23541 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro en Identification PERMIT NO.
Building Addnes:
2
3541
are +m: phone -
APPLICATION A
-3Y3t CITY OF CUPERTINOBUILDING DIVISION
canndvr'a N.me: Lie.No: APPLICATION / PERMIT '
o It- C'-)6 -55'(x13 BIALDINGELECIWCALrLUNBINGMECHANIGV. CATEGORY - CONTROL Y
ArthBect/F glrcer. Llc No.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addr.s PFRh9TI4T1ANCE �� 1:1 F-1 ❑
LICENSED CONTRACTORS DECLARATION
lh mbyafflrmthatlunlxmaeduMerpm WmaofChapter9(amnmrne, APP[LAN RESDEM1AL JOB DF5CRfl'I ION
hDoaal.e lhlain
I.ulHCrmanaDiofftertcrta. oflhe Buatnemand AcfeatlonaCode,and PANELS 5 CpYq ')'o` N
-
orUP TO 200AMPS
Sam.- �
ARCHITECTSDECLARATIDN MI-IODDAMPS
rc0 7. I undentand my pI..eha8 be used u public rermdd OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
WWpp uw�O
Sc Z Lkcnsad Pmfewlonal SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION f
Iherebyafflrmthatlameumptfa the Coma ori Lia Lawfmthe SPECIALCIRCUIT/M1SC
7 9 S following reason.(Sedco 7(015,Ruelneo and Profeabns Cade:Any city or
6G - TEV?METER OR POLE INST.
F4 anycounty which Parrotttocoorequsitar,lmprove,derrsub repair
any et mcturctatemeltehan he la,abornpurvthant to the provisions
to POWER DEVICES
to � Zile•signed vatement that he b Banned punuant b the provbbnu or the
TOLL Contnctofa Lkeneelaw(Chaptrr9(monurcndng with Section 7000)4 Divi-� VALUATION�OS Non3oftheBusin.aandProfem mCade)orthathebemniptthenefmmand
SWIMMING POOL
the bash for the alleged exemption. Any violation of Section 7m15 by any
6J app0ant for.permit urbjedathe.pplicanttoa civil penalty dont morethan OUTLETSSWITCHIESFDUURFS
c � Liv undrtd dollan(ySM.
I,a.owner of t he property,or my ampbyma wit h wag.u their sole NEW RESIDENTIAL FJ.ECLR_SEPT. STORIES TYPE CONSTRUCTION
cpnpematlon,will do the work and the atmaure Is not Wended or offered for
� p ah(Sec.704 Boosineasand Profesnbnt Code:Tho,Contractors Llmrue,Law
(✓j$g do.notapplytoan ownerdpmPertywho build.m Improvesthercor,and
o- who donauch work hhreeBathrough his own employees,Provided that such OCC.GROUP RFS.UNITS
ImprovenrcNs are not Intended proffered forsale.If,however,thebuilding or
improvement hsdd whhln oneyearalcmnplelbn,the avner-bullderwlll have
t rdan of proving that M did nee bund or improve for purpose oracle.). QTY, PLUMBING PERMIT FEE
LJ L..owner of the property,am e.huively mntrading with licenrtd IrIDOD7DNF. APN
osntracum to mmtmd the project(Sm 704 Bu orman and Profemloru Code: PERMIT ISSUANCE
The Contractor'.Lkxes Law does not apply to an owner d property who ALTER-DRAIN&VENT-WATER(FA)
builor Improv.thereon, and wino conrtnda for ad ;npjem with a
oW1(actaK.)Manned pursuant to the Canlndoea Lice.law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B &.P C for thio reason -
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
Owner
Data RECE PT 9
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a mrtlflute of consent to.eK-bwa,a a S PER TRAP SCHOOL.TAX Y N
RECEMT Y
3800,LabdWork<n'Compemauonlruurana oraadBled copythermf(Sec. GAS EA.SYSIFM-]ING4 OUTLETS PARKFEE Y N
po q lab CJ
TCoGAS EA.SYSD].(-0VE24(FA) - BUILDING
Co ray BUILUINC DI VISION FEES
Nfied mpybhenby fumlahad. CRPASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
edifled copy b filed with the city inspection division.
