23029 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro Identification PERMIT NO.
B o., 16 re 23029
rc e ' r r,, q on A
I�I.V t) aCI'IYOFCUPERTIN4BUILDINGDNISION
. G Ner APPLICATION It PERMIT l
BULDINC-11 tICALPLUMBINGMECHAMCAL CATECARY CONTROL e
ArchllM/Eng1 1l Na
AI �rn T��yy Q ELECCRICPERMIT FEE BUILDING PERMIT INFO
Addn�n (,,IL
( Iv ' � PERMITISSUANCE ❑ El 1:1LICENSED CONTRCT
AOIPS DECLARATION
I hereby affirm that l am licensed under prwbbru of Chapter9(oumrme APPLIANCES-RESIDEMTAL )OB D6C
ingwlth Sectbn7000)0(Divfdm3 oMeBusineead Professim.Code,and
raIlceI la In to dfed� PANELS ce ca•�+� +^ 11)U y1`►v'I YI�"v`�
ARCIIITECTS DECLAR&ION nA 000 AMPS
a0� I odentana my pl,..hall be used u pubucremrds OVER 1000 AMPS IT r /� FT. A $/SQ.Fr.
T R
r4 Llanseci Profesbnal SIGNSELECTRICAL P
< OWNER-BULDER DECLARATION SPECIAL CR2CUIT/MLSC /rr�
Z G Ihembma .CS tm7O3l Z, of mam the Comractors Lice o:l ydtthe / ^ /Q ,
Kzpp ❑ buvwing i.req Genian 70315,Basins and Pro pe , Code:My tlry r 2 ��!!!/// (fee !1I
ul wntywhlN requUvapemJtbmmtrun,alter,Unprove,denvWhor rvpalr �P•METR OR POLE WSF.
g'y5^J anyamr mprbrtalhbu eon ab mqu nWeappBantfw.uape to DAT
O E 6 Bk a signed statement that he b licensed pursuant to the provisions of the TKYWER DEVICES
��OSContatlorb LRene Lw(Chapter 9(comenendng wmn Section 70M of DM. SWIMMING POOL ELECTRIC
sion3ofrheBudnmadPdes.bnCode)orNnheireumptthert/romard VALUATION
Sr' the barb for the alleged eumpti ae. Any eiolatbn or Section 7MI5 by any
appllontfor.pemdt subjed.theapplkanttoa dull penalty dna morethm O�t� �
R hundred dollars%SM.
'fin �I,a owner of the property,or my empbyees with wages a their sole NEW RESIDENTIAL ELEM SQFI. STORIES M'E CONSIRIICTION'
�a< mmperonlan,vNldotln work and thestrutlureb not Wended or offered for
t D vie Gee 7014,Bu.Inos and Pmfubn Code:The Contractor.Wane Law
$$ does rot apply to an cnr r of property,who builds or Improvea thereon,and
C• whoda oeach work hlmxNor thmagh his own empleyeu
,provided that such OCC.GROUP RES,UM15
Lnpmo emenb an,rot Intended oroUerd forale.IL however,the WIldinga L—L TOTAL
Inepmverrcab. Wwhhbomrarofcanpletbrltheawnerbullderw[Move
benorpr ngthnhadld�wHderlmpr fe purpoaeorak.). 1QTy-1 PLUMBING PERMIT FEEFl.000a�Ne APN
Lj L as owner a the property,am eecWaivoly contracting with liamed
conmactoutomutruct the project(See 7034,Buslwsmai Prof®inn Cede: PERMITISSUAWA
The Contractor's License Law does nes apply to a owner of property who ��-DRAIN W k VENT-WATER&�
buddy Improves
or thereon, and who mntratle res vde projects with a
cgjWc rW Nansd pursuant to the Contractor.License 1..v. FEE SUMMARY
LJ I am eaempt under Sec B k P C for thin reason BACK FLOW PROTECT.DEVICE
DRAINS FLOG RODF, SANITARY Y_ N—
Owner pate R ARFJ.,GOND. - RFC=It
WORK MAN COMPENSATION DECLARATION FDnURES PER TRAP SCHOOL TAX Y.— N
Hereby orfHm that T have o amrlom or aae.ent to opythenm,tS a RECEn r
Late nrIt
�worYPer�i_ela p'e(rol Nlonfnunna a.anBkd copy tnereorl"ec. GAS FA.SYSIEfol-1 INC-41 OLn= PARK FEE Y N_
CoPol
Ir
m ^Y -)t Y3[�4,G"( •� - _ CASEA.SYSTEM-OVER4(EA)�tnt - BUILORIICv'C DI VISION FF.FS
Ce,i flM ropy b filedherew th the c d. CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertNed ropy,billed with the city Inge tion dW Wm.
