20238 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bufliln,project Idendfiutim PERMIT NO.
e7 Addha..: 20238
C>��o 4IYI�N 2ATJ4ADAKJS
CITY
APPLICATIONBUILDING
ERMTDIVISION
Ls
^, _ D
contnam'.�.mc— Lk.N.
BUILDINGF�.EC7itICALPLIIM9WGMECFIAMCAl CATFS-ARY CONTROL. 7
Arch eatA/E;gineer: I .f�« -J
ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PFRNUTISSUANCE Qp
LICFNS ED CONTRACTOR'S DECLARATION
IhthSb ffirmdatlam Me3sed erprovblonaofOaptcr9(tommm APPLIANCES-RESIDENTIAL
Ingwel'irw1on70(1eandeffect. ofNe8uduvand l'mfmloru Code,sed
Ibeue b In s forte and effect. PANELS
LDate Clam Cooh,ador UP TO 2DD ANCPS
AR TE CPS DECLARATION 201-1000 AMN
$7$��. IuM Iced upub8e remrtla OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Licerulld7ouboononall SIGNSELDCTRICAL /�
OWNER-BUILDER DECLARATION SPECALCBCUT/MSC /d
7F bb,Il Thereby aftlrmthatlamcxemptfranlhe Cordr or'aLlamaelAwfm Ne
FZ�o p n,ontyngreasm. iresap7ittowalnmand Pmlmbu CmEsh,o dty or
'ul tmnnty which requlmapermkromrwmct,alter,Mpmvt demoWh,arrepair TEMP.MITER OR POLE MSI'.
atmded statement lwurcpaborta,dp o, tto he fineuchna t e POWER D.W�
file a signed statement that ha b r9(on d pursuant to the tion n) d the
Ce.3.1thLlceuelaw(Clupter9(commencing ellh5edbnherefom.nd SWQ,fh9NG IDOL ELECTRIC
F,�OJ abet 3 of lhor the el sed Rofesabn. Kry orthwheb exempt therefrom and A UATION
p K+ the bub for the alleged<x thi.. Any oto atbn of nadbn 7031.5 by any OUTLE7SSWIT'CFWSFIA-I'URES
appRunt for.dreddoemdt S50(f. heapplkanttoa doll pemlydnm room than
Bve bund owerrofthe,p . NEW RESIDENTIAL ELECTR FI'.
4] ❑1,a owner of the Property,or my empbyee with wage u tb<tr sob ARIES TYPE CONSTRUCTION
U 7< mmpcwt wdldothewmkandthewmdumbrmtbdeMe or offered for
_ 0 sole(Sec 7D11,Rustiness and PrMenrbrr Code:The Contraaora umme Taw
dos net apply to an owner of property who,bulla or lmprwes thereon,and OCGGROIIP RES,UNITS
0.0. whodoea a uchwarkhlmulfmthwgh Meownemploye pr idedthateurh
Impmve.rta are not Intended oroffered(orsab.If however,the Wiling or TOTAL: 30.8 �J�
Improvemerrcbwld whhlnorcyearofcompletion,theowner-bullderwlll have 1G.
