23143 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POIfiIT PEfN ONLY
tlulldin Pro'catlJentlflnHon PF.NMITNO.
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I b3 WI��P2��f� l�R- �` �f'
mr�e!ame: one: q
bOVCh(G"r - C17YOPCUPERTIN66UILDINCDIVISiON �
� c°"�°�"'"'°:��u � � ���.N�: APPLICATION I PERMIT Z�.� U �
BUILDINGFIF.C'IRICALI'LUMBINGFfFLHAMCAl CAT�RY COMROLM
ArchitM/Englneer Lic.No:
Q'rv ELECTRICPERMIT PEE BUILDWGPERMITWFO
Addmc: PFRA9TISSUANCE ❑ ❑ ❑
LIC[NSED CONTRACTOR'S Df.CLAMTION
1Lercbyafltrm�hatlamllcmud�MerpmvlsloneofCA�pter9(rommen �1Pf73ANCFSRESIDEM7AL ]OBDPSC ON
IngwltASeRion70W)ofDlvlelon3oftheBuelrieeeandProkeslw�Cade,andmy ' �� �
lircnceleln(u0loraeanddkG. PANFlS ' '�
LlmneeClan Lk.M ' Q
Date Contractor
ARCHITECI`SDECLARATION p�'����
�Z lunden/andmypla�uelu116eueedupubilcrecardw OVERIODOAMI'S' �.R.FlOOR A §/ .FC.
OC '�� Licenxd Pta(mla'ul 9GNSELEC7RICAL A L E D
�< OWNL'R-9UILDER DECLARATION ��7pLCIXCUII'/MLSC {�/J P U T E
z�.,,�' Iherebya(firmtFut7emexemptfromtheCommcmr'eLkevel�wforehe
(ollowing reanon.�Senion 7Q11.5,Butlnma anG Profevelene Code:Any dty or
O F.� 7EMP.ME'1'hIiORP04HINST. / /�/��
�� ewntywFlchrequlrteapemJtlocoeutrvct,dMqlmpmve,demolbh,orrcpalr �'�
�§ anyatructureprlormlmbaaKe,aleorequlmtheapp0antlwwchperMtro �W�p�� r
��a � Ole a tlgvcd shrement thal M b IlmnaM pun�anl ro tM proWlom of thc
��,� Contnctori Gce,ue Iaw(Chapler 9(mmmencing wlth SeRbn 7000)o!Divl- ' �����
30 ve�3olthe9uelnenamdl'ra(mbroCodc)orthetheleerem tAeretmmand SWATMINGI'OOLFJ.CCfRIC ypLUA770N
��yd S the basle for tAe alleged e�empllan. Any WolaHon o!5ectlon'9Q11S by any
�Q� appllcentloreperMteubjnTetheappllnnttoadvllperultydnMrtnrclFan ��'E�'SWITCHFSFiXTIl72FS
llv�undrcddollan( �. . �WxEqpp,MIALELFGTR_$Q.FI. y7pW[S 7'ypE�pNSTkUCTION
� I,ae owner af 1he pmperty,or my empbyen with wagea es lhelt wle
rompenaaflon,w111dotMworkandlFeatructurel.�no[intendedorotfemd(or �
O vk(Sec.76iq8uelnescandPmlenbreCade:7heContncmreLlmmel�w
5� docanolapplytoanownerolpropertywhobuildeorlmprovntMreon,and , p�C,CROUI' ' RFS.UNITS
who dcee euch worQ hlmvel(wthraugh Na mvn employeee,prwlded tM1at ach
improvemente are not In4nded aroflered foruk.It,M1owever,�Aebullding w Tp7p�,;
improvemenl h eold witM1ln oneyea m(mmpteHan,the mvnervbullderwlll Fave '
tt�urdeno(pmvingthatFmdidnaWlldorlmprovc(orpurpoeeofule.). Qpy, pLUMBINCPERMIT �E WppD7ANE APN
U L ae awner o!Ihe pmpcny,em eaclueively mnwning wilh Ilmnxd PERMIT LSSUANCE D
mntnctam to mwwR the pmjeR(Sec.7044 Buelness end I'rofeeelone Codc ��
Thc Contnnofe LI¢nee I�w don na�pply to an owner o(property who AL7i•R.DRAIN 4 VEVf-WATER(EA7
builda or Improvo thereon,and wFo mntnRs(w such p�ojnb witM1 • FEE$UMMARY
cqN�acTor(s)IkenaMpunuenttotM1eConhanoY�LimnmLaw. BAQCFLOWPROTFGT.DEVICH
.Lf 1 am evempt under See B k P C far thb rcaaon
D2VNSb7.00RROOF.ARLA,COND. SAM'fARY Y� N
�'�« Date RECQPf N
WONIQ.tANCOMPFNSATIONDECLARATION FIX,NRFSPEIt�RM Spi00LTA% Y_ N_
❑I hercly a(firm thal I have�mni(lote of coneent�o w141narc,m a '�� RECEQ'f M
mnlflra�eofWorkenCompe�uatlanl�uunn¢oraceNlflMcopythemaf(See GASFA.SYSfEM-1INC.fOU7LEfS PAFtICFFL Y N
3800,I�b C.)
