27497 APPLICANT TOFILL�IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO m A' PERMI"°'
PLUMBIG-MFCEANI
BUILDING DIVISION APPLICATION/PERMIT BUILDING
PROIIC1IIFICAlION
27497
R1111-DING ADDRESS - SANITARYNO. APPLICAIO•NNSUBMIITAL DAIS
�Q �� UNIT« LOT#
:RSN E: PHONE: CO A( R'S NAML. LIC O:
c E S3 / NIC CONfROLX
\RCHITF.CI'/Fi1JGIN1iER: LIC NO: A )1 ❑
o b EE �i
CONTACT: PHONE: QTY. .' '`F.EECTRIC PERMIT PEE BUILDING PERMIT INFO
." 1 Z p 1rr " BLDG ELECT PLUMB MICH
PERMIT ISSUANCE L ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL ^' LOB DESCRIPTION
I hereby affirm that l am licensed under provisionsal'Chapter9men
(comcing with
�00 Section 7000)of Division 3 aide Business and Professions Cale.and my It..is in PANELS a
,�,b Mull tome end effect.
FZ, License Or. Lic.# UPT0200AMPS
rn6y Date Contractor 201-10X0AMPS
Z FOyZ AlocBrTECpS DECLARATION OVER 1000 AMPS SQ.FT.FLUOR AREA $/SQ.FT.
O Z Z 0 I understand my plans shall he used m public retards.
L:-Rs oa SIGNS ELECTRICAL
LicenaN Profession)
2�y.CQ OWNFILRUILDER DECLARATION SPECIAL CIRCUDMISC.
e'. I hereby affirm that I em exempt from the Connectors License Low for rhe
W 3 a rf following reason.(Section 7031.5.Business pod Pro r mioCode:Any city or county TEMP.METER OR POLE INST.
F
0< whieh requires.permit m transport,.]an,improve,demolish,or repair any.pomurc
WWT� priorm its issuance,also requires the applicant for such Permit to file a signed statement POWER DEVICES
W K< w
O that he is licensed pursuant to the provisions of the Contrmrs License law(Chapter
o.`a C 9(rommencin with Section 70011 f Division 3 of the Business end Profession Cale SWIMMING POOL ELECTRIC
Kca gwi )o ) VALUATION
or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCEPS-
FIXTURES
.Za Stern..7031.5 hyany.pplicannfar.perminmbjectamheapplicenn mecivil penalty of
not more than five hundred dollars(150E.C NEW RESIDENTIAL ELECIR _SQ.FT.❑ Lasownerofthepropery,ormyemployceswith wagaenheirwlecompenseuon, STORIES 'TYPE CONSTRUCT ION
a _ will do thework,and the sormarm is not intended oroffered fromfic(Sec.71144,Business
and Professions Code:The Contractors License Law does not apply nom owner or
prepertywhobuildsor improve.,thereat,and whodesessuchwork himselforthrough his "
own employees,provided that such improvements arc not intended oroffemd forsale.If. - OCC.GROUP RES.UNIT'S
however,the building or improvement is sold within one year ofcompletion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
x la).
❑ L,asowneroflheprnpeny,amcnclusivelycnmruaingwith licensed commnom in QTY. PLUMBING PERMIT FEE FLOOD ZONE MIN
construct the project(Sea 7044,Business and Profession%co,to The Commeres
License Lew does not apply to an ownernlpapery wholooldrarimproves thereon,and PERMIT ISSUANCE
who amtmets for such projects with a cimmmtm(s)licensed pnronmUo the Contractor's
Lisette Law. ALTER DRAIN (FA)) FEE SUMMARY
❑ Iran exempt under Sec. ,11&PC for this reason BACK FLOW PROTECT.DEVICE - 0131SIDIS SLI:.
SANITARY YN_
Owner Dute RECEIPT«
WORKMAN COMPENSATION DRCLARATION DRAINS-FLOOR,ROOF,ARF:A,COND. '
SCHOOL.TAX YN
❑ em'Compensm lhmlhmnceor enifieeonsemmwlLinsure,o.Lah whie h FIXTURES- RECF.IPTp
PF.R'IRAP
Wotkcrs'Compensadnn lnsumnm or.ierlfiW copythcmof(Sec.JSW,Ltlh CJ wM1lch PARK FEE YN
xivens all employee's under this permit GAS-BA.SYSTRM-I INC.40UTLETS + RECE:IPTp
Policy# BUILDING DIVISION FRES
Company GAS.EA.SYSTP.M-OVER 4(EA) PLANCHECK FEE
EJCer ified copy is hertby famished.
