S 2192 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO RRIANG-ELI?CrRICAL Pr: rr No
4LILIBINOhDIVISION APPLICATIONIPERMIT ODBING CT IDENTIANIFIC ` 219 2
ISUILOD N:CT Il3EN'1'IPIG'CION
BUILDING ADDRESS: SAN]TARY NO. APFUCA'I'ION° 11'1'1'AL DATE
10250 Sok..X LO �- S-- �n
(lW 11 i'S NAMIi: I'Hf1NE: C( RACIOR'S NLIC NO:
�3o NIC CONTROLM
0 RCHI'TECTWINGINEE : LIC NO: ADDRESS: v �� -?y3 I INry1 4.iCO/N�T�kAC�T: � ymfONE: l�. BUILDING PGRMIT INFO1' Woo� Cq]�)p 2CI -q5$(S ❑ Consultant d by Applicant(Initial) BO ELO PLUMB MECCH
LICENSED CONTRACTORS DECLARATION QTY. IC PERMIT FEE•1 hereby affirm that I am licensed under provisions of Chapter 9(commencingJOB DESCRIPTION
with Semlon7000)of Division 3 ophe Business and Professions Code,andmy license is ^ RFSIDENTIAI:00 PIiRMrr ISSYn full foreeand eif t. Arbo ❑SFOWL ❑KITCHF,N kIiMODF.L
R galV F License14� Lic.M eL 1776 U ra ,T APPLIANCFENf1A1. ❑ADDITION ❑PLUMBING NEPIPF.
F�w Dote TT�� Cono..it,, �l'-�-
ti d ❑MITI:I'I-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
~,a,z I understand my plans shall he used as pnhlic records PANELS MODIFICATION
OZ42 IIP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1"W Licensed Professional 2111-I001AMPS IMPROVEMENT SWIMMING POOLS
OWNER-ISUILDIiR DECLARATION OVER He1DAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
tY Q I hereby alarm that I am escand from the COnitacha'a Lictnse 41w for the
ip5, d U follnwlne reason.(Section]1131.5,Business and Professions Codr:Any city or county SIGNS ELECTRICAL OOTHIiR
la LL 0 y which requires a permit to cnn.wn,altar.improve.demolish,or repair any strvnure
prior to its issuance,also requires the applicant for such Permit file a signed statement SPECIAL CIRCUIT/MISC.
�y brommeslicenwit rSectio 700dufDisinnsof thebe Bmirto,rcucemn Law 1.Cad.)
q1H (cot he i,eneue ivoron9mlol th th....on3 ofthe Business and Professions Cndd nr TLh11'.MFTIiR OR roLF:INST COMMERCIAL
IAL•
d y m C that he is 31.5 b therefrom and too basis for the rti,the
exemption.Any l Penion of ❑NEW BLDG/ADDITION ❑FOOD SERVICE TION
Way Section 7031.5 by any applicant forapennit suhjecNs the upplicam macivil penalty of POWER DEVICES ❑TIiNANT ❑FOOD SERVICE
m more than five hundred dollars($50m, IMPROVEMEN'1
Sp ❑1,mowneTof theproperty,of my employees with xa,uois their no le compensation, SWIMMING POOL ELECTRIC �a p,p�0_� &%
p.. will Jo the work,and the stmemre is nm intemovalm.ffered for salv(Sce.J(1W.Business OTHER . I
and Professions Code:The Coniocmr'n Licemu Law does not apply to an owner of OUTLETS-SWITCHES-PI%TURES
L property who builds or improves thereon.and who does such work himself or through
his own employees,pow ldcd that such improvements am not intended or offered Tor NEW RESIDENTIAL ELECTR
sale.IT however,the buildingorimpmvcment is sold within Inc yemal completion,the SQ.F1'.FLOOR AREA $ISQ.IT.
ovicer-builder will have the burden of purring that he did not build nr improve for pur-
posc inside.).
❑1,as owner ufthe property,am exclusively amuactin8 with licensed volume...m
onavuct the unuct(Sec.)(Hq Business and Professions Code:)T he Central 's Li-
cense Law does nmapply toanowner ofproperty whobuilds mimproves thercnn.and QTY. PLUMBING PERMIT FEE
who contracts for such pmjecls withnurmract r(s)lice pursuant m me Commerors
License L:Iw. PERMIT'ISSUANCE
I oro exmnpt under Sec. .B&P C for this mown
ALTIiR-DRAIN&VENT WATER(I?A) VALUATION
Own Dote
W'ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEV
461 I
G�TJ�
I hereby affirm under penalty of Peru
jry one of the following drelaratium: //��s C sm
❑I have and will maintain a CenificamofCommtit m self-;Imre for Wallace,Compcn- DRAINS-FLOOR,ROOF,Z. STORIES TYPE CONSTRUCTION
action,as provided for by lection 3700 of the labor Cork,for the peammucc ,"toe
work for which this Permit is issued. FIXTURES-PER'TRAI'
El I have and will comm in Workers Compensation Insurance,as required by Station
3]Wofthe taro Codel'or the performance of the work for which this permit is issued GAS-EA.SYSI EM-I INC.40UTLETSOCC.GROUT' APE
MY WorWkc.Co.ycnatiu, sura ecorrie Poli Policy
myCc wo land Policy
!.>LiLi, GAS-EA.SYSTTiM-OVIiR4(IiA)
S� Q`CIiRfIFICATE OPEX131,1P1'ION FROM WORKERS' GRBASU1NDUSTRL WASTE IMERCF.PTOR
COMPENSATION INSURANCE: BUILDING DIVISION FEES
(TTis rxeJnnnreJ not bernmplomJif thepermit is fornne hundred dollars(Ston) GREASETRAP
m let .) PLANCHCCK FEE
I toddy that in the performance ofthe work for which this permit is Issued,l shall SEWER-SANI'T'ARY-STORM EA.2110 FI'.
