24204 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ad Identification I PELWTN¢ 4 2 0 4
Building Address: CKWS
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nff9 dIM: nn e:
-QtQaCITY OF CUPERTINO-BUILDING DIVISION
cor'•Nanr: (^^ Lie.No: APPLICATION /PERMIThediLd
�•'�� U BUfLDINGELECTRICALPLUMBINGMFLHAMCAL CATEGORY CO J.1
Architect/En neer.�y Lk.N. CJ
QTY ELECTRICPERMITBUILDING PERMIT INFO_
Address: PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby a Rum that l am lkensed under provisions of Chapter9(commenc APPLIANCflSRES] 'NIIA JOB DESCRB'DON
Ingwith Sction7000)ot DiWMon3ofthe BuAnessand Pmfes•IonsCod dmy
limns,is In full force and effect. PANELS
License Clam LIc.It
Data Contractor Li an,i
ARCHITECTS DECLARATION ODYATAPS
coq X0C I understand my plans shall be used n public records. �AMP .FLOOR ARFA 8/SQ.FT.
E u Licensed Professional SIGNS EL CAL �I
L
GQ OWNER-BUILDER DECLARATION SI'ECIALC U /
Iherem byaffirthat lam exempt from the Comranoes License law to the
O
pp following reason.(Section 7MIS,Business and Professions Code:Any city or Z F.. TEMP.M O POLE INSI.
Fy � ceuntywhich requires apermit tomrutrua,alter,impmve,demolish,orrepalr
g �,a anyatructure pdorto its Issuance,also require•the applicant forsuch parent o OWER DE CES
t51 file a signed statement that he Is licensed pursuant to the provisions of the
G61 Contractors License (ChapterLaw 9(rommencln ithSection7000)ofDWl-
30�^ son 3 ofthe Buslncssand PromassimsCods)orthatt hela exem them to od SWNIMIN POOL FIE C VALUATION
the basis for the alleged exemption. Any violation of Section 7¢11.5 by any OUTLETSSWITC FIXNRES I �!
�ry applicant for a permit subjects the applicant to a civil penalty of not nnre than
G five hundred1,as dor ars of
00). NEW R AL ELECTR SQ. . STORIES TYPECONSTRUCTION'
7� ❑I,as owner of they wort yaorhe employees with wages as theles ole
7Q compensation,Z,ilheworkandthestrunurela Contractors orofferedLaw
❑ sale(Sec. pply to alnower Professions Code:Wids Contractors Lenon,ad
does does
apply to work
owner of property who n Wilds or Improves thereon,•cad
�5..
who doessuch work himself orthrwghhis ownemployees,provided that such OCC.GROUT' RFS.UNI'T'S
Improvements arc not intended oroffered for sale.If,however,the building or TOTAL:
Improvement Is sold within oneyear ofcompletion,the owner-bullderwiil have
th,s.¢urden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with Bernard
contractors to construct the orced(Sec.7014,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does no apply to an owner of property whoALTER-DRAIN&VFM-WATER(EA)
Wilds or improves thereon, and who contracts for such pRojecis with a FEE SUMMARY
�ndtrfselects)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
cc L11 am exempt under Sec B &P C for this reawn
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT N
f
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCIROOLTAX Y_ N_
❑1 hereby affirm that I have a certlRcate of consent to cell-Insure,ora RECEIPr N
certificate ofWorkns Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FTE Y N
3800,lab C.) RI:CEO'1'N
Pollry p CAS EA.SYSTEM-0VPR d(EA)
Com any BUILDING DI VISION FEES
F_1ia
C fled copy hereby(umished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHGCK FEE It ♦ N^
❑ _cmhad copy is filed with the city inspection division. �C /L>d7
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Chis section need not W completed If the permit b for one hundred dollars SEWER-SANITARY-S IORM EA.IfpF7. Date Recei is
saw-
($100)orla..) WATER HFAT77i W/VENT/ELECTR ENERGY FEE _
I mreByth•t In the perfornanmofthcwork forwhlch this pennitlsissued, I O ((7
1 shall not employ any person In any manner w as to become subject to the WATERSYSTEM/TREAITNG1
Workers'Compensatlon lawn o(Californla.Date PAID
Z Z NOplicant TICE TO APPLICANT.If,after making that Certificate of Exemption,you NEW RESIDENTIAL PIM¢. SQFT. D t Recel ted
O should become subset to the Worken'Compenuatlon provlslons ofthe Labor TOTA _
CC j Code,you mut forthwith comply with such provisions or this permit shall be JFEEP�
UILDI a^
deemed revoked.
W — CONSTRUCTION LENDING AGENCY tea. ETS 'EE _ �Q
d Ihembysfflren that there b a construction kndingagency mrthe pectore, L'CTR
Z ance ofthaworkforwhlch this permit is kscued(Sec.3097,Clv.C.)
00 ]ander:Name LNG 'L•E
IL r lender's Address QTY. MECHANICAL PERMIT CH I L FEG
U Iurtifythat l have read thisapplicationand rtatethatthc above informationewmet.l agree to complywith all city and county ordinances and state laws P' MITISSUANCE EES PAIrelating to Wilding construction,and hereby authomm mpcolmativesofthbcity to enter upon the abovcmenttoned property for bupectlon purposes. TERORADDTOMECH.(Lye)agmrtosave,Indemnify d epharmlcat the City of Cupertino w DatC Receipts
ag tllabRitis,jdgmenh,rortde nsesI maylnay culla AIR HANDLING UNIT CFO 10,ODOCr SUBTOTAL:
g twid City In con n the acting is permit. �^ AIRFIANDENGIINIT(OVER1Q000CF) ONSTRUCTI TAX
g rcof Appllcan/Contractor D 4EXHAUST HOOD(W/DUCT) ONSTRUCTIO TAXPAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies cat or future building occupant store or handle azardous HEATING UNIT(TO 100,000 BTU) Date
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the - O-
i Iealth and Safety Code Section 25532(a)7 I]EATING UNIT(OVER 100,000 BTU)
❑Yes M No
Will the a pplicant or future bu ilding occupant use equl pment or devims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardWs air contaminants as defined by the Bay Arca Air
Quality Mit.sement District? BOILER-COMP OFIPOR 100,000 BTU)
4Yea �I No
havcmad the banr`iiousmateriabregWmmentsunderChapter 05of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,2S&D and 25534. 1 �/ 6�
r understand that if the building docs no ter
art,have a tenl that it is my NEW RESIDENTIAL MECH. SQ.FI' bV ��QO•�
responsibility to notify the occupant of the requirements which mut be met sys7G
prior to Issuance of a Cemficate of Occupancy.
�l'fY Vr_ Uli�r�,u�
Owner or authorlud agent Data ISSUEDO -11
TOT L:
OFFICE COPY