27804 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEUI'RICAL PERMIT NO. 27804��O
APPLICATION/PERMIT PLUMBINGMECHANICAL _
BUILDING DIVISION BUILDING PROJP.CT'IDENTIFICATION
BUILDING ADDRESS: {/w(''��^ 1n/�//��'^�^l ///{r�� SANITARY NO. APPLICATIONSUBMITTAL])AM
-
2A G(n _ r V #
O NAME: PHONE: NTACTOR'S NAMEDT# LIC NO
l� N/C CONTROL#
RCHITECT/ENGINEER: LIC NO: ADDRESS: El'ONTACT: - PHONE: ELECTRIC PERMIT FEE BUILDING PERMIT INFO
- W
X9'22-2— PERMITISSUANCE BLDG ELECT P UMB MECH
❑ ❑ ❑
LICENSED CONTRACT
erproSDECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
p00 Ihercby afford ofDivihatl 3 of[linsulinss and refesofGupter9(commencing with
�r10W0 Section 90W)o[Divisinn3 of the Business and Professinnn Code,and my license is in PANELS
,dE fu 11 force ani effect -
<'�,W License Class hie.# I ..,` UP TO SW AMPS
by Date it
201-18(10 AMPS
x;LOFy� RCHrrECTS DECLARATION OVER IOOU AMPS - SQ.FT.FLOOR AREA $/SQ.Fr.
OZsG InndentanJ my plans shall he used as public records.
SIGNS ELECTRICAL
•<'"Sj Licensed Pmfesaimul -
1�yy, <
OWNERBUILDERDECLARATION SPECIAL CIRCUIT/MISC.
003¢ZFusi hereby affirm drat 1 um exempt from the Cont2tim''r License Law far the
followingreasen.(Section 9031.5.Business and Professions Code:Anyoity..count, TEMP.METER OR POLE INST.
which requires a penult to construct,alter,improve,demolish,or repair any structure ,
prior to its lsmanee,rho requires the applicant for such permit to file a signed statement POWER DEVICES
O<O that he is licensed putsuan to the provisions.1 the Contractor's License Law(Chapter -
,4wo 9(e.mmencing with Section 7000)of Us isina3 of the Business and Pmfessions Code) SWIMMING POOL P,LP,C'FRIC' VALUATION
ou hot he is exempt therefrom and the basis fmmealleged exemption.Any violation of
y Z¢ Section 9031.5 by any oppliGnit fur u permit subjects the applicam m a civil penal ly of OUTLP.TS-SWITCHES-FIXTURES
nal more thin five In drul Ao lnrs($50U). NEW RLSIDENTIAL ELEC'PR _SQ.PT.
p ❑ 1.7
with wagesustheirsolewmpensnci.n, STORIES - TYPF:CONSTRUCI'ION
ii will dothe work,and the structure isnot intended oroffemd forsale(Sec.9044,13usiness _
and Professions Ceade'The Contractor's License Law does not apply to an owner of
k property whobulldsorimproves thereon,and whodees such work himselforthrough his
own employees,provided that such improvements are notiatended reoffered Textile.If, DEC.GROUP RF:S.UNITS
however,the building or improvement is sold within one yearofatmpletion,the owner-
builder will have the burden or
wner-builJerwillhavetheburdenof that he did not build or ire purposco - TOTAL:
proving prove fm f
n sola). 11 QTY. PCOMBINO PERMIT FLOOD ZONE AM
❑ has owner orthe property,am exclusively contracting with licensed contracrorsm
rnsvuct the project(Sec.1044,Business and Professions Cade:)'no Contracmr's -
whonsel.uwdoes nal applymanoh acialowtonsy licensed
Dreamed
tothe Conlin,and �PERMIIISSUANCE _
who e.mmets for such projects with acontreemr(s)Ilcensetl pursuam m the Cnmmnods
- License Law. ALTGR-URAIN&VEN'T-WATER(EA) SUMMARY
❑ 1 am rxempl under Sec ,B&PC for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner - Date DRAINS"-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Ihaeby affirm lhnllM1avea coni0cate of wnsun to aelFinsure,rracc.dllcale of
FIXTURES-PP,R TRAP RECNIPI'#
nrkers CnmpennomiInsuruneemacenifiedmpythere.f(See,3800,Loh CJwlOch O PARK FEE Y N
coven allempl�aj it. �� GAS-EA.SYSTEM-1 INC.4 OUFLETS RECEIPT#
11
Palicy# JJ w/ BUILDING DIVISION FE ES
Company
❑ Certifiedcopy is hereby furnished. GAS-EA.SYSTEM-OVER 4(F,A) PLANCI HECK FEE
❑ Cor ied copy is filed eeiduhe city inspectiondlvlsion. GREASEANDUS'I'RI_WASTE INTERCEPTOR
GRADING EEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'fRAP SOILS FEF. -
COMPENSATION INSURANCE
(This section real not be encountered ifthe permit is foronehundred doll.($Hep SEWER-SANITARY-STORM EA.2011 ENERGY FEE
or le".)
