24304 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification I PERMIT NQ 4 3 0 4
Building Addrtv: -
�rCW IFt�a\SIV
Phone: CITY OF CUPERTINO-BUILDING DIVISION �I
a VJ Cit k.Nm APPLICATION I PERMIT
V
BUILDINGELF7CTIUCALP�UMBINGMFLHAMCAL CATEGORY C
Anchitet/Engineer. Llc.Nm
QTY ELECTTaERmrr FEE BUILDING PERMITJWO
Addrtaa
PERMIT ISSUA
LICENSED CONTRACTOR'S DECLARATION
I rebyaffUmtlutlam Bcenaeduriderpro Wmisof Chapler9(mm a APPA ES L I e
Ith Seaton 7!1(10)of DWldm 3 ofth<Bualwsand Prefeaurr eCode,+nd my
hours.la In fuR force and dfeet. PANELS
LloeorcChw Lielf �V• T �,^,
Date 47muractm,
ARCHITECTS DECLARATION 1
Q COC IunderetaM my plan shall be used ae public rcmrde 1 SQ.Fr.FLOOR ARIA �_—
6i o U Lfo need Pmf.ioral SIGNS L tt, -t
"%- T-,
GG WW OW R-BUILDER DECLARATION SI'ECIALC T `�T•
7p (hereby af/irm
that lam exempt from the Contrador'e lim L f h
6Z lolbMng rtasm.(SMIm 7m1S,Bualrand Prolesbru Codd or TEMP. RPoLEINST.
F' mu my.hich mryLeapermitomrutvtl,aiter,impmve,devn h rrt Ir
�y < anyatrudurt prortolt L+vuane,aleo re9umi°th<appBanticesu pemdt to pOWFRD CES
� V fit a algned gatemen that he t Iteemed pursuant to the of the .
7pp755Ow Contndor.License Law(Chapter9(mmmeneing with fDivl-
F,�O elo lofthe Bu.slnmand Pr ms mC:MolorthathebemmptthemfmmaM bw"MING POOL ELECTRIC VALUATION
Q the Walt for the alleged exemptkm. Any violatbn of Healon 70315 by any ET SSWITCFIESFI)('IT1RFS
•ppUontforapermltsubjectttheapp"nttuadvllpen hydnmmomtm. �L 1 ASK
five hundred doll..f%W. NEW RMDF24TIAL ELDCTR
7 ❑1,as mweer of the Property,or my employee with wage a.theiranis e''Q'FT. STORIES TYPE NNSIRUCHON
� � campevamon,wllldolhewmk+nal thegrudurctnot Welled or aliened for
D sale(Sec ppy Bu.lrcae and f pa p y Cade:Ther i rp Olt W.,Law
S$ d odro pply rkhv Umth ghhi.h neniplaym pro idedthatmch d OCC.GROUP RES UNITS
EEEEEE whodoessuch workdIntededoraerediownemp,howevt,thr throng or
improvement arenwtintendedvarofcd[nidal..t hover- tMerw ham
improvementbsuN wlthinoneyearofcompletlori,theawner-buBd<rwW Wve
the
urdov
en of pring that he did wtimprove for or improfm purpose oftale.). QTY. PLUMBING PERMIT FEE ZONE APN
LI L ae owner of the property,am exclusively centracHng with IkrruM FLOOD
rontadon to emetmct the pmjed(See 70K Btudr,.all Profmb.Code: PERMIT ISSUANCE r'
The Conradoe.Llrerue law doe not apply to an owner d property who
bu0da or Improve If. ,.nd who march for sure projedt with a ALTIIt-DRAIN VENT-WATER TA)
oo¢traetarta)Iken+ed pursuant to the Contractors Llabe Law. FEE SUMMARY
U I am uempt under Sec B k P C for this renin BACK FLOW PRDTFL-I'.DEVICE OUTS1 OF FEES
DRAINS FLOOR ROOF,AREA,NND. SANITARY Y_ N_
• Owner Dns RECFR'rI
WORK MAN COMPENSATION DECLARATION FLY7URES PER TRAII SCIIOOLTAX Y_ N_
❑I hercfry.rke.that I have•rerti. of consent to self-Inum,m . RECEPr if
