27647 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINQ LI)ING,EL ^ PERMITNO.
BUILDING DIVISION APPLICATIQN/PERMIT PLUMBING-MECHANICAL (��/ rg
BUILDING PROJECT IDENTIFICATION L r [�
BUILDING AnDDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
?z -L civ wUST# LOT# '_eIC
OW 'NAME: PHONE: CONTRACTOR'S NAME: LIC NO: NM CONTROL#
,gwsvN A4,z Ny48
ARCHITECI'/F.NGINEER: LIC NO: ADDRESS: ❑
CONTACT: q PHONE:
D �C/a l QTY. ELECTRIC PERMIT PEE BUILDING PERMIT INFO
B ELECT PLUMB MECII
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONdmdcrp vidonx LARATION APPLIANCES-RESIDENTIAL
p 4'Z Thereby of Division that I
3 afthnsetlinssand rifesions Coder and mmecense with TOB DESCRIPTION
oa100 Section 90rad ff Divis on 3 of the Business and Professions Code,end my license is in PANELS
FC Z full tote and effect. t
F Z W License Class Lia# UP TD 200 AMPS '
y h Date Contractor. 201-1000 AMPS
f"
ZOr�h ZJ ARCHITECFS DECLARATION SQ.Cr.FLOOR AREA
O Z,Q I understand my plans shall be used as public recoNs. OVER I"AMPS
rn
,� SIGNS ELECTRICAL
6" Creased Wnfesstonel
E C .J 6 OWNER-BUILDER DECLARATION SPECIALCHCUIT/MISC.
x00, 1 hereby affirm Nat I an exempt from the Contractors License Law for the
W 3t
m fallowing reason.(Section 703 L5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST,
Von which requires a permit m conscruol,alter,improve,demolish,m repair say strveture
V¢� prior to its issuance,also requires the applicant for such permit to file a signed statement POWER DEVICES
MR5p O that he is licensed pursuant to the provisions of the Condolences License Law(Chapter
a• p 9(commercial with Section9000)of Division 3 of the Businessand Professions Cade) SWIMMING POOL ELECTRIC VALUATION
or that he is exempt herefrom and the basis for Ne alleged exemption.Any violation of
KgsSection 9031.5 by any applicator for a permit subjects the applicant to a civil penalty of OUTLETS-SWITCHES-FIXTURES
not mare than Ove hundred dollars($500).
qq� ❑ I,asownern@he property,ormyemployeeswiNwegesastheirsolecompecomon, NEWRESIDENTIALELECTR _SQ.FT. STORIES TYPE CONSTRUCTION
will do the work,andfie anaxone isnotinended mothered forsole,(See,7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of
property who bu i I ds or improves thereon,and who does such work himwl f or through his
employees,proviJeJNet suchimprovements Creno[imm�dedor offeredforsnle.
If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one yerrof completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of TOTAL:
ala).
❑ 1,mownerof Nepropeny,wnexclusivelyconhactingwiNlicense emu ctorsto QT' PLUMBING PERMIT FEF- FLOODZONE "N
construct the project(Sec.9044,Business and Professions Code:)The Contractor's
License Law does not applyto bn ownerofproperty whobuilds orimproves thereon,and PERMIT ISSUANCE
who contracts fnr such projects with a conoactors)licensed pursuant,.the Cmductmes
License Law. ALTER-DRAIN&VENT-WATER E) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for this reason BACK FLOW PR C EVICE OUTSIDE ES
Owner SANITARY YN
Date DRAINS- DOR,ROOP,AR. COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION
❑ I hembyaffirm that l have acenificamofconsenrtoself-insum,oraertSCH001,TAX YN
ificamof .pI URFS-PER TRAP RECEIPT#
Workers'employms under
this Permit.
certifed copy Nereaf(Sec.3800,Lab CJ which PARK FEE Y N
covers all employee's undenhis permit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT p
Pomp BUILDING DIVISION FEES#
Company GAS-EA,SYSTE -OV
[:ICertified copy is hereby famished. (EA) PLANCHECK PEE
❑ Certified copy is filed with the city inspection division. OREASFJINDUS NTER R GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' OR SESOILS FEE
COMPENSATION INSURANCE
(this section need notbe completed iflhe permit is foronehundred dollars($100) S - A -SIO .200F3'. ENERGY FEE
or less.)
I certify that in Ne performance of the work for which this permit is issued,l shall W HEAT /VENT LECTR
not employ any person in any manner so as to became subject to the WorkersPAID
Z Compensation Lawsof Culifomia. Data WAT YSTEMITREATING Applicant Date Receipt#
z 0. NOTICE TO APPLICANT:If,aRm making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.PT, TOTAL:
F Ln become subject to the Worker's Compensation provisions of the Labor Code,you must
a ; fon ovals comply with such provisions or this permit shall be deemed revoked. BUILDING ME
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I hereby affirm that there is a construction lending agency for the performance of
(� O Ne work for which this permit is issued(Sec.3199,Civ.C.) TOTAL: ELECTRIC ME
Lkr rr Lenders Name
O l-� Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
>" LUkII cenify that I have mad this application and since that Ne above information is
FRr coreIt.Iagfee to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL PER
" building construction,and hereby authorize representatives ofthiscity to emerupon the
(, 7 above-mentioned property for inspection purposes. ALTERORADDTOMECH. CONSTRUCTION TAX
a (We)agree to sora,Indemnify and keep harmless the City of Copenino against
liabiliticsJtidgments,costs andexpense Ichriayinanyw ryeocrucagainstsal C AIR HANDLING UNIT(TO 10,000 CFM)
nseque sof the looming of thi ran
AIR HANDLING(MIT(OVER 10"CFM)
Sig reaf Applicant/Contractor Date EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MAB oce.pSDome or handle
HEATING UNIT(TO 100,000 BTU) Dam Receipt#
Will the applicantsero Mu buildingde,Camsncre or handle Heath anmamrial
as define)by the 32(a)?nu Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER I W,000 BTU) 'TOT
Colo,Section 25532(a)?
1:1 Vies ❑No VENTILATION PAN(SING LE RESID) Oil IL-0
BOILER-COMP(311P OR 100,000 BTU) ISSUANCE DATE
Willthel"icantorfmure buildingoccupent useequipmentordeviceswhichemit PAID h-.I ous air common ams as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IOO,WO BTU) Y" Ly
District? I
LTYes ❑No NEW RESIDENTIAL SUCH. SQ.FI'. ® v
read the M1azaMaus mmeriels reyuiremenrs under Chapter 6.95 of the J•aaV 23ealth&Safety Code,Sections 25505,25533and25534. 1 understandNatg does not currently have a tenant,that it is my responsibility to anti fy thethe requirements which must be met prior to issuance ofa Certificate of �'� Uf'
horizeJ agent D ce TOTAL: ISSUED BY:
OFFICE
® 10300 Torre Avenue
• t;il` 111. Cupertino, CA 95014
�y
.lt1J(:.rti-110 Building Division
(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 soclion need not be completed if the permit is for$100.00 or Iess)
• --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 cc ply with those
provisions. Date /— Z 3 y , '=Applicant:
by Section 3700 of the Labor Code for the perfor nce of the work 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.
I'unled an I Veeia;l:l I'opm