20053 T
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project lJenJf Jon ' D PExwT 20053
ua
Buing Adage:
1.1eP�1S
Owner.Name. one:
rORLIJK G—(2Wd3 CITY OF CUPERT[NO-BUILDINGDIVISION -'�-�� pQ
c do aN ne: LIcNo APPLICATION I PERMIT —� CJ�
•"^^�� /Q BUIL.INNGdBCTRICA4PLUMBINGMFi1iAN7CAL CATEGORY CONTROL
�/&'Birseer: Lk No:
2 BUILDING PERMIT INFO
QrY ELECFRICPERMIT FEE
Add— I'FRMITISSUANCE ❑ ❑ ElI(�
LICENSED CONTRACTOR'SA
DECLARTION �J
I hereby aRbm that lam beensed under provWons OEChaper 9(oonrmam APPLIANCE RESIDENHAL JOB DEscRIFTIO
ingwlih Sectbn] )of Division 3ofNe Boa1..nd PmfessJm.Cndq androy, c n
il¢nselafnfuillco, n cff� PANELS
Lice
Date _ Contactor N
ARCIIMCI'SDECLARATION eJ55 701-1000'
pW MO ZO I understand my plan sha0 be need w pubic neoade. OVER 1000 AMPS SQ.F7.FLOOR AREA f/SQ.FT.
F LI¢vd Profeasbnal SIGNS GAL - L E D I N
fn 61 OWNERexNLDER DECLARATION SPECIALCIRCUIT/MISC P UTE R
tIherabyafBr (Sectiamuemptfromthe Contractor's U¢nse LawAny for the
Kp q fO1lntYw season.melon 7 to Businer and Pro pe , Cady.Any city or DOW
ul countywhmpretesapemdtt aWre a,alter,tmptm,deesuah,orrepatr TFI'P'METFROR EOLE INSf.
S`'0 7 any wudurctatement 9heisabo¢qubnthe ,tothet(m.uchpemdte �R DEVICES
&sea 5
file a eyed statement th.t he b r 9(coed paracent to the provbmro of the
60wE� Contndot's Lkcue LwlL'haptn9(commendngwith,Section 7000)dD1W-
WW O J aim3 ofthe Businesa and Prafembru Code)orthat he Y exempt therefromand DM-
SWIMMING MJDL ELECTRIC VALUATION
y.'.•71 the basis for the alleged exemption. Any violation of Section 90715 by any apphantforapeOU7i.EI5S117.ICFESFD(.I.UAES
OA rMtsubjedetheappl¢ ttoad ipenakydna =cotn¢
�.. nve hundred dollua(5.A0. NEWR®FNTIALE.ECTR
❑ 9QFi. STORIES TYPE CONSTRUCTION .
I,as owner of the property,or my employee.with wages aa their ante
7a eomptwtlmt,wBldo the work.aodflo, rcorebrofbdended or offered for
O
sale(Sec.70N,flue,
0 and I'mi.ioro Code.The Cmarad.e.Llceme law
dos not apply to an owner of property who bulk6 or Improves t hereon,and OCCCROUP RES.UNITS
EE who dmauch work himself or through his own employees,provided that ouch
impmveme a¢notintendedoroffemdfmua .IL havever,the bulldmgor 'TOTAL:
knpmvem MbwldwithWoneyearofc¢nplet mtheowner- Werw shave
t enofpmwngthatn dWm buudorirnpmwforpurpoeaofaab.). QTY, PLUMBINGPERMIT FEE
C u owner of the property,am exchaively contracting with licensed FLOOD TDrIE APN
contratlon to construct the projed(Sec 70K Businesa and Profesebu Cad'.. PERMIT NUANCE
The Contractor's License Taw don Mt apply to an owner d property who ALTER-DRAIN&VENC-WATER(FA)
Wilds or improvon
es there ,and who mMracb for such ptod
Jes with• FEE SUMMARY
gnt+d¢ pursuant
(s)Bormed to the Cmoadat's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt.order Sec B&P C ler this recon
11F FTE,
DRAINS FIOOft,ROOF,AREA,COND. SANITARY Y_ N_
Owner Dale RECEIPT 1
WORKMAN COMPENSATION DECLARATION
r IAtI hereby affirm that I have a¢difcate of consent to mB-insure,or a F7%TUR0,I'ER TR/P S HOOLTAX Y N
r` ¢ta of Warken'Compewtlon lrwrran¢ora¢rtlfled coPY thereof(See OAS FA.SYSTEM-1 INC-4 OUTLETS PARK FEE YECF N
;b clap II 10 0 RECI9Ta—
/ a cy �1 CJ _
t nY 1 OAS PA.SYSTFAf-0VFR4(FA) � BUILDING DIVISION FEES
�CenBied copy b hereby fomished. GRFAMANDUSIRL WASTE INTERCEPTOR PLANCHrCK FEE
(7FCeM1Ned copy b filed with the city iupeelbn dlddon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONLNSURANCE SEWER-SANITARYSIORM El 200FT Date Rece{ t#
TThlasectbn need rat be comptded B the pemat b forone hundred dollars
151001Q1eseJ WATER HEATER W/VENT/EdFrrR - ENERGYFEE Y N
1llamempmcon person
of thewmk mr s to bloupenal1.iwed.
