22834 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bonding Proed Identification PERMIT NO,
Building Addroor 22834
Al. oT1i ILL Lv D U 3-014/ ( e L
rp; e am: one717
— SIG VGr+s 06. 4 9 3�L88 CITY OF CLI ERTIN BUILDING DIVISION
Contraatcrs NamrLie.Nu APPLICATION / PERMIT
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• O w N {,�/fr N {' Bar"'��
BCATEGORY CONTROL 0
Architect/Englrne LIC Na IIILINNGFLFLTWCALI'LIJMBINGMFLFIANKAL
�N Q
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address /I'1/a~// Af. ✓ PERh9TISSUANCE ` ❑ 1�
LICENSED CONTRACTORS DECLARATION
Ihereby SEctio70thatlam Bcn3oftbunder prwblo.dClupterode,an mi AI'RxANCFSRESIDFNML JOB ial y t
lice.IngwithScctbn7rceand effect.
Bu.lrceeand PmfeWonsCode,and
Branae b In full force and c.0 PANELS
License Clam Con
Dae Comractor UPT02DOAMIS
ARCHITECT'S DECLARATION 1-1000A.MPS
q�u oc Z I underrud ery plana shall be used n public records. OVER 1 WO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
& Lia.ed Pro(®conal SIGNSELECTRICAL
<^� OWNER-BUILDER DECLARATION SIrFfIALCIRCIRT MISC
r Iheraby.lfirmtlutlam exemptfromthe Cemractori Lice.Law for the CIRCUIT/
1,1192
folbwing reason.(Section 70315,Bualn.and P.levb.Code:My city or TFL03 METER OR OLE INST.
F� county which require a pemdt to curuwct,alter,Improve,demolbh,ormIniJr
d< < any Yr mpr tohabeuance,alaorequr theappBcantf«auchpe to POWER DEVICES
C O flit•Ygaed entennent that k b B«naed pursuant to the provleb.of the
�a Contractor.Lice.l F,(Chapter9(commenctng with Section 7000)of D1v1- SWIMMING POOL ELECTRIC
Off' sbn3°fthc Basins and PrdembvCsde)ortha Mala eu therttmmaM VALUATIQ!!
the meb for the alleged exemption. Any Aolatbn of SMrb 703IS by any �OO
p Tsj OVDE[SSWITCF45FIXHJRES
•ppb.ntforapemdtaubjectsthe.pplanttoad 1pe.ltydndmorotlun L
flue hundred dol"%goon.
F�I,as rof the property,or my employee with wag.a their wk NEW RESIDENTIAL ELDZTR—SOFT. STORIES TYPE CONSTRUCTION
penertlori,BwWdotkworkandtheetructurebn°timerdedorofferedfor
J ❑ sale 0"ar.7031, ounea;and Prdo.bns Code:The Contractors W«.e Law
fir d.notapply to an owner of property who builds or impeavra thereon,and OCC.GROUP �.
GG whodmwchworkme
hlelforthwgh Msown emplayeey prwlded that ercL
UNITS
improvememe an not intended oroffered for-sale.If,however,thebollding« TOT
bnprovement is o within-ner-Iofcomplelbn,thewvner-bullderwW have
M .e of proving that he did m build or Improve f« we purpofeak.). QTY. PLUMBING PERMIT FEE FLOOD 7DNIE APN
L a mvner of the properly,am e.hubely contracting with Ibensrd ora to oxnutruct the project(Sm 70tk Busines aM Prolmloru Code: PERMIT ISSUANCE
The Contractors Lioe.e Law doe nor apply to ao owner o(property who
Wilda or Imprav thereon, and who contracts fee such p," wIN a ALTER-DRAIN&VENT-WATER(EA)
agaq+aoRe)Manned pursuant to that Contract«i License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am E-11V ands,Sec B &P C for thio rt
uon DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
l Owner —Dam RECEV.T
WORKMANCOMPFNSATION'DECLARATION pp(NREg ppR TRAP
SCHOOL TAX Y_ N
m ve
❑1 hereby affirthat I haa nertiBrme of conself
sent to .lnwm,ce a I
' antificate of W°rken'Compensatlon l. a«
urana ertiand coreo
copy thef(See. RECFFBfI,
3300,lab G) GAS F.A.SYST12/1 INC./OU[IE[S PARK FEE Y N
Pd Ry R CAS EA.SYSTEM-0VER 4(EA) RECEIPT
Coy^Y BUILDING DIVISION FEES
e�N,d ropy le hereby fumbhed.
