nhnvc-mentagra(propertyformnify and Jamesharness ALTER OR ADD TO MF.CII.
�--t (We)agreent save,indemnifysed kip har
the City ofe agent mid against
liabilities, expenses which may many way vicerueagainstsaid City AIR HANDLING UNIT(TO IO,IXq CFM)
in consequence ofthe granting of this Kt AIR HANDLING UNIT(OVER I0,000CFM)
Signal of ApplicaaUC0nusena, `r — pme'�S EXHAUST HOPD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 101LOW BTU) Date Receipt a
ill the applicant ord'u]ure building occupant store or handle havudous material HEATING UNIT(OVBR IW,IXNI BTU) TOT
as dli"I'by the Cupertino Municipal Code,Chapter 9.12,end the Health ad Safe,,
Gule.3enion 255J2(n)1
11 yes C3 No ENVTILATION PAN(SINGLE BUSED)
BOILER-COMP(JIdP OR IBB,l10B BTIJ) ISSUANCE DATE
Will the applicant intrinsicbuildingoccupanmeeequipmm
eardevices whichemit
hazardous
1
air contaminants as defined by the Buy Area Air Quality Management BOILER-COMP(OVER I00,000 BTU) .
Diarrinl
❑Yes. El No NEW RESIDENTIAL MECH. SQ.FT. ��� _ ����
1 have feud the hazardomm
us erivls rcquiremem.under Chapter 6.95 of the
Califnmi.Health&Safety Code,Sections 25505,25533 0nd 25534. 1 underst.nd that �y f,�/�
if ilm building does not currently have a Imam, it is my responsibility to notify the - C�11 Ur �/Urt ��l\V
weapon,of the requirements which mutt be met prior to issuance of a Ce tifca a of
Occupancy. .
Owner nr unthnriud ng no Date T ISSUED BY:
( k
f ` f
. 10300 Torre Avenue
Cupertino, CA 95014
Caperti11.0 Building Division
I (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: `f7jC{ka kcl G��-�-
(this section need not be completed if the permit is for$100.00 or Icss)
• --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 ofjhe Labor Code, I shall forthwith comply ith thos
provisions. Dated—OC;4:kApplicant:
by Section 3700 of the Labor Code for the performance of the workfor 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,...Rer.reletll'ry>rr