23442APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
OFFICE COPY
Building Proed IJentl(l.tlon
Building Addreca//''�4
Pl'J(MIT"L
3 4 4 2
o / MIA2
pP
ern m: Le(•EB
' -
-BUILDING DIVISION
APPLICATION SUBMI I JAL A .
APPLICATION 1 PERMIT
BUILDINGELECTRICALPLUMBING-MECI IANICAL
Co ad 'aNnme:/ r 2 Llc. a
(I
_
CAIWORY CO 7�
`
rt TIM/Engineer. Lic. No:
xe u
g .
• M?7Kaw e.., a - R� aWac.r r p
f'W'—'St"P'FFTRIFUR�tITI: a�'-
sur •
i-�@.`a'
., a .1P.I I4RING'PERMIT INfo o-
PLUMB MLLH
Address:Bit
PEIMTISSUANCE I AVJ
AR7i
❑ ❑ ❑
�Q
LICENSED CONTRACT 5DECLARATION
Ibarbyalfirm thatlam Bcrosed er provWona of Chapier9(mmmem
APPLIANCE"F4PENTIAL
P
JOB DESCRIPTION '
PANELS
Ingwe Is In bn7000) of 1%vlel the Buatnessand ProfmslmsCode,and my
license is In lull forte and
LI '•Claw Ic.N
Contrador
ARCHITECT'S DECLARATION
lumferstend mypismsha0beused upub0c rocorda
- PS V
-
ER l000AMPS
SQ. FT. FLOOR AREA
k/SQ. FT.
SIGNS ELECIRICAL
Licensed Professional
rEC1ALCIRCUIT/MI FZ
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contrador'. License Law for the
TEMP. METER LE INST.
following re...(Sedlun7031S, Bu.m...d Profeulom Code: Anyctyor
aunty which requlrm a permit to mmtrud, alter, Improve, denollsh,or repair
anystwdure prior to its lswance, also requlresthe applicant for such permit to
file a signed statement that he Is Ilcamed pursuant to the provisions of the
POWER ICES
S INGIWL -LECI'IIC
OU7IETSSWITCI IPSIBXM4FS
r
1
.i
A
k'
�n
Ossle(See,7W4,Buatmwanl
Contractor's License Law (Chapter 9(mmmencing with Seaton 7000) of DWI-
ston3 ofthe Buatne...nd PmfenbroCode) orthat he is exempt themfromard
the basis for the alleged exemptlon. Any violation of Sectlon 703L5 by say
appllant for a permit subjects the applicant to a civil penalty of not num than
fiNL.'reddolWrn(f50O).
I, as owner of the property, or my employees with wages as their wk
amp enuIf... willdothe work..d thesUucture tarot Intended or offered for
Profesalam Code: The Contrador. License Law
I'- VALUA]tX7
OQ6
NEW RESIDENTIAL ELEC'114 SO.FT.
STORIES
IYPECONSIRUCTION
$
does not apply to an owner of property who builds or improves thereon, and
whodoeseuchworkblmse0nrthreugh hlsownemployem, provided that such
OCC.CRONa
RIS UNITS
Improvements are not Intended orolfered for sale. If, however, thebuilding or
TOTAL:
Improvement issold withlnoneyearofcompidlon, the owner-bullderwlll have
Ih-k.rden of proving that he did not build ar Improve fee purpose of I.J.o
Lf I, as owner of the property, am eadmivdy contracting with Berate
mntraeton to mmtwd the project(Sec. 70441, Business and Professions Code:
.,.., ..
_, .... .. ..... .. .� ..
'�,'w�f:'�P UM 81 CBj EER T" -�%�
IME",,'
FLOOD LONE
APN
PFRhlTT ISSUANCE
The Contractor's License Law does not apply to an owner of pmpmty who
Wilds or Improves therms, and who contracts for such pipleds with a
cond(actor(U licensed pursuant to the Contrador. License Law.
Ell am exempt under Sec B 4 P C for this reasonOUTSIDE
ALTER -DRAIN 6v VENT- WATER (PA)
'"-'•`zfr:: Kot E SUMMARY`
FE.
BACK FLOW PROTECT. DEVICE
FEES
GRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT N
Owner Data
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to wlFlnwre, ora
cedill.teotworicen'Compemationlrouanceora.difled mpythenw!(Sec.
