28051 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTI NO RUILDING-ELECI RICA PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. n O O C eI
IIIIILDIsNG PROJE(A II)ENI'IFICATTON G o J 1
BUILDING ADDRESS r�///� SANITARY NO APPLICATION SUBMITTAL DATE
O _ /� I A II UNIT LOT#
OWNERS AME CO��(��jt/AI�!�'T��fOR'S LIC NO I NIC ••7 CONTROL q�•J
Us eC / GIN131!RI IJC NO A. RhSS: ❑
.CO TACT: \� PHONE: QTY, B1.ECFRIC PERMIT FFIi BUILDING PERMIT INFO
�' 2u9-/�Z zyC .��L� BLDG ELI P UMB MECH
.7 V P13RMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. �3O�N
py.z, Ihcreby affirmthm lamlicensW under provisions ofChap¢r9(d ybenogwith DE RIFTfON
+�JOO Scnton]1KK11 of Davision3of the Busmen and Prafesao�CWe std PANELS
y bccnu is m
CW lulllmce unAe
Fyly Date Cone .� UP TO 200 MPS
wQy Date Comrecmr 201-It100AMPS
7[ONZ� RCf11TECTS DF. L RATION OVER HIS)AMPS SQ,FT.FLOOR AREA $/SQ.FT
OZ^O I understand oty plum-bill be toed a,public iccnrde
�y(=; SIGNS EI.EC'TRICAL \
licenud l4ufes-tend OWNER BUILDER DECLARATION SPECIAL CIRCUTCM[SC.
p,Oa 1 hereby affirm Oat 1 am enempt from the Contractors License I.uw for Om
t�u3u-r<rFi following reaton.(Scaton 70 315,Busmno and Professions Cale Any cityorcoumy THMP METER OR PDLEINST. I '
t�C J which requires a permit m curenram,shed improve,demolrsh,err repmr any stmmuie
a: prior to an issuance,also requires the applicant for permit to rile asigned,tatemeal (POWER DEVICES
m_p0 mal he is licensed punuammthe postsion-ref the Con tractors license l.mw(Chapter SWIMMING POO^.ItL[CI'FtIC
2y�fL 9lcommcneingwnh Scaion7W)ofDivumn3ofthe Busincssand Profesoitm Code) VALUATION
-, or that he is exempttherefrom and the basis for the alleged exemption.Any
'intermit.f -
a
Section 7031.5 hyany apphciml lot apermit,wbye,,meippbconuoacivil penalty nr OUTLETS-SWYNIIES-FU('It6
mresume than five hundred dollars($500) NEW R' II� E2fR S FT
❑ I,mownuofihepropeny.ormyemployeeswithwagesestheirsolecompcm,aatm Q I STORIES TYPE CONSI RUCTION
will do work,and the structure is not tinendedorolfcred fnr,ale(Sec 7M4,Bus mess \ �
and PmleWors Cale:The Cnnlmctnr's I.menre Law does not., IY man owner of
pmpeny whobutldsorimprovn thereon,and wlmdoa ouch work him se In hrough M1is ) '
hoemployees.provided Nat such tmprovemeinsamend inleoed.rmffend 1,rsal�l, OCC.GROUP RFS UNIT'S
wever,the building or improvements sold within one yearofcompletmgtheownen 1
builderwJl have ficburdennt that hedid not build.,ice roveho r ` TOTAL:
pnrvaaK P purposes
,ale) TY. PLUMBING PERMIT FF.E I FLOOD ZONE APN
❑ Las the owner N,j(See property.ame,siac,,and Prtruungwithl¢enscd con carols Q
mswm the proyeu IScc ](144,Business and IknPosmns Code)The Cnntrucui PERMIT ISSUANCE y
License Lawdoesace nimly man nwnecof prnpeny whis builds or improves therein,and
who contracts forsuchjamiits with a contractors)heemand pursuummthe Contactors ALTER FA FEG SUMMARY I
Lwea,e Law. l 7
❑ 1 um exempt under Sec. B&P C for this reason BACK FLOW PRO'(',p DEVICE. Ot ITSIDE FEES
Owner SANITARY Y N
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF.AREA, RF.C131PT#._
I SCHOOL TAX YN
yatfnia thmlhuvcucenafane of ctnsenuo self-tenure,oracenilicam of �2 pIXTURIiti-PFR'1'RAP I_,_`�]tI II'ARR PF.P, YI.fI•IPTn N
ker,'Cord,r,atlom lmvmmceoracenifieJmpy thereof(Sec Jg00,LnbC)wM1ich ^ 7
all employees under this permit I GAS-EA.SYSTEM.I INC.4 OUTLET S RECEIPT#
covers Polsyp - w I BUILDING DIVISION FEES
Cnmpany_Z�&O L CAS-F.A.SYSTEM.OVER 4(EA) PLANCHECK FEE
❑ C railed copy is hereby furnished.