¢n1,1ab of Worken'Campevnlmlwnnna ars autaled mpythereof(Sec. Coq EA.SYSTEM-1 INGB OVILEB PARK FEE Y_ N
RECEI38(9,Lab CJ
Policy DING DI/
GAS EA.SYSTEM-0VFR�(E1)
?�ry,L_lfiedis
BUILDING DIMS NFEES
ropy heli withmecitylel. LTOR PLANCHECIy FLSuedropyttbawth h alywpdmnawan. `/Cj(//``
CERTIFICATE OF EXEMPTION FROM WORKERS PAID
COMPENSATION INSURANCE "^r
(IhteectlonneMnotirecompletedlftMper t6fmomhundmddoUm(5100)«les.) 101T.WA TER / ENERG E2!pull
1 �^
Ianotmpoat in the person perftheworkormance for watchmthis pe. Btissued, .`/
I aha.not employ any I:ram In any mso n to biome grbjed to the Pff
WATET!sit
Worker Compmstbn Iowad California.nt.Date PAID
PP SQFT. Date
n boat
Z Q NOTICE TO esubjeANteW.drmakingt..tIoflpmotm .�ptInftheLyau NEwRmDPMiAi.l'(MB.
i eM1mld become subject to the Worker'Compermatlan proWalom of the Labor T TAL:
(A Code,you rt.at for hwlth comply with such pmvbbntm thb permit shall be
LU > deemed rmvoked.
BUILDING FEE
CONSTRUCTION LENDING AGENCY EISMIC FEE
CL O Ihembyarem,thattheme amn dlmk"ingagencyforthepedorm ELECTRIC FEE
= dna of the work(or whieli tht permit 6 beeod bee 307/,Civ.G) TOTAL:
V O Lender's Name PLUMBING FEE
LL F Lender'[Address QTY. MECHANICAL PERMIT FEE MECHAMCAL FEE
O W Iarlfythtlhavercadthb.ppBa naMd to thntheabov<InfomWI —
S tmned.Iagreetocomplywhhandtyandcwntyordlna wigs .on PEDAUSSUANCE FEES PAID:
} to relating to Wilding mrolrVdlon,all hereby auth«t repree,mu sof thb 'y
[•. dty to enter upon theabovcmevtlored Property for Wpedlon purpme. ALTER OR ADDTO MECH. —L
? (We)agree to save,Ind emnfy an d keep hared®the City of Cu per Ino Date Recei t# -
V egatmtW dit en andexpreseswhlchmaylnanyw.y.crue AIRFIANDLINGUNI'I(TO10,000CFM) SUBTOTAL:
+gall.[ dCltyt o grant NgdtNt permR.
_ AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUC170N TAX
Appbant/contras«�_ Data F]OIAUSTFIOOD(w/DUCI3 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wthe applicantorfuture building occupam.torcor Wndle haaard. HEATING UMT('M 100,000 BM Date Raei tp
Llai as defined by the Cupertino Municipal Code,Chapter 9.12,and the
F hheM Safety Code Section 25532(t)7 HEATING UNIT(OVER IW,000 BTIr1 TOTAL:
❑Y. JL—.,I No .
Will theappil.., fu m building ottvpant useequlpmen«dev4 VENIIIATIONFAN(EWGLERFSID) ISSUANCE DATE
which emit harartloua air mntaminunte as defined by the Bay Area Air
Quality M.ugemen Doric[? BOILER-NMP OFI'OR 100,0(9 BTU)
Oa ❑vueNo
4h avereaathehvdvueta b
glremnunderCM1aper695of BOILER COMP(OVER I P0,000 ITTU) PAID
5
theUWmat Heahh4Safdy Cod,SMioru2rSC5,25533and2S53/. I P A 6 D
undebtaM that if the building aces not currently have atenarr,that It is my NEW RESIDENTIAL MECH. SQFr
reponuibWty to notify the occupant of the mqubemens whzh rust be/ret
prior to[nuance of a Certlfette of Oeapancy. NOV 1 e7 v
Owner or authmiaed agent DateISSUEDBY: (f
OFFICE COPY