22660 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building P,.en Id.wiflr.d.. - PERMIT NO.
Building Addraw w FI—OwF p— w 22660
wners PTAPhone:
[/ nl 7�- SJOj CITYOFCUPERTIN0.BUILDINGDIVISiON
tnda
Cones Name: Lir.No: APPLICATION /PERMIT �J
BUILDINGELEPL
CTRICALUMBING-MIGFIANICAL CATEGORY CONTROppp
Architect/Engin r Lk.No: � L�
cJ BUILDING PERMIT INFO
11�442QTYW � QELECTRIC PERMIT PEE
Address: PFRMITISSUANCE
LICENSE CONTRACTOR'S DECLAR 1 N
thereby
hth Se d(I70 ehelai licensed 3.ftunder provisions
essand Pen sakes 9(mmmen AI9'IdANCESRESIDENTIAL JOB DESCRIPTION
Ingwiliomseh infull force
effect.
Bueneseand ProfeseloneCode,end my
license la In full force and effect. PANELS
License Clam Lk.p IFS]
Date Contmdor —UP TO 2DO AMM
ARCHITECTS DECLARATION 1-1000 AMPS
q�q�uu Oot Zp I understand my plana shall be used es public records. OVERI"AMPS � SQ.FT.FLOOR�A-RI-EtA /�$/SQ.FT.
S%�ta Licensed Professional SIGNS ELECTRICAL 222 1 9n:� Of
OWNEReBUILDER DECLARATION SPGCLAL CIRCULI/MLSC �, 1. ►}t l 2(pa cyrt
Zs, Thereby affirm that I Ann ERDEeLARATorBLicense law for the �[(�J V
OO following Cession.(Bedion 70315,Business and Professions Code:Any city or
O Z 1:. E ER OR POLE INST.
r TEMP.M� c°untywhichmuimsapermlttomrotrud,alt°r,impmve,demolish,orrepalr
$$$ 66 anystmdumpd.rtolts smance,aLwrequimatheappllnntfursuchpermiteo POWER DEVICES
q U ilk a signed statement that he to licensed pursuant to the provisions of the
3w� Contract°(.license fAw(Chapter9(mmmendSection+ SWIMMING POOL ELECTRIC
�03 the bsRhe Business and Pmlmlon. Any viotheheh exempt 703LS by any VALUATION
the bean for the alleged exemption. Anyviolationtolatbn of penalty
on 7I11S by any OUTLETSSN7TCIIESFIXTURES
Applicant fora Permit applicant too dull penalty°(not morethan 1 VVV a
live net owner of the pr). NEW RESIDENTIAL ELECTR
�n I,1s owner u(the property,or my employee with wage as there sok �'�' STORIES TYPE CONSIR[KTION
C m(Sec.744,Billso the ess and rkand the s Code; hnot intended e.License LAW
",'�'�l�a�S I^ta l
q does e(Sec.7ply Business and Professions Code;The or Improves
Limner Law <
3� don nonsuch tork ownerofproperty hisohemplrlmproovidedreoryand OCC.GROUP BES.UNITS
who doessuchw.rk himaeBorlhmugM1 Motown emplgee;provided that such
improvements are not Intended oroffered(°reale.If,however,thebuilding or TOTA
improvement Issoldwlthln oneyearofcomplelogthe owner-bulWerwlll have
tiBLIlurdes of proving the he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD LONE APN
Lj L as owner of the property,am exclusively Contracting with licensed
contractor,to Construct the project(Sm.7044,Business and Professions Code: PERMIT ISSUANCE
The Contmd.r's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who cortractq,for such pt,ojects with a
mn,ed pursuant to the ContoactlifiLlcerse Law. FEE SUMMARY
I re N under Sec B&P C for h re n BACK FLAW PROTECT.DEVICE
7t? 1A
Owner a Ar
ate DRAINS FLC6R, $ ,C(,N _ E: ID RY Y N
C CLARATI N RECFRTp
❑1 off at I ha ace e (consent m aelf-In ora HXTUR iS'-PERI % - LTA Y_ N_
certIII of Wor 'Compe uzance or a tented copy thereof fSec. RfLEI'fp.
