22381 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulletin Pro'oct IdemifloFRAB
tion PTNO.
B.Bding Address :_ v ; G Es e o �u� sect 5 r tw 22381
_
CITY OF CUPERTINOLBUILDING DIVISION
ca v.c° .Name: Lk No APPLICATION /PERMIT rQ
• BU[LDINGELECIRIC.V�I'LUMBINGMGCHANICAL CATEGORY COMROLI
Amhdeb/Engircer•. Lie,No:
QTY ELECTRIC PERMIT ):EE BUILDING PERMIT INFO
Add. I'QLWTISSUANCE ❑ ❑ ElLICF.NS ED CONTRACTOR'S DECLARATION
�hereby.lflrm that lam likened under prwbiona o(Chapter 9(cmvrenc- APPUANCESRFSBJEMTAL t. . ]OB DFSC N _
Ingwith5ecdena000)ol Dldsien3o(the0udmvand Pro/eslomCode,and 1
LaNelnly(u8 dLkr.I 6 PAPANELS1•
�
Date__S�GnntnaarI ,�,� �lL)n,b
ARCHafECTS ECLARATION
neZ Iurdenrand my phvshall be used upublic needs DYER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
WWCOC
GU Licensed Professional SIGNSELECTRICAL Imof�
/ /�I� C�
OWNER-BUILDER DECLARATION t
2: .04 1herebyafflmthat l.mm
exempt frothe ContractorLlam
. eiawf« SPECIAL CIRCUIT/MISC \ N the
o
O : followingrt+.m (S .70315,Busies®atdPmfesiors Cod,.Mycityur 1'
TQ.1P.MOR POLE INST.
rr,�p mhntywhld rtqulmapermit tocorstruct,alter,lmprwe,demoWh,orrepair ETER,
any atmmue pn«reit Lwance,abensedp rauaa to he
f«wNpermate POWER DEVICES
Ne a dyed statement that he b Barred pursuant b the pmvbbm of the Jq qq 7
sacr3oContor'suesmelaw rofmmmCm e)mn ohekh5esuon 70M)mpttlerefod DM-m.nd bWppBNGPOOLELECTRC
3 tion ally for .alleged Prdesbn. Any ooladon b 7BILS by
�� VED ALUATION
4 G$ the Walla for the all )a th cep lit violation of Section nm by any OU TLE7SSWITCHESFTX7-UR6
ate+ ❑ aPPBantf°ra perm!t wbjMathe applicant tea chill penalty dnm rtnre than
0. By hundreMwilidollars(fu00). ��
R I,as owner of the ro NEwR®FN77AL ELECTx SQ1T. NSf11UC"IION
7�n p perry,or my employees such wages u 1MIr sole
campewMoq wl B.M.E wait,and Nersumrreh not blended or oBrma for
O sic not apply toa now and fiafesbv Cade:The or improves
License Law
S$ does whodoesetch apply oars owrerdproperty,hisobulmptcymprovn terrors,and ocDN
whooverne hworkhlmaeB«throughed own..If,ho a er,thpronided that such
improvemew art not Intmded orof(ered f«sale.If,however,thebuiWbg or TOTAL;
Mprovermdbeold whhinorcyuro(ceenpldbn,th<wvner-bullderwBl have _
tt ,Jenof proving that he did wt builder Improve for pupo.e°f.ab.L QTY. PLUMBING PERMIT FEE
U I,as owner of the property,am exclusively cont 1-6 with ilxn.ed FLOOD ZONE APN
w
PERMITISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor.License Law don not apply to an owner of property who
builds or improves thereon,and who mMracta fee such pto)eas"Is a ALTER-DRAW 4 VENT-WATFR(EA)
acter(.)licensed Put nuantrothe CmunRer.11ametaw. enac FLOW PROTFrr.DEVICE FEE SUMMARY
LJ I am esempt under Sec B k P C for this renin
OI SN FLOOR,ROOF,AREA,COND. SANITARY - Y_ N_
® Owner Date - 1
RECEIPT
WORKMAN COMPENSATION DECLARATION FT%Tl1RES PER TRAP SCIdOOi.TAA Y N_
[�I hereby.!Aero that I have•eeni(kate of consent to opyteeff.busece,amed(S a
�r lQme of Wor4en'Compevatlmlrwrrana ora mntlfled copytherco((Sec. RECEIPT I
3800,laic C) GAS EA.SYSTEM-1 ING40[fILE15 PARKFM Y_ N_
Polkya 'Z-- S RECEIPT# .
