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23454 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PFR.WTNO. Bnudtng Addreas3 oe_- 23454 where�1 TO(\ me. CITY OF CUPERTIN UILDING DIVISIO APFLICA' A C "'°''°" APPLIC Nil �Z JJ BNLDINGEL TRIC PLUMBINGM 7CAL CATFCORY CONIC A Iter/ g(neer. r Lk.No: - (p QTYECTRIC E FEE BUILDING PERMIT INFO Address KPANELS �' LICENSED CONTRACTOR'S DECLARATION I hereby affirm that l am Demand under provisions of Chapter9( JOB DESCRIPTION Ingwlth Section 7000)of Division 3 ofthe Business and Professions e,an license 1 in foil and cited. ^ A f71 Limns fpm_ LieM / �"1 Y� V Datej(f-ate Contractor 7//V RCHITECI'B D LaRAT10 0�G0. SQ.FT.FLOO�EA 5/SQ.FT. Z f� Llm2.6� OWNER-BUILDER DECLARATION L. Z IhcrebyafBrmthatlamexemptfmmtheContmdor'sLimnsLawforthe ISTII,OZfollowing reason.(Section 7021.5,Business and Professions Code:Any city or 4�countywhichrequl apemmttomrrttmct,alterim p E INSI. ` LL OzJ : a prove,demolish,orre air anysuuture pdorto its isuance,ahn,requiresthe applicant for such permit to ^3 0 file a signed statement that he is licensed pursuant to the provisions of the WER DEVICES 8 O Contractor's Licence law(Chapter 9(commencing with Sction 7000)°�io (Divl- SydU1h9NG POOL ELECTRIC Z basis fo the Alleged Pmfcstion. Anyvirthathe Iseection herefromand ^ XALUATION appyi 3 the basis for the alleged exemption. Any vlolatlon of Se tion 70.115 by any /a� s(s/V_1 S ¢O5 five hundred apems($500eta the appilcantmadvil penaltydna motet OUTLETSSWITCH[SHXT[JRES C/ r. five hundred dolowner ofthe pro E]1,as owner of the property,or my employees with wages ntMir le NEW RESDENIIAL ELFCTR SQdrf. A STORIES r NSTRUCTION �7¢ compensation,wlldothe work and thestmcture Is not intended or offered for 1 !/\ G $ O sale(Sec.7064,Business and Profesocoxi Code:The Contractors License Law '� VVV 2 don not apply to an owner of property who Wilds or improves thereon,and who docssuch work himself orthrough his own employees,provided that such 9. F 7TS improvements are not intended oroffered for sale.ILhowevegthebuildinger TOT improvement issold within m eyearofcompletion,theowner-W arlerwill have thLInrden ofpmving that he did not build or improve for purpose ofsale.). QTy, PLUMBING PERMIT FE U L as owner of the property,am exclusively contracting with license PERMIT ISSUANCE contractom to construct the project(Sec.7016,Business and ProfessionsCode: The Contractors License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER ffN Wilds or improves thereon,and who common for such pt°jects with a cent[torts)ummed pursuant to the Contractor's License Law. FEE SUMMARY LJ I am exempt under Se. B& P C for this reason BACK FLAW PROTECT.DEVICE • Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ WORKMAN COMPENSATION DECLARATION RECEIPT M ❑I he affirm that I have a certificate of consent to self-irmm,or a FIXTURES PER TRAP s SCHOOL TAX Y N certificate of Workeri Compensadon Insurance ora ttrtlEed ropytherrof(Sec, I RECEL'f M 380,Lab C.) GAS EA.SYSTEM-1 INC4 OUTLETS �j PARK FEE Y N I'otrya -o' RECEIPT Is Cam any GAS V 4 ) BUILDING DIVISION—FEES one ropyIshereby fumIsnea. GREA q .v ALANCI-IGCK PGE ertifle copy Is filed with the city Inspection division. CERTIFICATE OF EXEMPTION FROM WORKERS' GR E PAID COMPENSATION INSURANCE (Thissection need not becompleted lithe permit Is fmrooehundred dollars SEWER-SANTTARY- RM ' Date Recei t# (S10D)orless.) Iremlythat in the performams ofthe work forwhlch this permit is Issued. WATT ENERGY FEE Y N_ I shall not employ any person in any manner so as to become subject to the O Workers'Compensation Laws of California.Date WATERSYSTFM/TREATING- - PAID Applicant Z 0 NOTICE TO APPLICANT:IL after rteking this Certl(lote of ExemptlanI you NEV✓RESD[NTIAL I'LMB._SQ.Fr. Date ReceI t# F — shcold became subFct to the Workeri Compensation provisions ofthe Labor TOTAL: WW Code,you rnustforthwith mm ply with such providers orthis permit shallW > deemed revoked. BUIL ING FEE d p CONSTRUCTION LENDING AGENCY SEISMIC PEE 1 hereby affirm that there Is a construction lending agency for the petorrry ELECTRIC FEE 7 Z ince ofthe work forwhkh this permit is lcauxt(Sec.3097,Civ.C.) T LL O Lendars Name PLUMBING FEE LL F Lenders gddre� QTY, MECHANICAL PERMIT FEE O W IceAifythatlhavercadthLappiimBonandsmtcthattheabovemforrutionn MECHANICAL FEE EL recorret.I agree to comply with all dtyand county ordinances and state lawsANCE �' FEES PAID: I. U) relating to building constmctlon,and hembyauthoriu representative°fthls H Z city to enterupon the ab°ve.mentiorm property for inspection purpose. DTO MECH. — (We m save,indemnity an d keep harmien the City of Cupertino Date Receipt# agai lab IOes pdgments,costa and expenses which mayin anywayaccrueNG UNIT(TOt0,000CFM) ag t City mon reofthagnnr ofmIs mutt. SUBTOTAL: NG UNIT(OVER l0,000CFM) CONSTRUCTION TAX Signa mo pp Ctctor to OD(W/DUCT) CONSTRUCTIO TTAX PAIDHAZARDOUS MATERIALS DISCLOSURE Will the applicant orfuture building occupant store or handle havardousT CFO 100,000 BTU) material as define by the Cupertino Municipal Code,Chapter 9.1$and the �"� Date RCCCI Il el hand Silty Code Se Uon 25537G)7 HEATING UNIT(OVER 100,000 BLU) TO ptilf ❑Yes' yyf No , Will the applicant 4f IDture building occupant use quipment or devices !ML (SINGLE REBID) (j T SDANCE DATE which emit hamm ous air contaminants as defined by the Bay Area Air1� Quality Management Dbtdd7 DR 100,000 BTIA R Ys No `p have read the hazXous rormnab requirements under Chapter 6.95 of BOILER-COMP 1W000 BTU) �T"II t�Y the California Health&Safety Code,Sections 75505,75533 and 75536.117�Hi fL1n� UR thatifthe Wildingdoonotcvrr tlyhaveatenanLthatitismy MECIi. SQ.F7 1797 me muytondilytheoccupantofthemquireoemawhichmuatbemetCITY pro mise ancedaCa ificate ry. `Ur _ ZSTI f f1YV Ow t orf d agent D e _ .: S ISSUED BY:�1 OFFICE COPY