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26846APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING —KLEC'I RI AL PERMiTNO. CITY OF CUPF,SIO NO APPLICATION/PERMIT PLUMBING-NIECHAN" BUILDING DIVISION renrr ra — gen...........—.T..... n e n A O A W KSVl OQ VIS• UNIT# LOT It _ pys% [t100F 4 U U fGW ,,W =m t ,,z p�`L'0 C¢ ,ti1 tnLLOy ; m L' 00 d4o� X r.,thin p � o 'j'�^..11 Q k�V,1 �£� 3�Z�`Q QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO BLDG ELF, PLUM❑B MECIT El ❑ PERMIT ISSUANCE �� LICENSED CONTRACTORS DECLARATION l hereby, affirmthat l am litensedunde Imiskionsof(Tepter9(rommencing with Second 70l Division Sof me Businessnnd professions Code. and my llceme is in full force and effect.` I V LicenxC l.icp 6 Z-1 1� Dam Commcmr A CHITECPS DEC ARAT N I understand my plumshall beused as Public tecmds. APPLIANCES APPLIANCES -RESIDENTIAL PANELS ' UP T0200 AMPS JOB DISC ITT ']ON U 281 - I AMPS r [---AMP OVER n00 AMPS I /� OOR m tE ^ ..s>•. h_J V YF•li� 1YP 7 - SIGNS ELECTRICAL , Licensed Professional OWNER -BUILDER DEC ConaduON ng ebymas affirmn.(Se mat 1 am exempt fdsm the Cosiones ro License law for the following mamn(Section]B31.5, Business and Profeasiom Cade: Any city or countyTEMP.MEfGR which requires a pennit it) construct, alter, improve, demolish, or repair any swcturt prior to its issuance, also inquires the applicant for such perming file a signed statement that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9(commencing with Section 7")nf Division 3 ofthe Business and Professions Code) deaempuoo civiny l of therefmmntdme basis fmmects the Section 7031.5 not m 'ban iv anyapplicantfora permit subjcctsthe applicanuoacivil penalty of not mom than five hundred dollars (SSW). ID1,mowneretmCPmpcny,ormyemployeeswiNwagesastheirsolecompensadon, will do the work, and the structure isnot intended oroffcred lots ale(Sec.](JeW Business and Professions Code: The Cnnvacmes License Law does not apply to an owner of SPECIAL CIRCUIT/MISC. OR POLE INST, POWER DEVICES SWIMMING POOL ELECTRIC VALUATION OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL ELECTft _SQ. FT. STORMS TYPE CONSTRUCTION ( 50 ANP CLCC.0 1 T —[aA G property who builds nr improves memon, entl who Dues such work himxl(or ttwugh his employees, provided that ach improvements are not intcndcderroffered forsale. If, however, the buildingm improvement is sold withinone yearofcomple ion, the owner- budder will have the burden of liming that he did not build or improve for purpose of sale.). OCC. GROUP RES. UNITS 'IOTA C3I,asuwmrofinepmpeny.mexclusiveLycono-atingwimlicensedcmn to to nnsmrd the pmjee (Sec. 70114, Business and Rofessions Crde:) The Comms or's QTYPLUMBING PERMIT FEE FLOOD ZONE APN License lawdoes notanly 10 an ownerofpepeny, whobuildsorimpmves thereon, and PERMIT ISSUANCE wbncommns fmr.mch Projects with. convae0r(.) licensed pumand meennewo, License Law. ❑ 1 am eacmpt under Sce. B & P C for chis reason ALI17R - DRAIN & VENT- WATER (EA) BACK FLOW PROTECT. DEVICE FEE SUMMARY OUTSIDE FEES Owner SANITARY YN Dao WORKMAN COMPENSATION UeCLARA'TION ❑ Iherobyaf6rtion Insuranceor