3g00,Lab GAS F.A.SYSTEM-1 A A Y_ N_
Policy p 4 RECFRxT If
Cam an - GAS PA. -0V
� Y -V/Ya aG BUILDING DIVISION FEES
Certl(Icd mpyk Fereby furnished. GREASE/IND -WASTE INTERCEPTOR PLA - GK PEE
❑Cerll(led copy h filed with the city inspection division. //��C�
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7RAP PAID'V�'7l MG—L Q
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT Date Recti tk 82�.
(Thissedion need not he completed If permit is for one hundred dollars
($100)orlem.) WATER HEATER W/VEM/E.FGTR ENERGY FEE Y N
Icenotify thatinthe persnInanerformance nannek forwhlch beca permitis issued, � l ��rQ2
1 shake not employ any person In any manner n as to became subject to the WATER SYSTEM/1REATING r D
Workers Compensation Lam o(Calif.mk.Date ,PAID p
ZZ Applicant NEWRESIDENDALPLMB. SQ}T. Date Recti t# 3Ysm
O NOTICRTO APPLICANT.If,.fmrmakingthh Cedi(Ioteof Exemption,you
Hshould became subject to the Workers'Compensation pmvhions of the Labor TOT
V9 Code,you must forthwith comply With such provhlons or this perMtshal l be O
LLI G decreed revoked. D 1
CL CONSTRUCTION LENDING AGENCY SEISMIC FEEr---/ L 6
I hemby afflrm that there C.construction lending agency for the perform ELECT'RI
D Z ance of the workfor which this permit I,Wucd(Sec.3097,Civ.C.) TOTAL t
I In T1
V O I,ceder'.Name PLUMB E
IL i— Lander.Address QTY. MECHANICAL PERMIT FEE MEC CAL FE
O W hcolard(ythatlhavemadthieappBmtisnando.tethattheabovelnformation
1 rred.Icgree to comply with all city and county ordinances ER
and state laws PERMIT ISSUANCE F•
r>- relating to building ronshudlon,and hereby authorize representatives of this
N
(_ city to enter upon the above-mentioned property for Ion purposes. ALTER OR ADD TO MECH.
Z
Z (We)agree to save,Indemnify an it keep harm1q4Ae City of Gu pe Ino Date Recti 1M
agaleut liabilities,judgments,cneeand expenses may In any way a AIR HANDLING UNIT(TO 10,000 CFM) U13TOTAL•
ag saidin ronsequencer, t aha this permit.
Y 1 /d AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIO TAX
Signator !Applin rador Data EXHAUST HOOD(W/DUCT) CONSTRUCTIO TAX PAID:
A RIALS SURG
Will t Capp][ nt of future buildl ant at or handkehazardooe BEATING UNIT(TO 100,000 BTU) Date .Cel IN
materhla by4 no Municipal Code Chapter 9.13,and the --
Health❑Yea
Sa sty Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BM %0TAL:
Will the applicant or future bcllding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANG ATE
Which emle hazard.,are coneamlnsnts as de0ned by the Bay Area Alr
Quality Management District? BOILER-COMP OHP OR 100,0W BTU)
4 Yea
n No
havemailtheh..gouo.sterialsrequiremeetsorderChapter6.95of BOILER-CAMP(OVE1100,000DIU)
the Glhfc mia Health&Sa(Any Code,Sect ions 25505,25533 and 25534. I f+1I n 8
u ndersta net n that if she build leg doemt currently have a tenant,that it h my NEW ESIDENTIAL MECH, SQ.FT PA ID
responsibility to notify the occupant of the mil.immarta which must he scat
prior t.Issuance of a CcrtiBcate of Oompancy. g
01
OWnar.rauthodzcd agent Data ^ ^
TOTAL 1 ISSUEDBt
OFFICE COPY