22364 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Mulleins,Pro ert Ideml(ks,dvm -
BuildingAdd rm: PERMIT NO. •1
a 3S(, CsMi��q �/r yrs 27 2tJ rr,��
223 6 4
N" me:
' CITY OF CUPERTTNO-BUILDING DIVISION
e C°"tradora Narnr Lk.Na APPLICATION / PERMIT
AA� NG- ! +� '
BUILDIELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL Y
Mt
ArcW/EnREw,E
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - LUNIR
PERMITISSUANCE O LTJ O
LICENSED CONTRACTOR'S UECI,ARATION
I hereby aHlrmthatlam lkeved order provWms,m(Chap<er9(mrmnenc
APPLIANCES-RESIDENTIAL
Ingwlth Scdfon7000)of DldUm3ofihe Bugm andPmfmmsCode,and ���` °'�
Ikense is In full to. d dfed. 3 PArms '>�Adta Uv p&Y
sit,
LlClam L3 LrY /u�b
D.le 9f—CuMndor wAMPS
•r AR,sinsU CIArIATIO Tc E AMPS
O Z ]urdentad my plaru ahaB be used u Public remedy OVER 1000 AMPS r�9Q.F[.FLOOR AREA $/�.FT. '
E z Lkursed Professional SIGNSELECTRICAL Re ICE Lg5
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MIS t!!� N a+
Ihereby affirmthal l son exempt from the Contractors Llmae law far the r
pp folbwing rtuon.k9edim 70015,Buebm and I'rofemmru Codr.My dty or
OF Z i. TEMP.METER OR I'OI.E MST. n�
M4 myatm mpn totapemme,am requi ttheapUv tfe mcharrtpalr l..{.r7��
Y any tlncturtprlemen,Wuarcgabond!pursuant to wtforwc,ma,of he POWER DEVICES
C Co a signed statement(hat he br9(cxod rxer pursuant t it the Se pmWlora of the
Ou Cnntractori LkemeLaw(Clupter9(mmmendngwNhSea1nn7000)ofDivi.
30�n Ile basis for
the
and l'rafembru Cmde)orlhat hebeumpt thenfromad SWaSMING POOL ELECTRIC VALUATION
�^•g tis Mala for the alleged exemption. My Wolmbn of Section 70015 by any D -2SW,I�E1FgpIAfURFS LED I N
applicant fora permit infip s,the applicant to a evil penalty d not more than
M,gj�undnd dollars MM. NEW RE51DENTIAL ELECTR
Lf I,as owner of the property,or my Employ.with wegn ae theU sole TYPE CONSTRUCTION
k mmpeniatlon,wWdothe work,and thestructure is rot Intended or offered for
5 O mk(Sec 7D11,Bwlnm ant Prdmloru Code:The Contnctmrs Wmme Taw
( SM
does not apply to an owrcr of pmpertywho builds,or lmpmvnthaeoR and 0 1
R�UNITS'
EE whodons, &.,kMm iforthroughhleownemployen,provkledlhatach
Improvzm areretblendedoroffendforsale.Ifl, ver,thebuiWNgor TOTAL
Ire kerdenrdbsovi gthln oneyearofcompletbntkefn pbrpW oflBM1ave
t ram or proving mat M1eddmt bexchudmpmverarfing m weak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L,r L as owner of the Property,am 70K Business
ess and
Nath IsCode: PERMITLSSUANCE
TheuunC.,on to emedru".Lice the project(not 705{, I.
