24320 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'en Idemlrkadw PIX.wT
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IAL DAIL
CITY OF CUPERTINO-BUILDING DIVISION
Contnctara Name: Lk.Net APPLICATION /PERMIT tbs�;'Z
Archltect/Englrcer. BIIILDINGELF�f1UCALl'LUMBWGMBCFUNICAL CATEGORYCOMAOLN
IX.Nn
AdAdd. Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
't �-
LIC ENS EDCONTRACTORS DECLARATION PERMRISSUANCE ❑ 11
IMrtbyion70that lamsiceneed under prwWomaf�spter9(mmmen APPI.IANCESRESfD1:MTAL ON
logwith Section formol Divblon3 ofthc Busircuand ProfnslomCnde,en4 try
Mance la In bI bra and d(cct. PANELS c�
Llo. p�Lk.N 433 �.2'�
Date CONnCar /r .1-
ARCHITECI•S DECLARATION 201-
OG I understand my plaruaball be used as public records OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
❑O
�u Llanwd I'mfe:lorW SIGNS ErIC7RICAL
6 blaf OWNER-BUILDER DECLARATION
7tp a I herebyalgrmtbat l amesempt rromthe Contraotor'e Llarue Law forthe SPECIALCIRCUI'T/M6C
S� folbwing or..(Section 7MIS,1 utle.and Proferlom Code:My dtyor
07. court hkh Irma mattomrnw alter,bn demo orrt Ir TEMP.METEtORPOLE INST.
F tyw reqs pe ct• Proa<, h, w
"`�' anyatnuclurt prlortoltsiwarse,licca requbmthe appBontfaach permNto
POWER DEVICES
file a signed statement that he b limine!purwent to the provisions of the
Ou. Cantnctor'eLke.e Law(Chepter9(mmmentlng with Secbn 7000)of Div
SWIMMVALUATION
I.,�L1 Ii don3afthe Businev and Prde�bru Cade)orthat he laeumptthertfmmard NO POOL ELECTRIC
6 the basis for the alleged ezempbn. Any violation of Sctbn 7MIS by any OUTLETSSWI7CFES FI)MJRES
O applicant for a permit subjects he applicant to a tivllperulfy d not moretlun
ruiredi dollars MM.
I,a owmer of the properly,or my empbyess with wagesas their sole NEW R�'mPlJfi'LL Fn lY-R I -_ ^ r C. PECONSTRUCTION
compmsatlon,"Id.the works.a the stneture b not blended or offend for _
Oaxle(sec 7044 Busmen and Prof®ism Cade:The Cco anon•Gorse Law
$ does not apply to an owner of property who builds or improves t harem,and
who domauch work himself or through wown employee,provided that such tl RES
us
ImpwameMaannatintendedarafferedfmule.Khowever,lhebuildingor TO"fAl; t [�
tmpmvemeNbeol hffiorcyearofmmpletbn,lheow -bul)derwlil w / `
t rdenofpmvingthathedld not build orlmprow for purpose ofule). QTY. PLUMBING PERMI
LJ L as owner of the property,am escluaively mntractlng with Licensed '
PERMIT ISSUANCEISSUANCEANCE FLOOD ZONE _APN
mntreetan to m.truct the projed(See,70K Business am Profess Cade
The Contractor'•Lkxnse Law does not apply to an owner,of property who ALTER-DRAIN k VENT-WATER(EA)
bums or brymves thereon, and who mmncts for such ptojMa wkb• - FEE SUMMARY
ogLtfa�tor(•)Ikoses!pe truant to the Contradoes License law. BACK FLOW PRO'IELT.DEVICE
L-f I on ezemp under Sec B 4 P C for this neawn
• Owner Dale DRAWSPLOOR ROOF,AREA,GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT e
❑I hereby affirm that 1 haat a arli0cate of consent W self-iwre,a a FUCIlIRF_S PER TRAP SadOOL TAX Y_ N_
anBioteofWar4en'Compenaa lonlmiranm ovaarttfied ropy thereof Lee. RECEIPT
]g(),Iab CJ GAS FA.SYSTEM-1 INGl OUTGEM PARK FEE Y_ N_
I'o i GAS EA.SYSTEM-0VER4(EM DINGDI'I
Com ray BUILDING DI VISION FEES
ECertNed espy b hereby ftrNdtM. GREASE/IIJDUSTRL WASTE INTFI2CFPIOR PLANCHECK FEE
❑Cerlllled mpy b filed with the tlty tmpectbn dlWslon.
