22842 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEM ONLY
eulldin Pro ert Identification PERMITNO.
Badding Addrt,., 22842
vc
�on me: APPLICA nON sUBMil FAL
•
CITY OF CUPERTIN0.6UILDINC DIVISION
No: APPLICATION / PERMIT
AtJ✓nq cc C BUfI.iNNGELECTRICw4PLUMBINGMECHANICAL
Lie.No: MCATEGORY COROLY
A mhlted/Englrasr.
QTY, ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PFRNUTISSUANCE 1:1 ❑ ElLICENSED CONTRAROR5 DECLARATION
I hehSeeti n7Dthet) ivew3ofunderprovblou u(aapter9(mrtndto APla11ANCFSRFSTDEMTAL BDEBCRETION
Ing.ist. 7000)on M' PANELS Budvesand Pro(esdoneCode,and
Ibevebinfy{1 to an a�nQSJJrad. PANELS
License Chef:YJ[.sf�.a sy�3�✓
Dale G011trador AfA �a —UP TO 200ANIF-S
ARCHITECT'S DECLARATION 301-1000
�7. Iurderstand myphro shallbe used as pubecr.carda. JOVER1=ANOS SQ.FT.FLOOR AREA S/SQ.FT.
Lkensd Pmfmiaral SIGNSEI�GAL p 1 N
OWNER-BNIA
LDER DECRATION SPECIALCIRCUIT/hUSC T
'F, 3 meing yalflrmtlut lam e.emptfmmthe Contractorillcerae lAw far the t = ^ , K
following rtaaan.(Radian 70315,Bualneo and Pm(esbv,Code:Any dryer yV1
t. TEMP.METER OR POLE INST.
muntywhkfi requlrn a pemdt to rorocrvd,alter,improve,derm8sb,or repair
$QQ'�a[ anystmd m prlorto its if9rsn[e,ean requires;the appli=tfur such permit to POWER DEVICES
6 C a flk a signed atenment that he b Bcerned pursuant to the provbloro of the
[op o-� Cantraetrob Llcrme lAw(Clupter9(mrvrcneing with Section 7007)of Dm- y}yp,(AgNG POOL ELECTRIC ATE VALUATION
,.Lit don3oftbe Bus m.ndP mbr Code)orthMh eaemptthemf maM
L5p7 6 5 the 1oaeb for the alleged e.emptioo.cenAny d.Ieinn of Sedbn 70315 by any SSWPI>=F�SFt)CRIRES
eppBt fora permit subjeda the°pplkant to a dull penalty d not more than
n. flu hundrsd dollus lX5001. NEW RESIDENTIAL ELECTRSQFr. STORIES TYPE CONSTRUCTION
L as owner of the property,or my employees with wages as their sok
C 6 mmpvaelm,w111dothe work ancithestrodurelsoot Intended or offered for
p sale r70µBudnas and professions Code:The Contracto/a Deere,law
3� don not apply to an owner d property who build,or improves thereon,and OCC.GROUT' RES.UNITS
who doesauch work himself orthrough his ovch
s own employees,prlded that su
improvements are not Intended ormifered foreale.If,howewr thebuilding or TOTAL:
improvement beold wllhinoneynrofcunpldbn,lheavner-bulldvwW have
t rdennf pmdng the he did out buudor improve rrowrPme nr.,le.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am euW°hely contracting wBh Iberued FLOOD ZONE APN
mntndm to mrolrod the projed(See 7014,RualnmaM Prdeslons Code: PERMIT ISSUANCE
The Contnd.e.Lleem a Law dm rat apply to an owner d property who ALTEi DRAIN k VENT WATER(F1J '
bit Bds or Improves thereon, and who contnm ford
such pAuje .with° FEE SUMMARY
ryBmro
➢tre,or(O ed purauant to the ContnLlama Law.LlLaw. BAIX FLOW PROTECT.DEVICE
I_I I am aempl under Sec B k P C for thin means —
Owner Dale DRAINS HOOK ROOF,AREA,COND. SANITARY Y_ N
,. WORKMAN COMPENSATION DECLARATION RECEIPT
❑I hereby affirm that I have a re"Lloo4w
te of cogent to aeU- re,or a PDC S PER TRAP S(]i00L FAA Y N
renNete of Worken'Campers ationlrourance ora anlfled mpythereof(Sec. RECE]T 0
38W.I,C.) WC 9o99G S�.jo GAS EA.SYSTEM-I INc4OUILEIS PARKFER Y_ N_
RECEIPT X
GAS-EA.sysrEMovER a(FA)
Co�mparay - BUILDING DIVISION FF.F9
' mcc mpybhereby fumbhed. GREASE/INWSIRL WASTE INTERCEPTOR PLANCHECK FEE
(W{3 Cenl(led ropy b filed with the elty Iropeabn division.
