20868 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuiWing Proet ldrnnfiotlon I
{� PERIvEITNO.
Building Addeo,: �^ ^ ,� �\D E—: C�L ��� - 20868
ars ame:�,.1 I1,,.k'_\J`-tl-`J\ e A
CITYOFCUPERTIN4BUILDING DIVISION �_(g
Contractor',Name: Lle.Nm APPLICATION it PERMIT
BUrLDIN ELDC-IRICALPLUMBINGMFLHAMCAL CATEGORY CDMjU
Anititet/Isgln mr. Lk.N. !,D
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. ' PFRNI TISSUANCE ® 1�
LICENSED CONTRACTORS DECLARATION L�
I M1eraby affirm thatlam llcased urdn provblaa o(CM1apter9(mrveun APPLIANCES RESIDENTIAL JOB DESCRIPTION
Ingwlth SeNnn7000)of DW on3ofthe Busirca,and Profn.UmaCode,and my
umnac k m full m
rae.na efet. ��^ r,vrms
.cense Cks Llea �Lk
Date Contactor
ARCHITECTS DECLARATION AMPS
9OZ I understaM my pkv sWB records
be usd aa public OVERIODOAMPS SQ.FT.FLOOR AREA S/5Q.Fr.
wO �y
;�j Lkxnsed Professional SIGNSFIu'TRIGL e-f Ira / +If
< OWNER-BUILDER DECLARATION ` L L-1+
I hembyawrm that l am exempt frorn the Contractor:Lberoe law for the SPECIALCIRCU17/M15C
p following reason.(Sectlmi 7031 S,Businm a rd Profesbn,Code:An ct r
07 � Y ty° TEMP.METfIIt OR POLE A3T.
r,� mYgty =ehpgt.tapermktomvrequimthenph=tfrtnaM1,or repair _
any etsigred tatterent,hat he
aLcensed pursuant
to the
of to POWER DEVICES
to
01e•algned akt—La that he b Braved pu w(Chapter 9 cirg hi the tion 7 bro of the
ttt---3000)of DM-
0Cee' sion3of the Buninesa and Pmra,leveode)arthat hwhin
b eumpt therefmmard SWIMMING POOL ELECTRIC VALUATION
LS ^I the bank for the alleged eumptbn. Any violation of Seton 7MIS by any
65 aPPBunt(or•pamdt subjets the apperant ton nail pawky dnt mom thin OUIIRTSSWITCFIESFI)CNR6 11 lyyJ L
a fiv hundred dollen(x500).
C p 6 I,as ovvvr of the pmperty,or my employee with wage a,their wk NEW RESIDENTIAL FT DCIR W ES TYPE OONSIRUCT)ON
pale Ckv 0K Businees and kwdthesWcturt kmtbuaMedorerfeee Law
�0 eak(See 7044,eusbins and Prdeeloro Code:The Cordnctota Llmvel�w
docanmapplyt°ano mrdpmpertywho Wid orlmprwnthereon,and au X
e- OCC.GROUP RES.UNITS d..&work him,elforthwgh h1sownempleea
oy ,provided that such
improvcmewamro tmdedorofferedrmaale.ILhmwever,the WlWingm TOTAL: 1 Q
Impmvcment bsdd wkhinomyearofc.P,MbRtheawner-W IMnww have
t rdenofpmvingthat he aid eat Wuaorimproveforpurpmeor,ale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE AIN
as owner of the property,am eacbive
, ly cord acting with licensed
mntnctor,to mvtruet the project(See.70M Bu,lrm and Ihofesbru Code: PERMIT ISSUANCE ^`�
Tire CoMnGa,or's LbenLaw don nor not apply to an owner d property who ALTER-DRAIN 6 VFM-WATER ff.V <
hu Bds or Imov
prthereon,and who oaMnm (m sueh p\ojets with a
91134+dm(s)Licensed pursuant to the Contrador's Llave Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U Mn I am exempt uSoc B k P C for thin reason
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N
Owner Date gECppTpPP
WORKMAN COMPENSATION DECLARATION FIXTURES PER.TRAP S 001.TAX Y_ N_
❑1 M1eeeby arflren that I have a mnimte d cauent to mil-Wun,ce a
cotwe to of Worker:Compevatlmlrounnm or•mNffed mpythereof$ec. RD=0
MOD,Lab C) GAS F.A.SYSTEM-1 WC/OUILES PARR FEE . Y_ N_
R GAS EA.SYSTEM-OVER 4(EA) RECFdPT/
Y - BUILDING DIVISION FEES
Certified copy b d.