CERTIFICATEOF ID(EMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEWER"SANRARY-STORM•EA 3(I<ET Date Recel ulf
(IMseenbn need na b completed B the pend[b rmorc hundred dollen
(SlOmorleo.) WATER HEATER ENERGY FEE Y— N
tarluythat bthe perlarrtunaorthe wvk brwlaantwpemdtbba,ea, —
I.hall nut employ any pencm In any runner ao u W become subject to the WATER SYSTEM/TREATING
Wam
kers'Copensation lswsaf California.Date PAID
NEW RESIDFNTIM1 PLMB. 9,]FT.
Applicant
Z 0 N'OTLCETOAPPLICtt.the after makingtw CerlBlcate of Exemption,you Date Recel t#
y .halo become subject Wthe warken'Compematbnprovb4omofthe Labur TOTAL:
CC Code,youmnufo h"hmmplywlthachprwbbmorthhpemJ allbe BU
Uj > deemed revoked.
ILDING FEE
CL G CONSTRUCTION dimkcAgageY ISMIC FEE
M Z Thereby a(Orm t)uttkre bamnehuatlon kMing agemy(or th<pedamm TOTAL ELECTRIC FEE
� anaof the work forwhkhlhb permltbtmed(See 3097,CIv.CJ
U O Lender•wme PLUMBING FEE
LL0 Iaadera Adana. Q)Y. MECHANICAL PERMIT FEE MECHANICALFEE
O W mm I.Iagreet compleread y
with
hais ll tlothynand doourtethaltheabmedgat utlon
S bmrrnct.Iagrm to eoonmucti hall hrreb muhty, repreesand gate Laws I'FRMR ISSUANCE FEES PAID-.
} N relating
oenterbuilding mmtrvnlon,aM prcpeuthortre rtpresentstives of this
F Z tlty to enter upon the abovr.nentb�Property for lrmpectbn Purposes ALTERORADDTOMECH.
_ Date Recei tN
(we)agree to ave,WemNfy.n d keep h,r.naesa the City of Cupertino
U againstliabilities,tliabilities,Nd6new,costaaM eapemn which may in w AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalm d It U consequence of the gran!ing dtw permit. Aa a
AIR HANDLING UNIT(OVER I O,ODO CFM) CONSTRUCTION TAX
jigflaftireppll.f7t7imhacto, ate EZHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIAS RE
Will the applicant orfutum Wilding oaupant store or handle baNaus HFATINGUMT(I010DW(HI U) Date Recei ted
.denial as defircd by the Cupeni.M.Mdpa)Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,0(0 BTU) IOTA .
❑ Yes No
Will the a ppllant lgtue build ing« paol use equipment or devia-s VvrnunON FAN(SINGLE RESID) ISSUANCE DATE
which cMt hasandous At as defined by the Bay Ams AU
Ilty Management DWrin2 BOILER-COMP PHP OR IO(1,0(O BTU)
Yes No A
shaver and the ha s materials requirements under Chapter 6,95 of BOILER-CVNP(OVER 1W,Ol10 BTU) it
the CalBomb HeehhkSafety Code,Scab.25505,25533and25SM. I OC 4 1O
undenM tathat lithe building dm net currently have atenant,that itis my NEW REMDEf MAL MECH. 9QFT
�napo.bBltyronali(ythcocapeNdtarKy.lrcments which owst be net _
prbr to beusrre ole CerUfiate olOmnpauq•.
Owner our authotlud agent DateJA
70TA L: ISSUED BY:v
OFFICE COPY