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23940 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building Project Identification PERMIT NO. Building Addresses o O v 2 3 9 4 0 Hers Q� hone f\��• p CITY OF CUPERTINO-BUILDING DIVISIONIt e� con o .Name: a uc.No. APPLICATION /PERMIT ` BUfLDINGELFCnUCAI PLUMBINGMECHANTCAL CATEGORY Arohd / C Ofd Engineer. Lie.N. (� QTY ELECTRICPERMIT FEE. BUILDING PERMIT7NF0.. Address; BLOC PLUMB MLC1i PERMITISSUANCE 1:1 ❑ LICENSED CONTRACTOR'S DECLARATION I hereby ectionrmthafDiv Bcensedheunder Busi essandsof Chapter9(mmmen APPLIANCES E OB DESCRIPTION 'ngwLLh Section force and effe on3ofthe BusinnsandTmfessionsCode,and my license]sin full force and c.# P DcenseClass Lk.M l_X1. Date ContractoY ARCHITECTS DECLARATION /� - AMps Q 9 CZ I understand my plans shall be used as public record& ( ''1 OV 111W SQ.FT.FLOOR AREA E/SQ.FT. R Z 8 Licensed Professional `�11IY/ STG E CA as aL4 Z /� Q� OWNER-BUILDER DECLARATION S L N7/M1SC /r Lo., !. Iherebyaffirm that am exempt from the Contractor's License law for the following reason.(Section 703 1.5,Business and Professions Code:Any city of METER OR POLE INST. county which requires a permit to construct,alter,improve,demolish,or repair any atmos re prior to its issuance,also requires the applicant for such permit to POWER DEVICES c. O file a signed statement that he b hemsed pursuant to the provisions of the 1/1 O ea Contractor's Liceme Law(Chapter 9(commencing with Section 700D)of DI� VALUAI70 '0� sion 3 of the Business and Professions Code)orthatt he is exempt therefrom od SWIMMING POOL ELECTRIC S the Wks for the alleged exemption. Any violation of Section 70113 by any UTLETSSWITCHESFIXTURES applicant fora permit subjects the applicant to a civil penalty of not more than VCJ five dred dollars(5500). S, NEW RESIDENTIAL ELECIRSQ.Fr, E TYPECONSTRUC'1'ION j?< I, owner of the property,or my employees with wages as their sole 1-1 nsation,wlll do the work and the;ordure Is nm IntenAed or offered for $ O c e(Sec.70K Business;and Profeasiore Code:The Corrie o'.Wceres Law , S$ does not apply to an owner of property who builds or improves thereon,and RFS.UNRS who does such work himlforthrough hisown employees,provided that suchImprovements are not intended oroffered forsale.If,howevegthebuilding or TOT Limprovement bsold withlnoneyearofcompldion,theowner-builderwill have the burden of provingthat he did notbulld or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEEAPN ❑L as owner of the property,am exclusively contracting with Ikensed contractors to construct the project(Sec.7064,Business and Professions Code: PERMIT ISSUANCE The Contndor's License Law don net apply to an owner of property who ALM-DRAIN VENT-WATER(EM Wilds or Improves theren,oand who contracts for such ptajem with a FEE SUMMARY oqDS(+ctN or(s)licensed pursuant to the Contractor's License Law. - BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec. B&P C for ts reamn DRAINS FLOOR A,ROOF,ARECOND. SANITARY V_ N_ Owner Date RECEIPT WORKMAN COMPENSATION DECLARATION FD(.RIRES PER.IRAPSCHOOL TAX Y N N_ ❑I he affirm that I have a certlBca,e of consent to uB-insure,or a RECEIPT N certificate of Workers Comperuatim lwurance ora cedified ropythereof(Sec. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N 3800,Lab C.) RECEIPT e I�ohmyygN GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES �(gnRied copy is hereby furnished.coR ile i,uBTxL_wnSTEINTERCEe �1i PLANC14ECK Certified copy is filed with the city Inspection division. r t 77l Or CERTIFICATEOFFAEIPFION FROM WORKERS' , E P!I �+� II �i h� PAID . jh. J COMPENSATION INSURANCE SEWER�SANff� Y EA l Recei t# (This sedlon need not be completed If the permit Is for one hundred dollars f$IW)orless3 5+'&RgaA ENER FEE - N I comfy that in the performance of the work forwhlch this permit is issued, I shall not employ any person in any manner so ae to become subject to the WATER SYSTEM/TREATING Workers Compensation Laws of California.Date PAID O Z Applicant NEWRESIDENTIALPLMB. SQ-FT. Date Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you " r should becomesubject to the Workers'Compensation provisions of the Labor TOT W Code, m most forthwith comply with such provisions or this permit shall be LU j dee Code, Py P �� BUILDING FEE W — CONSTRUCTION LENDING AGENCY SEISMIC FEE L L CL Ihembyaffirm that there B.ronsuuction lending agency for the perform - TOTALELECTRIC FEEAZ Z once of the wor :k for which this permit Is Issued(Sec.3097,Civ.Q - — (,) O I.ender's Name 'PLUMBING F Lenders Address QT?. MECHANICAL PERMIT FEE. OW I certlfythat l have read thisapplication and statethat theabove information MECHANI LFEE 1 rent.Izgree to comply with all city and county ordinancesand state laws PERMIT ISSUANCE FEES } N relatinglobulldin v Ina ,andhereby.uth.dze prexntativesofthIs ct t enter o abov 1loned propertyfor inspection sets ALTER OR ADD TO MECH. ~ ? 'y(we)a se t n vet 1 Ify an d eeeds;;te Clry of cupennno Date Receipt# V agairet bilitle dg mkse expe which may in any way accrue AIR HANDLI NG UNIT(TO 10,000 CFM) BTOTAL: agai Bald Cilyinc enceo ing of this permit. AIRHMIDurvGUN1T(OVER10,tp0CIi.1) CONSTRUCT! TAX sig i t o to EXI-IAUSTHOOD(W/DUC I CONSTRUCTIO TAX PAID: HAZAR OUS MATERIALS DISCLOSURE ill,he applicant or future building oavpant store or handle hazamous HEATING UNIT CIO 100,000 BIN) pate Ceet material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely Code Section 25532(a)i HEATING UN1T(OVER 100,019 BTU) O ❑Yes MN. I Wilitheapplicant orfuturebuildingwmpantusecquipment ordevices VENIILATIONFAN(5INGLERESID) IS$UANC DATE which emit bavrdous air contaminants as def red by the Bay Area Air Iity Management District? BOILER-COMP OFR'OR 100,IXq BTU) +�J Ye. I�I No (have read the ha mous materials requirements u nder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) P A I D the California health&SafetyCoda Sections 25505,25533and 25534. I understand that if the building does not currently have a tenant,that it 6 my NEWRMSDENDALMECH. ' SQ.Fr responsibilityce of a Ctheiciaeo Occupe requirements which must bei NOV , A 19© prior to issuaMilian to notify y the occupant u a taupe Hcy. 1V V a2 Owner or authomeed agentDale ISSUED IIBYJr J II A TOTAL: OFFICE COPY