v tried copy is filed with the coy inspection divinon. GREASFJINDUSTRI.WASTE INTERCEPTOR (GRADING ME
CUR'I'IITCATH OP EXEMP IGN FROM WORKERS' GREASE'I'RAP SOILS FEH
COMPENSATION INSURANCE
Opaxoctinn need not he cnmpletedlfthe penman,for one hundred dollars P$10an I (SEWER-SANITARY-STORM F.A.2I017. ENERGY FEE
or lase 1
(cenify thatmthe per(nnnaneertbewmk forwhach Nis Permit is the ere IIIiA RW/VF.NT4i1.13CTR
not employ any'persnn m any manner so a-to become suh)ect to the workers' — ✓qIU
z Compensation Laws AE OEATING
z npphcun of Cnhfnme Dm- I I__ _Date Rec_a ps#
O
_I
NOTIC13TO APPLICANT ILnDermaLmg this Cenificetenf Exemption,you should P.WRESIDHNTIALPLMB. SQ.FT. TOTAL:
bcromesubject ply the Workers Compensation Permprovisions t tand fdicencorx,okedoumust ��ce ^��
lnnhwiN utmply wish such provisions onhi,permtnhullbeJecmed revoked L `, +- BUILDING FEE
1 (] CONSTRUCTION LENDING AGENCY Stv.M SHISMIC FEE
(hereby affirm that there is a construction[ending agency for the performance Or T
V O the work for which than Perin rst,med(See 3097,C1v.C) ELECTRIC FEE)
Lender's Nam-
0 U lender's Add,-= (QTY. MECHANICAL PERMIT PEE I PLUMBING FEE 1��r
I cenify that 1 have read this applicaunn and sate that the above mf camnac n i,
W runect.Ingmemunnply with till city nnJ Cnnnty nnbnance,and,mte lows relmangm PERMIT ISSUANCE I (MECHANICAL FEE
t0 bmldmg construction,and hereby euthonmrepresenwlives ofthincity mentcruponthe (
V Z above-calminaed property,for inspection psrtuses. I AL'IERORADDTOMECH. CONSTRUCTION TAX
(We)agree to save,mdcmmfy and keep hazmin,the Cay of Cuperono against
liabiliies,)ndgmento,costs and expenses which may in cry way accrue against said City AIR HANDLING UNIT 10 0.W0 CFkL
in cone luence of the granting of this permit.
AIR HANDLING UNIT(OVER 10.000 CI7M) I
Signature Of Applicant/Contmaor Date I3XHAUS'I'1 IOODI W/DUC'O
PAID
HAZARDOUS MATERIALS DISCLOSURE I HFATING UNIT(TO I W,"BTU) I Date Reci It
Will ilia'he Cuintorfmurcicipal goccupanterneor handle Benda and material TOTIJ
as defined by theCupnnmo Municipal Calc,Chapter..,Or and the eoeinates Safety I[EATING UNIT 104000 BTU) �YVIj--l�
Code.Station 25532tn)v V[:IJTILATION PAN(SINGLE RMID)
❑Yes ❑No /
Will fair co¢u contaminants s defined by the Bay Area nrdevm is which mnit
BOILER-COMP LHIP OR 100,000 BI UI ISSUANCE ATE '
me,? air conteminents as defined by the Bay Area An Quality hlnnagetnem I BOILER-COMP(OVER 100#4 BTU)
OasvmR
El Yes ❑No NEW RESIDENTIAL MECI I SQ,FT. P A I 1)
I have read the hssardous materials requirements under Chapter 6.95 mf Ne
Cubfnrna: Safety Code,Sections 35501,25133 and 25$J4. I under nodded MAY 10 �g95
ofth actin omnmcurvmJy M1ave ount.thutnismy re,pmnHJnymnotify the
Pant m mgmrcme s must le met prior m issuance of a Cenal, of
C�aup ,<=/may/�' CITY Ur
nor oramtmmsed agent Uate TOTAL: (ISSUED BY:
1000, '' OFFICE