24282 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PmK&Idevlfkatlma rER.wTNq,
Building Add.: r[)J
10(0 5 V u
282
am. ane:
CITY OF CUPERTTNOBUILDING DIVISIONeZ� f��
'e Ne e' LkI.� a APPLICATION / PERMIT 7CYl,
jtD BUILDIN'GE].FiTRICALPLUMBING H1ANiCAL CATEGORY CONTROL.
nh ver Lk.No
er' On ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addres; ` I'FRMIi ISSUANCE X 1:1 11LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Hansed order providma of Chapter 9(oomnnnnc APPLIANCESRFSIDENPIAL BDESCRQ'I70N
ingwith Settlor 700OWDIWal.3o11he guelneuaml ProfeuloniCode,and my
Ikevele In o 11����frrc�..e�t
PANELS
DatlContrardwrOh11UP TO 2D) tJ✓\v' • ♦l
ARCHITECT 5 DECLARATION 1-1000 ANI
¢OZ I underkand my plaro&hail he used As public m mord, OVER 1000 AhfP' _ S/SQ.FT.
5[j Licensed Prdesbvl SIC NS ELECTRICAL P e II T
ER
hatlamBmptf DECLARATION SPFLALCIRCIIIT/MI50 !YJ AVI
7x, IherebyaffimnttotlMmurnrytfmoeas.rd ,.f. .Cod :Arydrthr
foilowing reason.(Section 7031$Buabes and Ater,Imps bit Code:My tlty or J!
6' E•� 1T]v[P.MET6t ORIb�INS[.
FS anyam�ntyism pequlroa psuaneetooft om ,requiesth ImplleankemoWh,ormitto
YY any awcture semeior to ns that
M a,aLa and posthrappHuet otmatoor Mn,h permit a POWER DEVICES
0k•signed statement thrt M b Bayed pursuant to the proWbro of the
�q ConlntloYe Lkeror LAw(CMpter9(co.cirogwithSection7000)dDM-
t� OC' Men 3Ofthe Bualna and Prdrmbru Cade)orthat he b exempt therefromarW SWAIMING IA7a.ELECTRIC
ECIRIC
OI�'
AZ
VAL
G y.' the bash for the alleged exemption. Any vldatbn of Srabn 70015 by any LCj/yu
appb¢ntforapemdtwbiwtheapplkanttoad penekydnamomtWn 011'II.EfssW(1tF{ESFUC 6
five hundred dolbn Q5p01.� NEW RESIDENTIAL FyF.C,1,R j A F-11,u owner d the property,or my employee with wages u thetr sok SQ'PT. STORIES TYPE CONS RUCTION
mo
mpr edon,will do the work,and the rtaCYre is not,Intended or offered for
O v1e 5--70K Bushes and Pootesabv Code:The Coraradoes Derma,Law
don rot apply to An owner d property who Wil"or improves themon,And
OCC.—GROUP RLS UNITS;
who don alis work himself&through hb own employee,provided that such
Improvements are nM Intended oroHemd f«oak.I(however,thebulldlog or
Improvement b Mold within Oneyearofcompletbn,the owvr-0udderwif have
t rdenofpmWngthat hedkl notbuHdorlmprove fapurpoaeofsale.). QTY, PLUMBING PERMIT FEE F[ADD70NE APN
Lj 4 u owner of the property,am exwwNely mntraet ng with Ikeved I'FRAUi ISSUANCErxmtncton to mmtan the projcrt(gee 701,Busiwa and Pmfodoro Code:
The Contractor's Limnat Lew dwell not apply to an owner of property who ALTER-DRAINk VENT WATER(EN
W Ikb r Improves then on,and who mntrarta for Much p(poeta whh a
n acta(a)Hayed purwant to the Cortranws Lbeve Law. gA«FIDwPROiFfI'.DEVICE FEE SUMMARY
LJ I am exempt under See B A P C for this reason
DRAINS FLOOR ROOF,AREA,CDND. SANITARY Y— N_
O Owner Date _ RECE7IT0
&?!"h WORKMAN COMPENSATION DECLARATION FNTUI PER TRAP SCHOOLTAX Y— N_
&?!"hereby affirontolven C I have o Traonme of covens to aey-Wun,¢ . RECF�f
¢mtIf
I bC.WOrkan Canperartimslnannaaa¢rlfled wopythereof(get. GAS EA.SYSTEM-1 INC4 OUTLETS PARK FFR Y N
3&IQIab CJ(� ((�� c r: 3--2,q �
Pw pa-y—L •'Ib 1 a— L"7 C� �1 GAS E.A.SYRTM-OVER 4(EA) Rr�EI'mr#
ca�my y n\ate-rEo __ �E^_a o..r....'�'./1 6UILDINGDIVISION FEES
I ICeriOrd ropy tr filedv th the CRY
- GREASE/INDUSRtL WASM INTEFCEPNR PLANCHECK FEE
rl/ind ropy b filed with the tlty Iropenbn dlvWm.