i0cateofcopyther set ger. re,0r Lab C.)c which fieri copy merenf(Sec.3gW, Lab C.)which Workers' employeeSorer this permit. all emDloyee's under this permit. Policy Policy n DRAINS- FLOOR, ROOF. AREA, COND. RECEIPT# SCHOOLTAX Y N RECEII'1'# FIXTURES - PER TRAPcove PARK FEE Y —N - RECEIPT N GAS - FA. SYSTEM-] INC. 4 OUTLETS Company GAS - EA. SYSTEM -OVER 4(EA) BUILDING DIVISION FEES ❑ Cenified copy is hereby famished ❑ Cenified ropy is fled with the city inspection division. PLANCHECK FEF. GREASMNDUSTRL WASTE INTERCEPTOR GRADING FEE CERTIFICATE. OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRFASETRAP SOILS IEE This wetion'iced not be completed ifthe Peron is for one hundred dollars(SIW) orless.) SEWER - SANITARY - STORM EA. 2WF7L ENERGY FEF. Q O I certify that in the perfnrmence.fthe weak for which 'his p—it is issued, I shall m employ t any goner so as to b me ject��e_ Workers' nompenI yl ati( q�D'ute T Applicant luso /O4 WATER HEATER W/VENT/ELEGIR PAID Date Receipt if WATER SYSTEM/fRIiA9'ING z 2 Fonrect. U Z NOTICE T LICANT: If, afir—,.a ng this Centficamof Exemptien,y.. shouldMRUIDEWIALP�SQ. become subject to the Workers Compensation provisions ofthe Labor Code, you mast forthwith comply with such provisions or this permit shut[ be decided revoked.� CONSTRUCTION LENDING AGENCYSEISMIC 1 hereby affinm that there is aGnawtinlening agency for the performnce ofL.1 the work for which thisp.itc.3W], Civ. C.)TOTAL: Name—AA AOLenders Address t certify that I M1avc read this application and statemat the strove information is [agree to comply with all city and county oNimmces and stain laws rotatintoMF,CIIANICAI. building construction. and hereby amhodze representatives ofins city to enreraped the abate-mcntimned pmpcny far inspection purposes. (We) agree to save, indemnify and keep harmless the City of Canadian against liabiliti ends, costcand eapenxswhich may in .1 way acerae against said City in canucyuc dicgrantingof permit. / „ e_9-9¢ FT. TOTAL: 9UILDING Ig3E FEE ELF:CfR1C FET:Lender's T FEE PLUMBING FEE FEG ALTER OR ADD TO MECH. CONSTRUCTION TAX AIR HANDLING UNIT TO 10,Wn CFM) AIR HANDLING UNIT (OVER 10.0110 CFM) Stgnamre of Apple-1/11numna r Data EXHAUST HOOD(W/DUCD HAZARDOUS MATERIALS DISCLOSURE Wilttheappllcamm failure building occupant.wore mhandle bromem us mated.] as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Gide, Second 25532(a)F ❑ Yes Va No /S PAID Dme ReceiptN HEATING UNIT (TO IW," BTU) HEATING UNIT(OVER 100.000 BTU) T T VENTILATION FAN (SINGLE RESID) Will the applicant mfu[urr: builJingoccupant uxequipmemordevittswhich emit M1umdous tit conammunts as defined by the Bay Arta Air Quality Managemcm District, ❑Yes 5Nn BOILER- COMP OR IWpW BTU) BOILER- COMP IW,WO BTU) pI �U �NBC��E'DATE RR (� AUG _" 1994 NEWRESIDEWTIALMECIF SQ.IT. read the Infamous mammals requirements under Chapter &95 of me Health Code, Sections 25505.25533 and 25534. 1 undernandmat gds t=-dy have a tenant, that it is my responsibility to notify the the rpy ms � i h t be met prior to issuance of n Cenifiam of / ° L CITY Ur IA.( urtlil ..maorr'trcd ab."'r '"" ✓`T"'� Date BY: -' TOTAL: ISSUED