Coman �',ASPA.SYS'1'CM-0VQR4(EA) AECII['PM
� � Y 9UILDING DIVISION FC[S
CeKitledmpybhereby(umisLed. GRFASH/WDUSIRI,WAS[EIMFJiCQ''fOR PLANCHGCKIZE
Ceni/Ied mpy b(iled wlth Ihe Aty IrepMion dlvlslon.
C[RTIFlGTEOFIXEMPI'IONFFOMWORKHRS' G�SE�r PAID
COMPENSATION INSURANCf SewFR�snM7.naY sroa�t2n mou� Da[c RCtt'I t#
(fhleaeRlan need not be complMed i(the perMt�farorm Fundred dollare
�1001ar1ei.) wnrner�ewrQew/vFxrio.errrzrz ENERGYPEE Y N
]ani(ythatlnthepeAormanmo(thewmk(orwNch�FlepertniHebeued, ' — —
I aFall not emptay any perean In nny manner n ea ro bemme a6jea to tM1e WA1•FA S,S.fQ.f/7.REA,nhG
Warken'CompenaallonGw�afG11lomh.Date . �/��p
� Z Applicant ' ' �dEWRF9DEN'I7ALPLAf9. :n}T. DZfC RCtt'1 �N
Z � N017CETOA['('LICANT:I(,�kermakinglh6CeniflrateofEvemptbn,yw
� eM1auldbecomesubjectlotheWoeken'Compematlonpmvbbiuo(Ihel.abor TOI�AL:
� N Code,youmurt(onhwlthwmp1yw11hauchprovlalovorlhbperMtahallbe
> dremed revoked. DI G ��
�.a 0 coNsraurnoN�womcncwcr . SEISMICFEE
I hercby�(Orm ihat therc b a ro�t�ucUon Iending agencylor tAe perforrrv ELL�R�C��
� Z anceoftheworklorwNchtFbpermlt0lawed(Sec.3097.CIv.C.) TOTAL: 3.(1
(� Q t<�e�r.N,� - PLUMRINGPGE 3 D
LLF ��deraAddmw � QTY. MECHANICALPERMIT �E MECHAMCALFES
OW ImnifythatlFavereadlhbapplloHonaMpa�ethattheaboveln(orrtutlon ,
a bmncn.7agrrerocomplywitM1alltltyandmuntyaNinanrenandpamlawe rmnfrrLssun,�ce FBESPAID:
} N relalingtobulldingcoriatevcHon,andherebyautFotlzercpreeentativno(tFb
� Z dtyrocnteruponlMabovo-mcmb�uNpropertyforWpvcHanpurpoun. AL7EFIORADD70MFLH. Da12 ReC21 I#
ti — (We)a lo save,indc Ify an d kecp A�rMen the City o(Cupenlno
agaln me.,wa �m,�..�a �penxawhlchmaylnanywayacaue aRHANDLINCUMT(fO]O,OOOCFM) SUBTOTAL: D
Id Ity� e �hc amingWthleperMc -
AIRHANDLINGUMf(OVFR70,ODOCRM) CONSTRUCI'ION'fAX
SI a Ap nt/ ontanor Dnoe ocruusTH000cwi�ucn - CONSTRUCTION TAX PAID:
HA7ARDOIIS MATERIALS DISCLOSURE
WIIlthcappOcantor(uWrebulldingoccvpamatoreorhandlehvardoua HFATTNCl1MT('N100,OOOOIIq �Jate RCCEI fN
maMrlal as delln d by tM Cupertlno MuNdpal Code,Chapler 9.12,and lhe
HealihandSaletyC Ion75531(a)7 FIGTWCIIMT(OVCR100,IXpB77J) TOTAL: , Bj1
❑Yea No
Wllltheappll�anlor Nrcbulldingottvpamuwequiprrenlardevlm �FN77LA770N�AN($WCLENESID) ISSUANCEDA7'E
whlch emit ha>urdaue alr contaMwnle ae deMed by tM Day Arca Nr .
Qu IIIyMavgementDist In7 �ILER-CAMPPf�'OR100.IXqBTIn � �e
4Yn No �u�
� havereadtFeM1u. ematerlalsmqulremenbunderCFapkr6.95o( 110ILER-CONP(OVER100,OOON7U) '
Ihe GII(omW Health k Sil�ode,Seniav 75505,25537 and 2S53d.1 ��� �O ���
unders tluHfthebWldingdoceno�currentlyM1avealenant,tM1a�itlemy �WxGS1DFN71ALMfiCH, SQ.Ff
� Ililylo he panto(thercqulrcmenbwAlchmuct6errct
rlo Ma e Occv nry. i�O'_L( � «jI �Y' I' �YUrCFfIIIVU 1
� 1—
OwneroraWharludagenl Date ���pg �
11�TA1.:
OFFICE COPY