lt�parden nrprortng tnat ne dl not was ar Improve for purpwe of ub.} QTY. PLUMBING PERMIT FEE FT.aoomNE APN
Lj L u owner of the property,am exchoamely contracting with lianard
mntractme to aomtmd the pmjed(See 7094,Business and Profession,Code: PERMIT ISSUANCE l]
The Cordndo .Lberae Lw does not apply to an owner of property who ALTER-DRAW k VENT-WATER ffN
builds or improves thereon, and who coMnda for such ptojects whh a
'1 dors)Ilocnsed pursuantrothe ContnRor's LReue Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec R 4 P C for thb reason
DRAINS FLODR ROOF,AREA,GOND. SANITARY Y_ N
Ow <r Date —
WORKMAN COMPENSATION DECLARATION RECEIPT Y
K
01 hereby affirm that I have a ammmrt
rtflom of cnt to self-insert,or a RISS PER TRAP g QO S}OOL TAX Y N
a mfimte of Workers'Compeuatlm Imes ranee ma art0ltd copy thereof Gm RECEIPT Y
3800,Iab C) GAS F.A.SYSTEM-1 ING4OUTLETS JO PARKFFF Y_ N
�mY GASFA.SYSTQd-0VFRAMA) AE(:FIl'rY
Y BUILDING DI V IgION FF.FS
CertNN copy b hereby fuMahed. GAFASE/WDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE (36-R")
l Crit",ropybfiled Mth the tlty lmpMbn dlvWm,
CERTDTCATI:OF EXEMPTION FROM WORKERS' GRFASE7RM PAID
COMPENSATION INSURANCE SE�yp�yyk .�yb� �a70T Date Rece1 tp
(rMr aedbn need nabs compiled tithe perrtdt b(oranehundrtddollen
tslomorlnm) WATER HEATER w/vlxr/EIECIR ENERGY FEE Y N
am �OQ
I artily that In the perfoainceaf the work forwhich this permit b blued,
I shall not employ any poison In any canner n as to become object to theWATER SYSTEM/TRFATIIJG —
Worken'Compewtbn lawn o(GWomb.Date D PAID
Z = A UCEt NEWR64DEJTULPI R. SQFr. DatC Rccel tic
O NOTICE TO APIPLICAM:R,sRer staking lhb Certlflute of Exemptbn,yw
a cold become wbject to the Worker'Compeuatlan provbbm of the Labor TOTAL
CC N Code,yoa now forthwith ply wlthnuch prumdern rthb permit shill be
Lu > deemed revoked. QQILQfNG FEE
d.
p CONSTRUCTION LENDING AGENCY EISMIC FEE
Iherebyaffirmthatthereb•romhudlm lerdingagency(ortM pedortry ELECTRIC FEE
Z anceof the work for which thb;mnot b baued t5ec.30Y7,Co,.C.) TOTAL dD
U O ierderb Name PLUMBING FEE J
Iy F Lender.Addhess QTY. MECHANI P FEE
U W M la
MECHANICAL FE
mam U
bw . ageocompywa8ey.Mmntyodnnandtelamw
I'EiMIT ISSUANCE 1) FEES PAID:
} N relating toboling construction,and hereby audnxmo reprtaenUot of thb nn
F Z sty to enter upon the ab oo mentbrcd property for bapeetbn pu r ALTE R OR ADD TO MECH, a JV
— (WE)agree to save,Indemeay an d keep harmlem me Cly of�cauppenw Date Recti t>f
against liabilities,Judgments,costs and expenr which may inanywayamxue AIR HANDLING UNIT(IO]0,000 CFM)
.8.we yip any�.egae�of the gra49n tw pemhu. SUBTOTAL
AIR HANDUNG UNIT fOVFR 10,MCFYO CONSTRUCIION TAX
� �i3-90
X SlgnamreafA ant/Creta m Date f EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
FIAZARDOUS MATERIALS DISCLOSURE
Witt the appllant orfuwre wtidlg a:copant store or handk havrdoua HFATWGUWTT(TO100,000SII) Date RCCCI Iq
wterial as defined by the Cupertiro MuMdIol Code,Chapter 9.1Z and the
ITrahh end Safety Code Stolon ZS532(a)7 HEATING UNIT(OVER 100,000 BLU) TOTAL: ,3
I—I Ye r]Na
Illthe hapardNafuonotau0ding o«vpantuby the Ba AreaM vires VFNIILATION FAN�WCLE RFSID) IS$I�A[J(�GDAI'E
whicheMthagcnmrt aircontamWnbadeRrcd by the Bay Area Air 1r/'�lV
']❑sea Wy hUmgemont Di❑❑atrinl BOR Fa-NMP O}g'OR 100,000 Bll)
Ih�emadtheh. U.Ntmterlalerryuimmeob.rder Clupbr6.95af BOILER-COMP OVER 100,000 RTU) JUN i � 199u
tM CalBomle Healthk Sm(dy Code,Sedbu 75505,75533 and 755.74. 1
urdt'r thatlfthewlldingdmtwtmrrentyhaveatenanithatltbmy NEW RESIDENTIAL MECH. SQ.Fr
napotm8r8lty to nalfy the omoNon d the mlulroments e, stbemet,
prlortobu ill too,fOroopanry. �' Pity of Cuper4no
oo" "�-� 3/90
Ownllra athan,.N agent J J r
TOTAL: "'UEDB .
OFFICE COPY