-1 Certified copy is filed with the city Inspection divitlon. GREASE/INDUSTRL WASTE IMFRCEPTOR PLANCHECKFEE
CEItTIRCATE OF E)(EMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONINSURANCEBf SEVMt-SANTTARYSTORM EA 200FT Date Recef t#
(Boa lea ion need flat be completed B the pemdt b f«orc hundred dollars
%too)«Lev.) WATER HFATFRW/VENT/El.Tmt ENERGYFEE Y N
1a Ere rfifythatin the pemon neofthew«k for tobhich ecuspermitIsbo the
1 shag rwt empby any peaon In any mans at e to become vubkct to the WATER SYSTEM/TREATING
W«keno'Comipe.albn lave d Gll(omla.Date PAID
O Z Applicant
Z O NOIICETOAPPLICANT:If,after making ebb Certificate of Exemption,you NEW RESIDENTIAL PLMH, SQFT. Date RC i t#
N should become wbjeet to the Workers'Compe.atlon proWslorx ofthe Labor TOTAL:
Code,you narat f«thwBh comply with such pruvlab.orthb perMt shall be
LU > deenrd revoked. BUILDING
CL — CONSTRUCTION LENDING AGENCY S I I FEE
CL IhEmbyafflrm that there b a conatrcelon lending agency for the perfomm
7 Z ance ofthe work for which this permR is hared(Sm 30Y7,Civ.C.) TOTAL ELECTRIC FEE
02 lender:Name PLUMBING FEE
LL I- Leder%Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certlfytha l have road thbapplkatbn.rad stmetbat theabovelnformatlon I St '(� FEES PAID
Is correct l ogres to complywith all city and county ordl.nae and state PERMIT ISSUANCE
Nrelating to building construction,a rd hereby auNorfu repreentative of this
F. Z city to entry upon the.bov rn,ntloned property for Wpectbn pu rpoae. ALTFRORADDTOMECH. Date Recei t#
— (We)agree to nave,IndemNty an d keep harmless the City d Cu Penton, p
.gal.t WbWBes,Ndgments,cost.aM.pense which may In any way.. AIR HANDUNG UMP CTO 10,000 CFM) SUBTOTAL
-
y
inconsequence ofthe gaining d tN.pemdr.
e6 y AIR HANDLING UNIT(OVER 10,000CFMl CONSTRUC170N TAX
g• / lnci« pa EXHAUST HOOD(W/D )CTT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappBant«future building occupant store or haMk hazardous HFATLNC UNIT CIO 100,000 BTL)
nDate Recei t#
nterlal ate ddl.d by the Cupertino M.Mdpal Code,Chapter 9.1Z,and the
H.Ith and Safety Code Section 25532(.)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yee
I—I f`I No
Bl the appBam«Y Nrebuilding;.paotu. Equlpnm orda VENTILATION FAN(SLNGLE RESLD) ISSUANCE DATE
which emit"pious air contann.ms ate defined by the Bay Arca Al,
Quality Ala.gement District? BOILER-COMP OHI'OR t00,IXq BTU) PAM
4 hYa ° Ifap2PJ
avercad the
ealtha mode,Sertam Z5rcntsunder Chapter595 of BOR•GR-CVMP(OVER 1 W,000 BTU) Q ��•
u nde,llf°rnla H.Bh&Safety code,Sectio.alyh2,e 33and,that 1 OCT U g
uMcretaftd ditythit to
fthe tify the
docs not errenllre.ntethich chat Ito ret NEW RIDDFtJ7IALA1El7-L SFT A
rcapo.ibBlty to natty the Ica d the requlrtmems which suet be met
prl«to issuance da Certlliate°lOmupncy. a01as_, �R�
Owner«autharisd agent Date ISSUED BY �J 11 YY- ��11 �•
TOTAL
OFFICE COPY