❑ Certified copy is filed with the city inspection division. GRFASE/INDUSTRL WASTE UTERC R
RAGING FCE.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP SOILS FEE
COMPENSATION INSURANCE Is
(This section need net be completed lithe permit is forone hundred dollars F$103) SEWER-SANITARY-S WET. ENERGY FEE
or less.)
I certify that in the performance ofth.work for which this permit is issued,L.hat[ WATER BEATER W/VE /EL R
not employ any person in any manner w as to become subject no the Workers' PAID
Compevation Lawsof Celifomia. Dom WATER SYSTEMMEATING Date Receipt«
Q Z Applicant
Z 0 NOTICE TO APPLICANT,If,after meting this Certificate of Exemption,you should NEW RESIDENTIAL PI.MB. SQ.PT. TOTAL:
(✓ V) become subject to the Worker's Compensation provisions,of the lather Cade,you must
a ; forthwith comply with such provisions or this permit shah be deemed revoked. BUILDING FEE
0. Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
UZ Ihereby.ffmrm that there is a construction leading agency for the performance of
O the work for which this Permit is issued(Sec.3097,Civ.CJ TOTAL: ELECTRIC FEE
Lenders Name
0 U Leaders Addms QTY. MECHANICAL PERMIT FEE
PLUMBING FEF.
U 1 verify that I have reed this application and sure that to,above information i.
�" 1 correct.lagr Itnear,lywiNalleity.ndcounry ordinances andram law.adding to PERMIT ISSUANCE MECHANICAL FEE
buildingeommction.and hereby.mhorize reprenumunivesidmis city toemer upon the CONSTRUCTION TAX
U Z above mentioned papery purpose..for inspection ALTER OR ADD TO MECH.
(We)agree m sav Tdemnify end ilk ermlas. ey
the City of Cuperirm egainr
liabilif jud renes, code mm .anywaccreag St. my AIR HANDLING UNIT(TO UL00 M)
oft
AIR HANDLING UNIT(OVER IO,IXq CFM)
Signam of ro
1/Cnnuaao4Fate EXHAUST HOOD OVIDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0011 BTU) - Date Receipt#
Will the applicant or future building occupant store or handle hazardous material 1113ATING UNIT(OVER 100,1100 BTU) I'
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Ilea11h and Safety
Cale.Section 25532(e)?
1:1 Yes C3 No VENTILATION PAN(SINGLE RESID)
Will the applicam or Tpmrc building occupant use a,ripmem m shmicea which emir
BOILER-COMP CHIP OR 100,1100 BTU) ISSUANCE DATE
.
hazardous sir comaminwts as,defined by the Bay Area Air Quality Mnnegemenl
Di.,trier? BOILER-COMP(OVER 100,000 BTU)
PAID
L
Yea ❑No NEW RESIDENTIAL MECtI. SQ.PI'.
read the hazardous materials mi nimments under Chapter 6.95 of the
alth&Safety Cn le,Sections 255(15,25533 end 25534, 1 undersand thatJAi� Qry �(](�[does not currently have a6ari thin 11 is my me'sursibility,,nosily We t M (da 995he requireamnre whlth must M rata prior toIssmnmcnf.CertiOemen[ v CI !",G11C�Ij}k`�mrizcdegent Dote TOTAL: ISSUED BY: «j� 1
OFFICE
i
10300 Torre Avenue
(-i I` of
Cupertino, CA 95014
Cupertino 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 Re y�,sued y workers'
compensation insurance carrier and polic�{1u er e: / Zf /7_
(this section need not be ca plel t i is ror .0 ar ess)
--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 Sectio 3700 of the Labor Code, I shall forthwith comply with those
provisions. Date__J Applicant:
by Section 3700 of the Labor Code for the performance 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.
Printed nn Rer.,ded Paper