1 ork not empty any Peron In any manner at u to become aubjed to the WATER SYSTEM/'TREATING
Workers'Componsatbn Laws of GBfornla.Dale PAID
-
zZ Applicant NEW R6lDFNIAL I'LMB. SQFT.+ - Date Recei t#
Z O NOTICE TO AIT'LICANT:If,after making this CenBlcate d Exemption,you
should become sub)ed to the workan'Compenaat$on prowbns of the Tabor TOTAL
CC N Code,you mat forthwith comply with such provisions or this permit shall be
deemed ked. I
W GCONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby.lfi hatthereba ronrtnrdion lending agency for the perforn, ELECTRIC FEE
Z an¢of the work for which this perms b issued 30 Y/,Civ.CJ TOTAL:
O lender.Name PLUMBING
LL F Lerch,.Addnns QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtify that l have read this appIcatbnand atatethat theabove lnfonmaBon
bmrtM.lagreetncomplywithaBdtyand muntyardinan¢sandelatetaws PERMIT I.4UANCE 00 FEES PAID:
} N
H rtlating to bulding romisudlan,aM herebyauthodse repr�nnlivn of this
Z tltyto enter upon the ve-mcnt01=1
4�pffi�,Y;;",
npuALTERORADDTOM2M Date Rxei t# .
(We)
agree to nriuJty oCu pertlroagalmt uablut dewcros awayacm,e AIR HANDLING UNIT(rO 10pW CFh4) SUBTOTAL•agalut uld 1 e . _ AIR HANDLING arm rovFx to,aaocF�D CONSTRUCTIONTAX
s+ m AppHAlE RDOLdor Date EXHAUST HOOD(W/Dt1C1) CONSTRUCTION TAX PAID:
Hnt I fob
OUSMATERcuportIALS ore orh haSUREndle
-
Wiala.defined applicant umbuildingoaupantetonor landla havnthe HEATING UMTTIO lOD,000 BTU) Date Recei t#
—00
lealt ala Safety bythe Cupertlm MuddpalCode,Cluper9.1 z.and the
Tie❑]ye, Safety ems Ion 2S537(a)I HEATING UNH(OVER 100,000 BTU) TOTAL: t
Well the applicant futurebuBdfo8occupantuseequipmmtcrdevkn VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkhemithav sairconum msasdefinedbythe Bay Area Air
Quality Management Mrtrtn7 BOILER COMP DEIPOR 100,M BIT)
YNo
h.1%,the hazAs materials requirements under Chapter 6.95 of BOILER. ,MP(OVER 100,000 BTI)
the California Health&SafetyCode,Sedbm 75505,5533 and 25576.1
uMe Wthali( Ifldingdon ntlyhavea ant that It bony NEW RESIDENTIAL MECFL SQFT � Il I�90
respormmBNyt theoavpa d erequlrcme vhkh mem be met S�
prior to fou a aCertlB¢t O Panay.
Citi �t Cur4�t�ro
cr or authorised age. V Date
TOTAL "Z-) iSSUEDBY:3� I Iss�l'a M'C-C,1
OFFICE COPY