CERTIFICATE OF E%ENIMON FROM WORKERS GRFA.SETRAP PAID
COMPlNSATIONINSURANCE SEWER.SANITARY STORM FA 200Fr Datc Reel tit
(IorI inn need nes be completed N1M permit b(aorc hundred dallan
(5100)afy that
WATER HEATER W/VINr/ELECTR ENERGYFEE Y N
I 11 a employ
he any person
of the work for to become,
o j b bored, —
I snail nes empby any person f any manner at u to bemrrc subject to the WATER SYSTEM/TREATING '
O AplleW cornepeneanon l.w.of California.Date PAID
Z 0 _ NOTICE TO APPLICANT:U,after maWng tnb CertNkate of Euroapttb1og4,a, NEW RFSIDENIIAL PLM9. SQF. Date Revel tit
ahold become subject to the Wor ars'ComFereatbn Provision o(the Labor TOTAL:
~ fn Code,you rruItfathwith comply withvch provision orthb permit Wil be,
Cr > deemed revoked. BUILDING ME
LU
O CONSTRUMON LENDING AGENCY SEISMIC FE
I Hereby affirm itit thea b a conwdlm lending ager¢y for the perform ELECTRIC FEE
C)7 Z Lenderthe work for whkhthb permit braved 6ec 3(197,Civ.C.I TOTAL: PLUMBING FEE
O Lenders Name
LL 1— Iender.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertify thatl love mad thbappuatbn and statethatthe above informatlm
b mnect.iagtee to comply withWtltyaM countyordWnoesand natelawe PFRMRISSUANCE FEES PAID:
V) relatingtobulWingmnrrucHun,ard herebyauthorlmrepresntatheeofthls
F N 'ay to enter upon the above.mentbrcd property fabopection purposes. ALTERORADDTOMECI-L
? (We)agree to ave,Indemrdfy m d kap harmless the City of Cupertiro Date Reccipt#
V agahut Wbiffiles,)adgments,cone and e.pease which may In any wayaave AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL•
reg old City b�s uerce of gran n at pemek.
"1� L AIR FIANIX.ING UNIT(OVER IO,000CFK) CONSTRUCTION TAX
I roof App ca /C der Dar -`{s� DCHAUS'HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAURDOUS MA R1 LSDISC UR
WBl the appuant ce futon,building pantsrmeor lehavrdou. / 1'TEATINC UMT HO 10i RTU) —Date Reeei Ill
material., Rned deby the Cupertiw Municipal Cade,Chapter 9.12,and the
Hee.1th mil Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BM TOTAL:
EC YesNo
Hl the aPpliam or tort building mvpant use equipmentad
devices G
a VFMILATION FAN WGLE RESID) ]�r.D C'•F fIATE
which endt hanrdou.W mntamin nts a dell rand by the Bay Arca AIr Ihh°Y �T'YVZ
Quality Mangemea Dbtrfd7 BOR.EWCOMP C3HPOR 100,0(D BM
4haveYes Nn DEG
ob,Heah &Safetmode,brtqu,a505,2SWaClupter695of NOERcomp(OVER 100,00pRM _ 1991
the CIffereraand t Health k Safety Code,not
currently
255)I nmt,that It y
rMerntiM that nailf the the cagdon oftherequirments which
that bbat NEW RFSIDFNITAL MECH. SQlI' 7
responsibility exaca to notify the oau,cof u cc the nequlrtrrcnb which nun hand /sI1 Y
prior to rsuance a(a Cedlftate o/Ocapanry. VI (1r VUpthI�V
Owner or.utherlred agent Date ISSUED e
TOTAL
OFFICE COPY