3800, lab C.)
Policy I
FDnURES PER TR"
SCI IDOL TA% Y N_
RFLETIT N
GAS EA. SYSTEM -1 INCA OuTlzr5
PARK FEE Y N
RECEIPT N
GAS EA. SYSTEM OVER /(EA)
Company
BUILDING DI VISI FEES
f 1Cedlficd copy Is herebyfurnished.the city
L�Ji Cedifled mpybflleJ with the city inspection dlvlNon.
CERTIFICATE OF EXEMPTION FROM WORKERS'
CREASE/INDUSTIM WASTE INTERCEPTOR
PLAN FLECK F�
�. �
P.—
I
GREASE TRAP
EA. 200FT.
COMPENSATION INSURANCE
((hl. eedlon need ata Ix complded lithe permit islorane hundred dollen
—C�SEWER-SANITARY-STORM
Date Recei til
WATFRttFATERW/VENT/ELECTR
ENERGY FEE Y N—
(f100)or lnssJ
that d.
tmiumer for
WATER SYSTEM/TREATING
Jay any 1. an to becomesubject
l .hall not employ any person In any manner at as to become wblM to the
to the
Worken'Compenutbn laws of Glllornia. Dale
PAID
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Compematlon provlsiom of the Labor
NEWRESIDENTIALPLMO. SQ.FT.
Dale Recei til
TOTAL'
Cafe, you at Iwthwiih comply with such provlslona m this permit shall be
deemed revoked.
UILDING1T' tj
SEISMIC FC5_
CONSTRUCTION LENDING AGENCY
IhernbyafOrm that there is a comtructlon lending agency for the performTOTAL:
once cal the work for which this permit Is Issued (Sec. 3097, CI,. C.)
Lender's Name
Lender's Address
I unify that I have read this appl atlon and state that the above information
is corms. I agree to comply with all city and county ordinances and nate lase
ELECTRIC FEE
QTY.
'.b3�'.(MECHANICAL PRRMIT, a a-
;'FEE
PLUMBING FEE
MECHANICAL FEE
_
PERMIT ISSUANCE
FEES PAID:
.I.ingwbulldingcmx udlan,.nd here amhorlurepresentalivesofthis
a,
dtyloenier upon above-mentioned Ay for lmpedlo PEertlno
(We)agrcc to v Ind Ilymd ep armless the Ci osea,
againu Wbllp ,jad uMex n swhkhrLuyl cctue
alms C In n the �tMs perm
\
Sig sur plicae /Contrador t
ALTERORADDTOMDCI I.
Date RCCCi IN
AIR HANDUNG UNIT (TO IO,ODOCIM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IQDIDCFM)
CONSTRUCfIONTAX
IXIIAUSf HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS DISCLOSURE
FLUTING UMTOO IOO,l1W BTU)
hotbuddiA occupaRIALS
Will a efired lme ure building odipalCode,Ch pierhandle9.haandous
material as fL(cty by the Cupertino Municipal Code,Chapter9.12, and the
I
Health arul Safely Code Sedlon 25532(a)7
Y. MN.
Date Rece 1p
HEATING UNIT (OVER 100,000 BTU)
-
TOTAL:
VENTIIATION FAN (SINGLE RESID)
ISSU1Y6NG{A{EPUE
Will theappliantor future building onvpamuweq.Ipmmtord.vicca
which emit haaarduus air contaminants as defined by the Bay Area Air
ality Management Dindn7
Yes FINu
Rave read the h�a`rTou. materials rcqulremcnte under Chapter 6.95 of
the C.lifornla I Imbh A Safety Coda, Sect Ions 25505, 25533 and 25534. 1
1
APR 16
����
BOILER COMP OHPOR 100,0(0 BTU)
-
BOILER -COMP (OVER 100,OOD BIL)
NEW RLSIDENTI AL MSCI 1. SQFT
understa ad that if the building does wt cammaly have a tenant that it 6 my
rapomlbllity to notify the occupant of the requirement$ which moat be met
prior to lwuame ole Certificate o(Ocmpanry.
�s T
CI I Ut' 1,Ur,cti fly
�F
ISSUEDIJ ztce::�-1
D.vnerm..thoriaed agent Data
TOTAL:
OFFICE COPY