Certified ropy is filed with the ehlrepetbn division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF FJi1MPTION FROM WOR KERS GREASE TRAP PAID
COMPFNSATLON INSURANCE SEWER SANfEARY STORM EA 20fF1' Date Recd t#
(this section need no be ENSATed tithe ptrodSURA b(more M1undrtd dollars
($10(Iorlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N <
I certify Wt in the Ferfomunm of the work for which Ms pcmat is luued, —
I,hall not employ any Person In any nunner an as to become aubject to the WATER SYS IN/TREATING
Workeee'Compenutbn Lws of GBforna. Date PAID
OZ Appueent SQ.FT. Dale Reoei t#
Z NOITCE TO APPLICANT:If, kl
,after nury thin Certi(leate of Fxernptbn, NEW RESIDENTIAL,PLMB.
should becomesubkcl to the Workers'Compensatlon provbv loof the Laybwor t'� ^ t�O TOTAL:
CC N Cade,you at fort hwith comply with,uch provbbv or thin Perrot,hall be 1 t �L LNG
j deemed revolted.CONSTRUCTION LENDING AGENCY � SEISMIC FEE c
CL Ihembya/firm hatthemis mmtructlon krdingagenry farthe peeartm
D Z ance of the wohbr which thing=b bored(See.3097,CW.C.) TOTAL_ ELC•CI'RIC FEE
02 Lender•Name PLUMBING FEE
LL ~ Leoder's Addnsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imni(ylhatl FavemadthbappB tbnaMoatet attheabovelnf°mutlan
b corrtct.I qnm tocmnplywkh W city and county ordWnmand slate laws PERMIT ISSUANCE J � FEES PAID:
N relaIF.-
ling aMm,aM krtby aulhoNe reprexnalNn of thin
F Z city mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Recel t#
t e, and p harm:.the City of C.'it tra Pg .fid a ,n whlcb may In any wayamue AIR HANDLING UNIT RO 10,000 CFM) SUBTOTAL:
fthe mi,d Ws permLL
AIR HANDLING UNIT(OVER to,=CFM) CONSFRUCFIONTAX
Signa m o pph. t/cantrw,m Date E](HAUs'I How(W/Dues CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appfiantor fuvrt Wliding oavpant•tort or handle hawdous HFAT1NGUNTT(TO100p00BTln Date RCcel t#
material a defined by the Coped["Muedtpal Code,Chapter9.1Z and the
IkahM1 and Safety C�lon 75532fj)t HEATING IIMT(OVER IOD,I%10 BITJ) TOTAL:
❑ Yea o
Wllltheappllont future Wlldbgo pantum aqulpm Mmdevlcoa VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardcusa mnamivM,a,defined by the Bay Area Air
. Qu Iky Ma gemeAh'
BOILFR+ZOMPOHPOR100,000EI IT)
Yes
I we a thcate ale requirerrnts under Chapter 695 of BOILFRRDMP(OVER 100,000 BTT))
theCalif Healod ,Sm 'rd,whnd 25534. 1
urdent t tir d y have a tenant,that it k my NEW RFBI DFNTIAL MECH SQFFSEP 12 1990
ropo B re oat renew whkh reut be nRd phb to rodo
neror thin:' agent Date TOTAL ISSUED BY ��lf'w7D�"^"'V
OFFICE COPY