CERTIFICATE OF EXEMPTION FROM WORKERS CREASE TRAP PAID
COMPENSATION INSURANCE SEWS-SANTTARYSR)RM EA 30�T DaIC RCCCI tN
(This aedbn reed rad be completM B the permit b intone,bundred dollars
RI D3)a1es.) ENERGY FEE Y N
I certify that in the pedor anes of the work for which Ws permit is beued, WATFRHEATERW/VENT/E'CS'TR _
1 shall rat employ any penmt lo any manner so as to become zeda)tt to the
WATER SYSTEM/TRFATI NG
Waken'Comperaatbn Laws of California.Date - PAID
NOTICE
O = NEVRF51DEN77ALP . SQFr. Date Recei tM
Z z NOlioant AI'PLiCANT:IL after making this CedBlnte of E.nmptbn,you
F N ehmidbemme°ubja tache Workers'Comperaatbnprovlsioroofthe Labor
Code,ym mat frrthwith comply with such provbbro or thin permit dull be TOTAL:
CC
y domed revokd
e . BUILDING
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihuebyafflrm thatthenleammtrudlon lending agenry forthe pedomm ELECTRIC FEE
= ..of the wnrkfor which thbpnrndt b bated(5ec 309.7,CIv.G
(� O L,eder.Name _ PLUMBING FEE
LL ~ Looder,Addre,a QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lanitythatlhave read thbappllotbnaM Yatethattheabwelnfommtlm
1 limned.IagrtetocmnplywtthaBdtyandmuntyordbanmand Yatelawa PFRMR ISSUANCE FEES PAID:
} N releingtobulldingmrotmdion,and hembyauthoruo,represntatNnofthb
H Z dty to enter upon the aboscmendorcd property for Inspection purposes. ALTERORADDTOMFOH. Date Recei tp
— (We)agree to save,Indemd fy an d keep harmless the City of Cu penal
age WtllabiBiks,jadgrr�nta,mtsaM eapertan whkh mayN any wayamve / AIRHANDLINGUNIT(TO10,000 CFTU SUBTOTAL:
age Wt said City in me pe.of the granting of this permi
AIR HANDLING UNIT(OVER IgBaocFM) CONSTRUCTION TAX
SlgneurenlAppuram/Comrade Date E UST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the epplloM or future buBding cocupet store or haMW havrdmn HEATING UNIT(TO t(1O,L BTU) Date Ret: tN
material as deflmd by the Cu Penin MuNdpaI Cade,Chapter 9.1 7,and the
Fkaith a.m Safety Code�dlan 755 W? HEATING UNIT(OVER 10),000 BTU) Q TOTAL.
I—I Yn I,y{W
Bltheent haplicant odusa tcroam ding aocrupert s defiedi by equipment ardevkn vpxnlATloiv FAN(sweee RF57D) ISSUANCE DATE
whkh emitlarerdmeairrict? untaude0sd by the Bay Ana Mr
Q�Lalfty Managcrr`nt District? BOf1.ER-COMP PITT'PR 1 W,IXD BTI))
Yn No
1� have read the barns materials requirements under Cha Ater 6.95 of BOILER-COMP(OVER Im"BTU)
the GBfomla I IeaNh k Safety Code,SMbro 755LL5,75533 and 755M. 1
uriP.nbatlatlfthe aifythdingviaetdth currently..t.tena .,that itbmy N'EY.'RmDFN17AL MECH. SQ.FT
uMmud that
notifytheingdoet oftherttntlyha awhkh ousthmet I�
prbr< eraco Cen ate ofOavpra��nJcy.
n authorisd.gen Qp • Date ISSUED6
OFFICE COPY CITY UF CUPtKI INU