CERTIFICATEMPE SATION NS FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANDARY b�RM E.A. S. Date Recti tk
IT)orI.) need not lee completed HtM permit bla one hundred doHan
({]m)alrm.) WAMRHFATERW/VENT/ELD7R ENERGY FEE Y N_
Illnot empbthe person
dNework sorwMchtw pemdteIto the
I shall not employ any prawn In any runner in u b become subjc¢to the WATRRSYSIFM/TREATING
w«kem�cwmpen.rtbn l.weof California. Rine PAID
O Z NDTICRAppil.t NEWRESIDWrIALPLMB. SQFI.. Date Remi tp
Z p NOTICE TO APPLICANT:If,after makingtw C«1Hlate of Evemplwn,you
ahwuld become subject to the Workers'Com teruatton provbbv of the Labor TOTA
cc N Code,yon=9forthwith comply with ouch proWsbv or this permit s1u11M -
deemed tevoknd.
SG CONSFRUC'1'ION LENDING AGENCY SEAS IC FEE
I hereby a(Or .1 v then e•mrut is is a kndbg 09,CI sur tar perfoary ELECTRIC FEE
7 Z ante of the workfar whkhtw permltbbvnd Sew.3097,Civ.C) TOTAL:
O O Lender'.Name PLUMBING FEE t
LL H Lender,Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W FE
Irer"atl havewpplir,
VO mad tatbn and statethrtthe above information
barrer.lagree to comply with sd tltyamd raantyomdlnanm and tlatelawa PERMIT ISSUANCE ES PAID:
>_ 1 NUingtobuiMd gmvtmnbn,and Mnbyauthor pr ntatheofthla -
�— Z sty to enter upon theabovo-mentbred property for ivpetion purpom. AI,MRORADDTOMECH.e) Date Recei tk
V — (Wagree to save.Ivdemniy an d keep harndesa the City of Cuperw - P
agalrus Wb ,adgmenit, and expeves"k meyinanywayacaue AIR HANDLING UNIT CIO I0,00p CFM) SUBTOTAL'
agalaty tyb wrtM gr.r; tw pemmn' AIRHANIXLING UNIT(OVER 10,0(IOCFTD CONSTRUCTION TAX
Sigatureaf pp t/ ont Dater EXHAUST HOOD(W/DL)CT) CONSTRUCTION TA P
HAZARDOUS TERIALS DISCLOSURE
Will thcappllont or future building ar pant Mom or handle hazardov HEATING UMT(70100,000 BTLD Dale RCC i fit
mater,il u defined by tis Cupertino MuMdpal Code,Chapter 9.17,and the
Health and Safety Cade Seetion 7SSM(a)7 HEATING UNIT(OVER 10D,OM BTU) TOTAL:
❑Yes
Will the Applicant¢ an budding—Not use equipment or dev. VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which coat Mvrdous air contardvnb as de0rcd by the Bay Area Air
Qua lily Maagemema DbtrM7 BOILER-NMP(SHIP OR 100,000 BTU) A I D
yet, ❑No
have mead the havrd.1 materials mequinrrcnb under Chapter 6.95 of MOILER-CONP(OV17t 100,000 BTU)
the Callfomla Health k Safety Cade,SeGbv 75505,25533 and 255M. 1
undmtand that It the budding don wt m eptly have a tenant,that it b roy NEW RESIDENTIAL MECH. SQ.FT JUL 29 �( 3
reporobHky to notify the occupant of the requirements whkh ryes be met (i1�7 �7a7J
prior to bsuaae da Certlrkate of Ocavpa rye s
All �`Il`f Ur t:t'rr
thorlred eat 76
Date
T7ITAT ISSUED BY:_
OFFICE COPY