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