27793APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO HII:DI." i - ELRC'1'RTCAC
APPLICATION/PERMIT PLUMBrvG-MECHANICAL
BUILDING DIVISION I BUILDING PRO IFCT IDFIVOFICA
LICENSED CONTRACTOR'S DECLARATION
Oa'z Ihereby affirm that l am licensed umbrprovisionsof Chapter9(commencingwith
�00Section 7000)of Division 3 ofthe Business and Professions Code, and my litems ism
yU� full force and effect.
FZu] License Class Lick
HQy Date Cmmaclor
7Osoz ARCHITECTS DECLARATION
7 1 understand my plans shall be used as public records.
h
licensed Rnfessi.nal
OWNER -BUILDER DECLARATION
kOaO 1 nothy If. thin I no exempt from the Const..', Licenm law for the
W yafollnwingremon.(Section ?031.S,Bosincss and Professions Code: Any city ...... ty
1-
°' J which respires a permit to consumer, alter, improve, demolish, m repair any structure
7�YS priormits ismance,also re9uiresthe applicant!orsuchpamitmfileasignedstatemenr
cit
Id, <C) that he is licensed....am name pr.vislomofthe Contractors License Law (Chapter
o-Xo� 9homatmemg with Section 7")of Division 3ofrhe Business and Professions Cale)
m_y .rebut he is saempt therefrom add the basis far Ne alleged exemption. Any violation of
F _zQ Section 7031.5 by any applicant for a wroaf subjeses the applicant to a civil pens
not mom than rive hundred dollars ($500).
K o ❑ I, as owner ofrhe property, ormy employees so comNotation,
a3=° will do the wo.k,and the succture is not imendedmidfferedf e(Sec.='Rmimss
and Professions Code: The Commeme.s License 1, cev not apply m an owner of
,ropers who WildOnimprow. Nemon.an net such work himaelforrhmugh his
wnpmployecs.provided llutlsuch int omen¢amnminendedorofferedfsradc. If,
M1nwevcrdhc huilJing.rimproven tis sold within one car ofcomplerion,the owner -
builder will have Ne burden of pt ving that he did not build or improve for purpose of
sole.).
❑ Las owner of the property, nexclusivelycont tingwiNlicensedconuactomto
answer the project (Sec. 7 . Business and protestors tide:) The Convertor's
Licenselawd«anotappbtoan woe, of properly who builds or improves Hereon,and
who contracts for such projects thacontracmr(s)licensedpursua Bothe Convector's
License taw.
I]l sm eaamp under Sec. a 14,Adhismood
Owner
WORKMANI
MPENS DECLARATION
❑ I hereby affirm]hast haveenifcam sent to self,,���=yyyyy r��� cam f
Wakers'Compensnlinn lnwrat acrmd copymereo S which
covers ell cmployasundcr thireit.
Policy N
LJ Certified copy is fled with a city inspection division. /
CERTIFICATE OF FMPTION FROMW ERS'
COMPEN TION RsISURA
!This section need not be comple if Nope, is for me hummed dollars($ I Ip)
orlea)
I testify that in Ne Perfamana of Ne work for which Nis permit is issam. I shall
not employ any prison N any manner so as to become subject t. the Worker'
z Compensasiou Lawsof Corfomia. Dare
Q Applicant
z 0 NOTICE TO APPLICANT:If,after raking this Cenifiate of Exemption, you should
P11- become subject o the Worker's Compensation provisions of the labor Code, you must
> forthwith comply with such provisions or this permit shall be deemed revoked.
y Q CONSTRUCTION LENDING AGENCY
z I hereby affirm than ume is a construction lending agency for the perfimmunce of
U O the work for which this permit is issued (Set. 3097, Co. C.)
Lender's Name
O U Lenders Address
I ceree
rtify that I have reed this application and smte that the above information is
Gcorrect. I agree to comply with all city mod county ordinances and some laws rehiring to
,1- building commuction, and hereby auNorim representatives of this city to enter upon the
U Z above-mentioned property for inspection purposes.