I real fy that in the zefidfrombe of,he work for which this permit is issued,Ishall WATER HEATER W/VENT/P.LECTR -
nnt employ any per In ny n mer ns t eco. subleel to the Workers' pAlp
C.mputsatia — J- WATER SYSTEM/IRP.ATING Date Receipr#
C) Applev.
NOTICE'I'O PPLICANT:If,alder mal this Certificamof Exemption,youshruld NEW RESIDAP
. SQ.FT. TOTAL:
Zi become subject loth,Worker's Campws ionp..interior the Latin,Cale,you muss
forthwith comply with such provisions or this Permit shot be deemed revoked. BUILDING FEE
RWi Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
0- I herebyaffirmihanhe,,is amnstrunim lending same,for the performance of
the work for which this hermit is inand(So.3191,Civ.C.) T L' �� ELECTRIC FEE
Lead,,v Name -
Q,U Lerder'a Address QTY. MPERMIT FEE PLUMBING FEE
I unify that 1 have read this application and state that the above inhumation is
mored, l agree to comply with all city and county ordinances and state laws reducing to PERMITISSMECHANICAL FEE
building construction,and hereby authorize.rpresentativecoftbis city loenterup.ntheCONSTRUCTION TAX
U Z abovomemmund property for mosscome'mover'. ALTER OR A(We7 ngJee to eaonemmfy at keep harmlesey o[Cupertino agelnsllumilities,jadgrnyn andexp swhieh may io any way accrue egonm eaiJ City AIR HANDLI0,000CFM)
in runs (( ��ff tV•e I xennl. AIR HANDLIR 10,000 CFM)
Ago2p W AppmadeLma for - ,.Dam EXHAUST HOOD nc PAID
HAZARDOUS MATE IALS DISCLOSURE HP,ATINO UNIT(TO 100,0011 BTU) Date Racelpt#
Will the apPlictmt or future building recup o t store or handle hezaalous material
as defined by the Cupertino Municipal Codc,Chapler 9,12,and be Health end Safely HEATING UNIT(OVER 100,000 BTU)
Cade,Seeti El Yin,2(u)"yf Nn VENTILATION FAN(SINGLE RESID) .
._ ❑Yes ya
Wid Om mcom mitmnts a,building by tiro Bay equipmem unlit Management
BOILER-COMP SHE OR,100,000 BTU) ISSUANCE DATE
zordous air commitments an defined by the Bay Ater Air Quality Management BOILER-COMP(OVER IOQ000 BTU) PAID
11 Yes �3 No NEW RESIDENTIAL.MECH.—SQ.FT. {Ilye(�I
I have read the hazardous materials requiremse s sad.,Chapter 6.95 of the - '••/'AR.1 5 19,95
- Culifarnlu Healltf&Safety Code,Sections 25505,25533 and 25534.1 understand the
if the building does concurrently have a gaunt,that a is my coponsibility to notify the
crapatd nnho requhemerds which mast beard,prier to isommee of a Cenifteate of CI1 Y UI' VUNtN I
Occupancy. ... - �.
Owner m a umerized upo nt' DateTOTAL: ISSUED BY:
OFFICE
I
10300 Torre Avenue
Cupertino, CA 95014
llpCl�'� 117.0 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 p� s cJ Qywgorl Ars'
compensation insurance carrier and policy number are:
(Ibis section need not be compleled iflbe permit is for$100.00 or less)
7� --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 w kers' c pensation
provisions of Section 3700 of theLabor Code, I shall fib
p
provisions. Date �, -J S �/�j Applicant:
by Section 3700 of the Labor Code for the perform nce of the work for w c)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.
II
Piinlerl on Recydod f'.pmi