20006 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Id ti(1 shoes PERMIT NO.
"Building Address: 2 0 0 0 6
�38ov u p yrs I , 13 P� F}
rcn area: one: APPLICAA
FJZu &Q-cuil CITY OF CUPERTTNO-BUILDING DIVISION q
APPLICATION I PERMIT
1 . ^' At 3 N BUIL.IXNGELDCTRICALPLUMBINGMCCFIAMCAL CATECARY CONTROL
II ArcA'eG/Fsly �1 C7Na
C, 5--), ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address SS(QVb' ('_ e� F PFRMTEISSUANCE ❑ ❑ ❑
LICENSEDCC)NTIIACTOR'S DECLARATION
Thereby affirm thatlam l{cmaeduMer prwWone of Chapter9(carn�m APPWANCESRESIDFNTIAL JOB DESCRIPTION
ingwith Sedbn70W)of Dhi m3oftk Budru-nandPmfe maCode,and
lirenx is In fulljpr,and effect, ' //et, PANELS I ►la-{-(�+� l�--51 I-
L'vnxClase Lb Y =7p�a-----. AMTS
Date_ ��ah�JContndor Y1�+•FIW
D ARChall br s ECU ION
z ZT I undeuland my plan aha8 be used es public recoNs OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
°y�Q� ED Z�j Lbcrund Professional SIGNSELECTRICAL rrIRK•ar
Q OWNER-BUILDER DECLARATION 1 , r �
7pr�� Iherem�Sy.M.that texampfrom the Contrador's Lkense Law for the 9TCIALCRtCIRT/MISC
U- TCT.a/ folbwing noon.�eatlm 76715,Bualnm aM l'ro(mloru Cody.Mydty or
K
7�F- cvuntywhicA im
requapermktommemcl,alter,Imprwe,demoWh,orrepair TEMP.METER OR POLE MST.
q anysmdurtpdwmlta bararcp,alwrtquimtheapp8antfwauNpermHto POWER DEVICFS
g file•signed statement U he b licensed pursuant to the provbbm of the
poI Contndm"llcenx law(Chapter9(mmmendng"hSe on7000)of DW- SWIJA INGIWL ELECTRIC
F- ebn3oflhe Businmand Prof mbm Code)orthathebevemptthen maM VALUATION
Q �'�, lk basis for the alleged exemptkn. My viblatbn of Seribn 7m15 by thany OUT ETSSWITCHFSFIXTUR23
QQappeom fora permit wbjaYsthcappecanttoa tivll peroltydnd moman
06undyed dnllan MM.
NEW RESIDENTIAL ELECTR SQJT. STORIES TYPECONSTRUCDON
<, I,sa awrcr of the property,or my empkryen with wages r there sole
t� compensation,will Sualraek workandthesmdurtheCne0 not ade.ed Limner for
Law
p sib freedoes pply to.. and Pp.partmCode:Tk Contrtdora I.Irerne Law
whodo"sech tom ownerdpmpenywho
nemporlmprovnted that such
OCCGROUP RFS AMTS
whodoe"
am h tin d throffe hifmwn .Ithow,provdrdthatarch
impmve msart not Ntanom Proffered(prole.ILhonorer,theerl tngve TOTAL:
Mprovemem iswld wlthinor�eycaro(c pldbn,thewvnerbullderwBl have
t rare prpmdngthnkdd mtbuildorimprowfwpurposeo(sale.). QTY. PLUMBING PERMIT - FEE
L j Las owner d the property,am ex,hulvely mnvaNng wkh Ibnued FLOOD ZONE APN
mntractan PERMIT ISSUANCEto comtrud the project(Sae 7044,Bustnm and Pmfeaee ns Cade:The ComnGorb Lksrue Law don not apply to an owner of property who ALTER-DRAIN kVETT-WATER TEN
toads or Improves thereon,and who wn rads for such ptoJects with a
rypjEaRa(a)licensed pursuant to the Contndors Live.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt urder Sec 8 k P C for this reasonOUTSIDE Hr'
Owner para DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RM=
euby aHbm thrt 1 love a IF
mrdca
6m d e.nt to calf-issuers,Q a f�NFS RPER TRAP `SCIR I TAX Y N_
RILI]I'I'
38 Nate of Workeni Campematlonlrouranm wa artlRed ropy theno!(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK IEE Y N
3800,Lab G)
Cooney#,K/3yQ (7 RECEET Is
CAS 1:A.SYSTEM-0VER 1(EA)
FyBUILDING DIVISION FEES
CedHied ropy b he fumlahed. GREASE/MDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
('QCertHied mpy is filed ith the cfly iropection division.
T CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER.SANITARYSIORM EA.2(IRT Date Remi til
(fids welter need not be a orplded If the per it bfor hundred dollars
f3100)wim') WATER HEATER W/VENT/ELECIR ENERGYFEE Y N
1¢not that In the podornunrxof ny m nark for wto lb this pemdt a IwN,
I aloe not empty any penwn In any manner at u to become ubJed to tk
WATER sys1FA(/TRFAnNG
Wwkm'Compenvtlnn laws Of California.Date PAID
C• Z AppilunNOITCEt NEW RESIDENTIAL PLMB. SQ.FT. Date Reoei ht
Z O N'07TCE TO API'I.ICAM:It,ager making thisCertificate of Exemption,you
should become abject to the Wonken'Compensation provisions of the labor - TOTAL:
CC N Code,you must forthwith comply with such pmrisio ,or this pemJt shall be,
W > deemed re.otrd. BUILDING
a f] CONSTRUCTION LENDING AGENCY SEISMIC FEE
of the work
bacomtis Issued
laMingagcuy(artk perform TOp� ELECTRIC FEE
Z Larder'. work for whkhthb pemde btaaed l5ec.30Y7,Civ.C)
O IaMela Nime
LL H Landeres
,Addre QTY. MECHANICAL PERMIT FEE PLUMBING FEE
O w 1art"at l have read this appeatlon and sate that he above lnformanpn - MECHANICAL FEE
CTCI-30
bmrrea.lagreetocomwply .Udtyardmuntyordirunmmdaatelaws PERMIT ISSUANCE I�X FEES PA I6.
} N relating to building mmemWon,akk authoriumpre,etutb pfthis -
F Z citytorrecrupon vcmentb rty for lro ion purposes: ALTFRORADDTOMECFL Dale Rttei t47
V _ (We)agrm t ,IMrmN n d p harm) n CRY of Cupertlro
agawthabl8 ,hs rrcnva, card perm may Lnanywayamue AIR 1ANDLiNG UNIT(TO 10,000 CFM) SUBTOTAL-
agalrutvl uy ren rce of gram permit.
_ ALRHANDUNC UNIT(OVER 10,600 CFM) CONSTRUCTION TAX
✓ CONSTRUCTION TAX PAID:
S of Appkont r Date FJUTAIJSf HOOD(W/DIJCO
HAZARDOUS MATERIALS DISCLOSURE
WL,dasdppncdb the
building omipal Csorehhard 9.haurdmn HEATING I1N7T(IO]00,000BM Date Revel tit
l 1,cit alas S fired by tk Cuprelno Municipal Code,Chapter 9.1j and the
Health and SafdyC Seaton 2953TW7 HEATING IJMT(OVER 100,000 BTU) TOTAL:
Rill
oodd4L��,�����I''INJoo .
Til the applla�ture bu0ding oavpam ux equlpmem wdevlm VENTILATION FAN SLNGLE RFSID) ISSUANCE DATE
which eMt Eaaa nI. a taminunts n deRrud by the Bay Area Air T�
QualHy hTanagemem�7 BOILER{OMP OEPpR 100,0(s)9117)
Yn
have read theh anutedab nequlrcmenb underChapterg.95 of BOILFR-0DMP(OVER 100,000BN) f(f( I��O
the GBlomla liwHhh fety Code,Sedbv 75505,5533 and 25534. I UVL
uid.und that bulldin notmrre have.tenant,that It is my NEW RESIDENTIAL MECH. SQFT
respomibBl o Ify the tdthe memo which runt be met
prior to dace pto.
I GI 1, I^ .riirn
7 3/ 9d SUP AtiJtL �L+�
ner orawhW agent Date Q�
TOTAL ISSUED BY:
,A.J
OFFICE COPY