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APPLI j
CITY OF CUPERTINIZLB I ING )N
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• APPLICAT19 PE MI 7/
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LICENSED LNSED CONTRA DECLARATION
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In
[.11 fruce.ed cited.
License C 1.N—
[)air Conlrador 2014
ARCHITECT'S DECLARATION OV SQ.FT.FLOOR AREA $/9Q.Fr.
'god I understand my plans shall be used a public records.
�'J SIGNS CA
,'Q U Licensed I'mIcRolonal
OWNER-BUILDER DECLARATION SPECIAL T/MISC
1 hereby afilm,that I am exempt fromtheContrarlm'PLImoseLavelorlhe
0 following reaxcn.(SectIom7MI.S,Ikt,lroro.rd P.fRRhm,CdR:Arycbym
,�.H�H-a countywhich rupolocs,a permit loconstruct,miter,improve,demolish,or repair—TEMP.M ORPOLEINST.
Qat any.truct.no prior to It.Issuance,alsorequires the applicant forsuch permit 10 POWER EVICES
Elle.signed statement that he Is licensed pursuant I.the pi-not-ime,of theOw —
Contractor's License Law(Chapter 9(communcing with Section 7000)o(Divl- SWIMMING 11001.ELECTRIC VALUATION
.[..3.fth,Bualorstt.ml I .mCcde)mIhxt he ta exempt therefrom and
N the basis for the alleged exemption. Any violation of Section 7031S by any
I L-t,F1 17.3 LkRR,, occ)
applicant fora permit subIrra the applicant to a civil pen.1ty.f.et.11(h-n TTE;;S,1TCifESwFIXTLjR%S
f ..d,dII...($SM. NEW RESIDENTIAL ELECER—SQ.FT. g JUES --TA-T—
ECONSURUCTIONV,,. .=rer
nif the property,or my employees with wages as their Role
will clothe work,and thestood-re Is not Intended or offered for
aptly
The
Law
does rest apply to an owner of property who bollds or Improves thencon,and
who doessuch work 14.11crothrough 1d,.wrocnpIyca1,prcwIdsdIIuttmch MACE Iq
�Improvement are not Intended oroffered fomite.Ifho,ven,erthebuildingor
-mprovcmrrrt issold withlooneyearofcompiction,the owmet,louliderwUl have
the burden of proving that he did not build or Improve for purpose Waste). EtTy.
, —PLUMBING'PERIVIM I. R:U-T-pER
F1 1,as owner of the property,am exclusively contracting with licensed P EMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and profession Code: IS —
The Contractor'.License Law does nor apply to an owner of property who -DRAIN&VENT- DAM
Wilda or Improve.s mercers, and who contracts for so& tonJects with a ALTER
=11M
csel.,O)licensedpunumtlo lhs Contractor's License Lew.
8l am exempt under See.� B& P C for this,reason BACK FLOW PROTECT.D fiICE
DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner ___Date RMCEH7 0
WORKMAN COMPENSATION DECLARATION rmvRF&pFRTRAP SCI IDOL TAX Y_ N_
Of hereby arflrm that I have.certificate of consam toself-Inure,ora H RECEIPT N
certificate of Workers Compensation Insurance or a certified copy thereof(See. CAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y— N—
1100,Lab CJ REcEirr N
• Policy N CAS.EA.SYSTEM OVER 4(EA) B UI LDING DI VI SION FE r
Com any
Com
copy I,hereby furnished. CREASCANDUSTRI,WASTE INTERCEPTOR PLANCI IECK FEE
Certified copy I,filed with the city Inspection division.
CERTH ICATE OF EX17M(TION FROM WORKEID
RS' GREASE TRAP PAID
COMPENSATION INSURANCE SEVVER.SANITARY.STORM G.20017, Date ?69!N�
(ThIs.collon need not be completed If the permit I,fovea hundred delta. LR J 1
($100)or less.) WATER I[EAT 0 W/VENT/ELECTR to ENERGYPEE Y-
1 certify That In the performance car the work for which this pertnll is hued,
I shall not employ any person In any runner u an to become object to the WATER SYSTEM/TREATING PAID
W.,krnf Compensation Laws of California.Date—
* z Applicant FIN RESIDENTIAL I'LMB.—SQ.M Date Revel til
* 0 NOITCE 10 APPLICANT:U,after making this Certificate of Exemption,You TOTAL:
7— should beemoo.0ject to the W.,kera'Coroperoodi..provI.I.n of the Labor
cc Code,you=at forthwith comply with such provNimut or this pormli.h.11 be
LU deemed revoked.CONSTRUCTION LENDING AGENCY
SEISMIC FEE
CL 1 be,rby.ffl,.that the,,is,.construction[ending agency to,the pef.orn, ELECTRIC FEE
:) Z ance of the work for which this permit I,Issued(See.3097,Civ.C.)
00 la.dc,',Name .......-�x 'I' PLUMBING rEEFEE 77 COLANA—
QTY. NZ-
MEC J� —1
LL Lender',Add.. MECHANICAUERIVII. ,1, HA L
0 0 1 cerillythat I have read this appllcrlkm and statethatflualowe information I
III currect. PERMIT ISSUANCE FEES PAID:
>- Q. rchillog to building construction,and hereby authomer representatives of this A—
V) city to enter upon the above-wittloned property for inspection purposes. ALTERORADDTOMECII. Date Receip'll
6VO agree to save,indernellyand keep harmless the CJtyofCupertino
osis galn,t Ila
w f hic,h—yinR.y.R a. x AIRILANDLIN SUBTOTAL!
g.lmt d0tyloinole It.;. this
pe I CONSTRUCTION TAX
--th. AIRIIANDLING UNIT(OVER I0,0L0CFM
Nor
MAT
"IRS_ tons or
d pant
D,it at LADS r I IOOD(W/DUC—n CONSTRUCTION TAX PAID:
a ppilesol ort clor
IIA RDO MAT CRIALS D I SCLOS URE
Will I he a pplica nt r tutu re lidin S occu pant store or ha od is hazardous I[EATING UNIT(TO I 00,0D)DIM Date Recekt 9
mtefl.l.i defined b theCupc no Municipal Code,Chapter 9.12,and the
�"i
rly
1�,a I I h rdSafoy C Section 320)7 1 IrATiNG UNIT(OVER 100,DUO BTU) TOT
1�11"Ye, —
I I on can
cbr applicant or torc b.11dirg part use equipment.1 devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which lemit harardous air contaminant as defined by the Bay Area Air 1-
0".111 M...Bement District? BOILER-COMPOIAP OR 100,D(XI BTU)
Na -U)
C*�"'c read the lutz.g.us materials requirements under Chapter 6.95 of DOE-1311-COMP(OVER100,000BI
the California I lealth&Safety Code,Sections 25505,25533 and 25534.1
understand that If the building does not currently have.I'mint,that It 1,my Nf:WRESIDENT1ALhfl1C1I_SQ.FT MAY 2 9 199?.
• responsibility to malty the occupant of the mclubcorands which most be mett
I G I Y 1jr 110rcwi IMPS
Owner m.uthodred agent Date77A I ISSUCDUY'.'\
-
OFFICE COPY
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