and PMembm Code:
The Co.,Imp I.I th a law eon not apply rt an owner of property who ALTER-DRAM k VENT-WATER(EA)
Wilda or lmprwea mursua and who mntnda for each plojecv with a
cWI(+dor(Uempt under
est to NeCminao/s,Ll¢ni Law. BACKFLOW PROTECT.DEVICE FEE SUMMARY
LJ I am eyempt urWer Sec. B k P C for this reason
DRAINS-FLOOR ROOF,AREA,ODND. SANITARY Y_ N_
Owner Date —
WORKMAN COMPENSATION DECLARATION REPT Y
gI hereby alBnn the 1 have a ttrtlBate of conrnt to self-Insure,rc a FIXTURES PER TRAP SCIROOL TAX Y N
Irate of Worken'Cornperortlm Iraurmeema mnifled copy thereof ls". RECEIPT Y
3800,LxbG GAS.EA.SYSCFM-1 WCEE Y_ N_
{OU7LETS PARKF
1'alicy# if7^6'14RECEPTa
CI
Cnmp nv an a (�9L GAS EA.SYSTFM-0VFRY(G) BUILDING DIVISION FEES
�+ert�m� retry}umls,hed. PLANCHECK FEE
EAMId copy b Med with the city ImUon Wpecdivision. GRFi35E/QJDUSIRL WASTE WIEiCEPiDR- CERTIFICATE OF IXEMPTION FROM WORKERS GREASETRAP PAID
COMPENSATION INSURANCE SEWER SANRARY STORM EA 20®cl' Date RecA t#
Crhbs,edbn need not be completed B the permit b/marc hundred dollars
R)
151I0)orlWATER HEATECW/VENT/ELECTR ENERGYFEE Y N
Irto 1 la me peHormanee orthewmk brwhdch this permit i.bn,eq —
I s,haB mat empty any perem In any Donner m u to become eubjeat to De WATER SYSTEM/TRFATTNL
Worken'Compewtbn lasve olGWomb.Date PAID
PP NEWRIDFNTIALPLMB. SQFI'.
A Ilam
E
Z 2 NOTICETO APPLICANT:If after making thisCertificate of Exemption,you Date Repel IN
ahmld become s,ub}ct b the Warken'Comperuatbn provbbra of the Labor TOTAL:
CC y Cade your ft hwkhc plywthwchpmvb morlhbpemJ allbe
W > deemed revoked. BUILDING
d G CONSTRUCTION LENDING AGENCY SEISMIC FE
ELECTRIC FEE
Ihenbyaf0ehat thercroammtrvdlm kndmgagercy fortineperfora.
Z an..fthew.Z0rwhks
hthbpermd isend(See3097,CN.C.) TOTAL' `
V O IemNa.era NaPLUMBING FEE
LLT– Lenderinddreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W l mortify tlodl have read this applk tbnard seethe lheabovelnformadm _
boo M. gnebcmnply wlthad tltyaed county oNivntteand sate laws PERMIT ISSUANCE FEES PAID. M
Il relatingtobulldingmrutmWor,arot herebyaumorir<rtpremntatfvn ofthb
N
city to enter upon the abovcmentbned property for Wpeatlon purposes ALTFRORADDTOMECH. I,
Z (We)agree to ax c,WcmNfy an d keep harmless me City of CupertW Date Recei to
V egaimt WbiBtb,Ndgn ,m saMexper whkhmylnanywayamuc AIR HANDLING UNIT CTO 10,ODO CW SUBTOTAL:
a
galruts, dCNy ere egnnting oflNa pemdt. AIRHANDLINGUNI7(OVERIO,WOCFh0 CONSTRUCTIONTAX
/ � B—h CONSTRUCTION TAX PAID:
Sigru re of pB /Cmlradm to EXHAUSTHOOD(W/DUCT)
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or hinambulding ar pent store or handle ha:ardoua HEATING UMTOO 10),000 BTIJ) Date RCCCi IN
material as defined by the Cupedirin Mur deal Code,Chapter 9.1 7,and the
Fkahhard SafetyCdr Ion25532fA)2 HEATING UNIT(OVER 100,00D BM TOTAL:
❑
yes To
WW me�ppBca to building omvpant ale aquipment or devim VENTILATION FAN(SINGLE RESID) ISSUANCEDATE
-
which emit hanndoes ab cvntamJmrda as defined by the Bay Area AIr
Quality Managemeot E W 7 BOMER.COMP PHP OR 100,0110 RTU) - -
Yee No
lhave readthe haaa nweriab requinmenb under Chapter 695 of BOILER-OOMP(OVER IW,000BTU)
the Ca OfomdErealthhSafetyCde,Sectbru25505,25533and2 U. I
undersand that if the building don ret arrently have+tenant,that it b my NEW RESIDENTIAL MECH. SQ.F-7.
responsibility to notify the occupant of the nyukements which mast he rnet
pMr to beuaroe dt c
ray.
,
7 z
� e/U
rwaulhedud t
- TOTAL ISSUED
OFFICE COPY