(We) -gree 10 save, imlcmnify and keep handless the City of Cupertino against
kohdoies 'udgmenls, costs and expenses which my in any way accrueagaimt mid City
I s asmN U rbc granting of This pnmit.� 1 -f
�/ Y•YIL�-�J�r �1 S
HAZARDOUS MATERIALS DISCLOSURE
Will the opplicam or fulum building occupant sane or handle hazardous material
as defined by the Cupertino Municipal Code, CM1ader 9.12, and the Health and Safely
Code, Section 25532(x)?
❑ Ycs ❑ No
Will the applicant or future building occupant use Nuipmenl or devices which emit
baz moms air contaminants as defined by he Bay Area Air Gash, Maragemem
IDistrict?
❑ Yea ❑ No
I have read she bmardous materiels reyuireomne' under Chapter 6.95 of IM1e
California Health & Safety Code. Soarers 25505, 25533 and 25534. 1 undervi nd that
Iftheb idurigJots not currently have a scram, that it is my responsibilitym notify Ne
occupant of the requirements which mel bre mel prior to issuance of a Cerifirnm of
Ocapudcy.
Owner or amhonzed agent Dale
MOM
O P6TIQ1- w47 S
ELECTRIC PERMIT
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UP TO 2W AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
IITLETS - SWITCHES - FIXTURES
NE lRESIDENTIALELECTR —SQ. ET.
TOTAL:
PLUMBING PERMIT
AL R-DRAIN&VENT-WATER(EA)
BAC FLOW PROTECT. DEVICE
DRAT qS- FLOOR. ROOF, AREA, COND,
T RES - PER TRAP
GAS /EA. SYSTEM -I INC. 4 OUTLETS
GAS - EA. SYSTE.M43VER 4 (EA)
GREASFJINDUSTEL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANITARY - STORM EA. 200F7.
WATER IIEA'TER W/VENT/ELECTR
WATER SYSTENITREATING
NEW RESIDENTIAL ELMS. SQ, ET
TOTAL:
MECHANICAL PERMIT
PERMIT ISSUANCE
ALTER OR ADD TO MECH.
AIR HANDLING UNIT (TO 10,000 CEM)
AIR HANDLING UNIT (OVER 10.000 CFM)
EXT IAUST HOOD (W/DUCT)
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER I W.OW BTU)
VENTILATION FAN (SINGLE RESID)
BOILER - COMP LISP OR Imorpt BTU)
BOILER - COMP (OVER IW.0t BTU)
NEW RESIDENTIAL MECH. SQ, ET.
FEE
FEE SUMMARY
SCHOOLTAX
Recciptst
El EC 'RIC FEE
FEE PLUM ING FEE
PAID I F3 6
15"AFV
MAR 13 1995
\CSI ICY/)1Uy�rjJwr tVV
ISSUED BY:
V 27793
SANITARY NO,
CATIONSUBTALDATI
APPLIMTI
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O:
r 349/
N/C
❑
CONTROL p
N I 1
FEE
BUILDING PERMIT INFO
4LDG ELECT PLUMB MECH
I��'IfW ❑ ❑ ❑
k-L1JP5jMj
4c- las, 1.1 "I-= I
FEE
FEE SUMMARY
SCHOOLTAX
Recciptst
El EC 'RIC FEE
FEE PLUM ING FEE
PAID I F3 6
15"AFV
MAR 13 1995
\CSI ICY/)1Uy�rjJwr tVV
ISSUED BY:
•
o l'
C �)
10300 Torre Avenue
Cupertino, CA 95014
WORKER'S COMPENSATION DECLARATION
Building Division
(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: ( I 672A -Q'-
(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 shall forthwith comply with those
provisions. Date -13-3 Applicant: _,
by Section 3700 of the Labor Code for the performance of the wor 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.
P,mfeo un nocydwl Pnper