CERTIFICATE OF IXFMPTSON FROM WORKERS' GRFASIE TRAP PAID
COMPENSATIONINSURANCE SEW1ER,SMTTARY-SIDRM FA MOFr. Date RCeel 1#
(IhlseMbn rie d rad be carryleted If the pemilt bfa one hundred dollar
0
R10)al®J WATEItHFATERW/VENT/ELECTRI shall ENERGY FEE - Y N
orI Wtin the pedomunaofthe work(orwWch Rhes pemdtb Woed,
W«ke not employ any person i mannerbeme any nnerr so as to cosubject to the
nmpe !,) AS1M � a.Cr�`
WNEAWTERRESYSTEM/TREATING
YSIR/TRE'ATING
PAID
Z Applicant n
Z O gen ofPy n,yn Date Recei-
t#
hmidomub)ctotMWoan'Compenioprobneoftheaor .
TOTAL
Cunand u meet fothwllh comply with such pmvi.lnm artMs permit Wil tr
W ] . dee.med revoked. BUILDING FEE
F3 coNSTxurnory LENDING wcwcY SEISMIC FEEa Ihereby afBrnthat there ba mmuuctim lending agency for the perforn, TOTAL: ELECTRIC FEE
7 Z ane of the workfor whkhthb permNbbeued(See 3097,CIv.CJ
LLO L<Mefs Na.
F lander.Addmw, QTY. MECHANICAL PERMIT FEE PLUMBING FEE
O W 1cedlfythat l have mad twotbud
appllnYatethat the above Information MECHANICAL FEE
bmarred.l agree to comply with all city and county ondlnanmand stale laws PERMIT ISSUANCE FEES PAID:
} M n tingto uiWd gwmmolon,andhenbyauthoK mpn..Uuv.afthh
N city to enter upon the above-mentioned Property fee inspection purposes. ALTERORADDTOMECH.
_ (We)agree to save,bdemNfy an d keep harmlea the City d Cuper lro Date RCcei t#
V ag.lrmt llabWtk.,Ndgmenb,rebased ezperm whkh myln anywayaen„e AIRHANDHNGUNITIT010,000CFM) SUBTOTAL-
g.WtsaldC io encaofthagra AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
Slgvm'rdof App ConG or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WWtheappllont.future bu8ding oavpant Ston or hamile harardou. H♦FATWG UNITODIM,"BTT/) Dale RCCC1 t#
material es defined by uac CupoM.M.Ndpal Code,Ch.pler 9.11,and the
' He.hhend Safetycode Section 255K(i)1 HEATING UNIT(OVEq 100,000BTD) TOTS
Y. MN.
—
Ill the appiland or futum building occupant use equipment a devka VENTILATION FAA[(SINGLE RFS) ISSUANCE DATE
which emit havrdous W mnnmhu MeaadMned bythe Bay Area Air
Quality Management WtrietT BO=-COMP OHHPOR 100,000 RT(]) PAI 1 D
/ Y. ❑F�No T 1
have and the haw . darlata requlnemenb under Chapter 6.95 of BOILFRLOMP(OVFR 10'0008111) '
the California Health&SafetyCade,Sectbru 25506,15513 and 25534.1 APR 22
,nderro.d that if the bufleing does not currently have a tenant,that It h my N'EWRF9DENTIALMECH. 1017 1992 '
roponbmWty to notify the occupant d mmo
the requirements which st be mat •I
prior to an f•�arub mofpPmv�
/J/ c �r� /a3 -�a. Cf fr�u^r�LyUF���n1/R��j
Owrc'W.0 art agent Data 1SSUEDBY�_! Yr7�1✓1
rorAL: ��Y�
OFFICE COPY