27427 (2)CITY OF CUPERTINO APPLICATION/PERMIT PLUMBING-MFICI UA KCAL
BUILDING DIVISION [NILDIN(: 1'ROJE(:'1' 11)ENI'IF1CA'1'ION,
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BUILDING ADDRESS: JJI
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SANITARY NO.
APPLICATION SUBMITTAL FATE
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CONTRACT'OR'S AMT?: LIC NO:
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CIII'IF.CTlENGINF.ER: LIC NO:
ADDRESS:
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CONTACT: PHONE
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, BUILDING PHRMI'1' INFO
BLDQ ELECT PLUMB MECH
j��Y ;9 El ElLICIMSEDCONTRACTOR:SDECLARATION
PERMIT ISSUANCE
I hereby affina that l am licensedunderprovisions of Chapler9(commencing with
ill Tartu d e(feDivision 3 of the Business and Professions Code, and my license is in
L.iccasc Class Lic.N a •
Data Contract., (iti
APPLIANCES-RESIDENTIAL
JOB DESCRIPTION
f.f JCI (QJ•/ `
Gr-r ^.�
iF
PANELSWEI
UP TO 200 AMPS
201 - 1000 AMP$
ARCHITECTS DECLARATION
1 understand my Mice shall be used as public records.
OVER IOOOAMPS
SQ. ET. FLOOR AREA
$/S .IT.
,
SIGNS ELECTRICAL
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby ME. that I am exempt from the Conuannr's License Law for the
following reason. (Section 2031.5, Business and Professions Code: Any city or county
which requires a permit to c0natr o, alter, improve, demolish, or mpan tiny swcture
prior to its issuance, also requires the applicant for such pito rile aligned statement
that he is licensed pursuant to the provisions ofthe Contractor's License Law (Chapter
9(commencing with Section 20 EA'Division 3 ofthe Business and Professions Code)
or he is exempt herefrom and the basis for the alleged exemption. Any violation ofOVILETS-SWITClICS-FlXTURES
Section 2031.5 by anyapplicantfar. permit subjects thevpplicantto a civil penalty of
not mom than free hundred dollars ($500).
❑ ],ax ownernl'theproperty,ormyemplmyeeewith wages ns theirsulecompensation,
will Jothe work.and the struqurcisnmt intended oroffercd fare sole (Sec.2(144, Bvsinus
end Professions Code: The Contractors Licemm Law does not apply to an owner of
property whobuildsor improves themon,and whodunits such workNmselfor throughhis
own employees, prmvidedthat such improvements rue not imendedoroffened fmrsale.If,
however, the mildfingia-firpmeemem issold withinoneyeaforcmmpletion, theowner.
huilder will have the Nadrn of proving that he did not build or improve for purpose of
sale.).
❑ I, asowoerofthe property, um exclusivelycommuting with licemodetntmemrs to
construct the project (Sec 70,14, Business and Professions Core) 'Me Contractors
License Lawdoes not apply to an ownerofproparty whobuilds orimprovesthereon,and
who cmmmcu for such projects with a contractors) licensed p minanuo the Conunct.r's
License Law.
❑ 1 am exempt under Sec. , B & PC for this mason
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE MST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
/ to�
`
NEW RESIDENTIAL ELECfR _SQ.fT.
STORIES
OCC. GROUP
FLOOD ZONE
ST
TYPE. CONS
RPS. UNITS
APN
QT;Y, PLUMBING PERMIT - FEE
FERMI'P ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
SANITARY YN_
Ifo CEIPTN
Owner Uma
DRAINS -FLOOR, RODE. ARI?A. GOND.
WORKMAN COMPENSATION DECLARATION
❑ erambyaffirmtnInsurancoraceateof copythe of(iec, 380, a certificatech
Worketv'CompenamiOn lnsumnc<nr0cenifieJ copy there0f(Sec. 3800, Lab CJ which
nallunployee' rql,
prdic,# �� e1�Y--
SCHOOLTA% YNR
RE?CEEPfp
FIXI'UR-PF.R
PARK FEE YN
RECEEPTp
AS- CA.SYSTIiM-I INC. OUTLETS
BUILDING DIVISION FEES
Campers �t 6t -KI �—
m
❑ Certifie pyishere yfumished.
Certified copy is fled with be city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('this section need not lx completed ifthe permit is for one hundred dollars ($1
or less.)
I certify that in Rte performunce of the work for which this permitis isms shall
not employ any person in any roomer an as m become subject to the orkers
COmpensationlawaof C.Nif0mi0. Doe
Applicata
NOTICE. TO APPLICANT: If, after making this Certificam of Exemption, you sho d
become subject to the Worker's Compensation previsions ofine LObor Code, you mu
forthwith comply with such provisions or this Permit shell be deemetl revoked.
CONSTRUCDON[.ENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3092, Civ. C.)T03'AI
GAS-EA.SY$T13M.OVER4(`M
PLANCHECK RSG
GREASRr[ND LWASTEI ER MOR
GRADING FEE
GRE T
SOILS FEE
SEWER- TARY-S'f M
ENERGY PTE
HEATER
PAID
Date Recc
TOT L.
'TER SY TING
'W RESED AL PLMB. SQ. IT.
BUILD
SEISM'E
^
13LECfRIC PEE
L.emki's Name
Lenders Address
QTY. -` ., HANICAL PERMIT FEE'
PLUMBING REE
I certify that I have mad this application and We that the obove information is
c.rm,. Ixgrac umamply with all city end county arJinancer and atom luwa relating to
building construction, and hereby authorise represenctivesofthiscity, 10 enmrupon the
above-mentioned property for inspection purposes.
Was) agree to save, indemnify and keep h s the City of Cupertino against
liahilitics,jud ts,c stsandc enseswhic tent waynccme egvinstnud City
in const oft gran' thio
'
PERMIT ISSUANCE:
MECHANICALFEE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT TO 10,000 CFM)
CONSTRUCTION X
AIR HANDLING UNIT (OVER 10,00) CFM)
Si tmurt of ApplicanUCam ate
IIAZ DOUS MATERIALS DISCLOSIJRF.
Will tM1e applicant rfuwrc building occupant store orhwdle hazuMws material
ss defined by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
Code, Section Y 11 No 25532(0)?
❑
Willtair co icuainrfm ax building bythe BayA pmir Quality Manes agement
Grardous au conmminants ax dcfinN by the Bey Area Air Quality MOnagemrnt
Dioriat?
❑ Yes ❑ No
1 have read the hazardous materiels requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 23533 and 25534. 1 undem tnd that
if the building dons not currently have a tenant, that it is my responsibility to notify the
ceupant of be acquirements which must be mot prior to isautmce of u Cenifieoe of
Oceapeaoy.
EXHAUST HOOD(W/DUC)
PAID
Date Receipt #
HEMING UND (TO EMO RTU)
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RHSID)
P
F ISSUAN AT
n
y 1 1Q9S
CITY 99
Ur �UNtHIlNO
ISSUED BY: V lA✓A
BOILER- COMP(3HP OR 100,M) BTU)
BOILER -COMP (OVER IW,000 BTU)
NEW RESIDENTIAL MECH. SQ. IT.
"' ^
Onoerorvmhodxed egem Data
TOTAL:
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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 is ued. 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 hall ith�omply h th e
provisions. Date Applicant:
by Section 3700 of�or Code for the performance of the 3,oll ror whic i 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.
Wonted on Weapciud Pape,