GAEA.SYSI'Fld-0VFR 4(EA)
YG�f� BUILDING DIVISION FF.Ef
weM
rtlfied copy lithe re Bled ropy b filed with the dcrtnmwGREASE/INDUSTRL WASTE INTEREF]PTOR PLANCHECK=—
ry Iropectbn dfvidm.y
CERTIFICATE OF IXEMITION FROM WORKERS GREASE TRAIT
(1'N..eebn need MSAT'ION t NE PSD
nabcaplecdgtepcmbf«orchundredollnSEWER-SANITARYSTORM FA 2DOF1
Date Rel t#
(IlMooles.) - WATER HEATER w/vwT/o.rcrR ENERGYFEE Y N
I mntifythai N the pedo-numm of the week for which this permit 1.Issued,
I sh.D not employ any pe.In any manner n u to become subject to the WATER SYSITTf/1RFAT[NG
W«keri Compensation Laws ofCalMornb. Date PAID
-
z 0 N011 0APPLICANT:ILaRer vubrhg this Certl/cant Iate of Fiemptbn,you NEW RF9DFNTIAL PLMB. SOFT. Date Recei [#
should become subject to the worker,'Compematbn provbbnu of the Tabor TOTAL:
CCN Code,yw mustforthwith comply withwch provision orthls permit 9.11 be
W > dmmed revuked.
CONSTRUCTION LENDING AGENCY ISMIC FE t
CL Ihembyaf/irm thatthereba mmtructlon lending agency for the perform TOTAL: EIEC I-RIC FEB / S�
Z arm o(the work for wFJch this pemJt b Issued(&ax, a,CN.C)
02 tendee-Name - PLUMBWGFLE
LL F Leeder.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify that l have mad this appBatbd r
n and that the above information MECHANICAL
Ismnect.Iagree W cernply with all city and county°rdlnanm and rote laws PERMITLGSUANCE FEES PAID:
>. 1 \ I
retail ng to buildmv
titling truction,and hereby aulh«be representatives of thin /\YY �t
F Z my to enter upon the alsve-mentioned Property for Inspection purposes. ALTFRORADDTOMTi1i. Date Recei t# -I
V a buteWbee to svemenb meetly an dkeep harrrdm the City of Cu pertbo
gee I✓ g pences which may b any way acvue, AIR HANDUNG UMr(TO 10,W0 CFM) SUBTOTAL•
ago0miv In Fthe grouting dthis permit.
AIR HANDLING UNIT(OVQt lo,00pcFr4) CONSTRUCTION TAX
51 reof Apponraeto IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will the Applicant«(unim Wedbg omrpant none or handle havrdoat HEATING UNIT aO 100,000 BT1p Date Recei [#
material a,defined by the Cupertlrm Municipal Cad,Chapter 9.17,and the
Health and Safety c loo 25532(A)? A
I HT'ING UNIT(OVER 100,DDO BTI TOTAL:
RYn No
lllthe appiio Nre building occupant use equipment or devices VFNELATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit h.mraous air contaminants as defined by the Bay Area Air
.� Q°alityManogement I BOILER-COMP OHPOR IM"BTU)
Yn "°
t
M1ave read the M1an ousrnuteMab rtqulmmtnb under CM1apter 6.95 of BOILER-COMP(OVER100,000 BTU)
the Cali(ornb FleahhkSafetyCod,Sect m75505,25U3and75534.I -
unders tWtifthe NildNgd«arwtmrtentlyhaveatenantthatitbmy NEWRESIDFNIIALMECH. SQ.Ff
respon t,cot the occupaidof therN.Imment.whichmMberrct
prior cydf/S I /c ofonvpancy�
eroauth dagent A6Z
TOTAL: ISSUED
OFFICE COPY