not employ nny person in any manner so as m Iecnme subjaa m the Wohers'Compen- ENERGY PEE
Z ,Z melon Laws of Cmifomia.Dae WA'I'17R HEATER WNENT/ELECTR GRADING FEE
Applicant
y NOICE'1'0 APPLICANT if,after making this Certificate of Enemption,you should WATER SYSTEM/TREATING SOILS FEE
a ' become subject to the Workce,Compcnmoon
n pwvinlns or tine Labor Code.you malt
LQ id comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RFSIDEN'I IAL PLMB. SQ,FT. jPA11`U Z (thereby affirm than there is a constmetion Tending agency fort erfmmance of Re<eiptp
wthe work far which thin permit;,issued(Sec.309].ClUmdett Name TOTAL:
U Lenders Address TOTAL:y 1 certify that 1 have read M pplicmion and Nice that the shove information is m corned.l agreem comply withnE city and county ordinances and,tate Iowa rdutinem QTY. MECHANICAL PERMIT FfiF.U Zbuilding conswction,and hereby athoH,c lepresmnatives oflhis city to enter upon the
uhove-memioned property far inspection Pmrsises. PERMIT ISSUANCE hiyinaneagaintidCityIiacome,amnec fthe nomargoflhn,cormtch may many way accrue against said Ciry q1:1'ER OR ADD TO MIiCH. .
in consequence Nthe grunting S AND UNDERSTANDS WILL COMPLY WITH AL1.NON-POINT p1µHANDLING UNII'(TO 10,000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING ONI'I'IOVUR 10.0my)CPM) CONS'FRUCf10N'1'AX
Signature ofAMlicanUComrocmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willthea,li,mum humebmldingocsvpum smmorhandlahmurdotionam ial HEATING UNIT(TO My"BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IW,1NM1 BTU)
Cade,Section 25532m)!
0Y" ON. PAID
VENI'ILAI'[ON PAN(SINGLE RCSID) Date Receipt p
Will the appheum m whim building oscupmn um equipment or device,which 110ti ER-COME'(9111'OR 100,000 BTU)
emit bazandous air contaminants as defined by the Bay Area Air Quality Manigemnnl e T
Ili,tnct? BOILER-COMP(OVER 100,00311 IT)
❑Yes ❑No
I have re ad the haauNnusmaterial,roqulmments under Chapter 6.95 of the Call. AIRCONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25585,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.IT. �—
building does nm currently have a�r multi that it is my resDmsibility to notify the occu,mm
di gairemeris which e
d pno2no imance of a Cendlcal -
Oven y
'r
TTA
O ncroreuthn ead +,"�-�-6Data : ISSUED BY:
OFFICE
3
D
' ; e
m
g
m
g o DE ANZA BLVD,
a
z
oQ R'
i 50'— M h--50'—+—•
zT T
z 3
>
25 O I
O Q fm � a,C f���� �'a�� .4, � •e t a a "t.:;x I
j x
Nl
59,d
i✓ sSty 'f 4�' IV 9 h� �' ��\1' •
Q cn
S M 4
I
ct
n
x
z
c�
s c 7-
0:1 CA an
71 i'
aim
zo
P� f �
• a
u
P
m
I
L/
0
c � NT Z DH
m m .
o Z
zC'I r e °
�. �MtIO r1OIA �izu—�su
; 2 z o
g / m z
_
_ _ _
b 2J r NN WN
U
z
y p C
9 M�
m �
lull
N
� m �
gm m z
m �
✓� T
aA Bl' � m �m�pp6 v � ��7cC3 � m
Q � T � r � hl > z � x 4l o Z Z 0 0 • •
hoc° 7o
z `n
> K � b" cn � og� tnom�' cDimon � 3Ni N
m tl mn � N G �
D
m N .� --1 tC- o Lam^ N V W -1 N D v N N
C � 6 T � � N O O K C'i (rye m
O 2 -rOn' � N� mW Cm
o o n C O T N S C C) A tn'..l `CZAS ,A Zcl
D add 999 ZZ� ;n -p T CeAp -N1 OC bC D C� V 1
m
0o pQ yygz, m
Q N m c rSi c z Fn
37 w O m Fn24Gzl ni N m m N
Z F rn T m 22
:E
� 3c
C� T
'R S y�y oN
9 i Q �Y i O _
t
> r-. 3 rl
22 p z (71 C x ZO o >
MU)
4 > 3 �10
Z a o m m
Mcca
m � i7nm
rn rn �
Nm ".
ai
Zm
�� s r
N �
' n 4
P
m
e N :r m v c� QW S• n .
z „ *, n ��jo ca � 7�a
= g % � � � �
L I�.�'• 70c m e 7mc rn D 7m0 N G>� yc M = �= �j Yn 3_ rn D [' �ai �^
. i o 0
7p n x D' G1 N C7 77pp 7c •.n
=� O 7NV � v 2 0 C7 N 2 S � � O Com') o O 2 A Sill,
.7 W n C n rvn rn O Z O y Z 1 p x C C r S?° ro rn UN N �y' p
pip 67 C ) 2:-, rn O C C7 G7 O E d 2a p x Z D D 0
O rn w v rn Z° 3 A N Z m K rn r+i z v �n c _ = ov o
y o rn � z > v{ o m o x [7�11t
r •� 7o C r 7c1 r-. .. O 2 N D rn x m
m 6 r p o D rn D Q
00 •rC c ,� x s z c t'^ v rn Ci C r rn y 2 rMs La rr.. N z r v x N
D
R1 2C N O D m O 1 Z
rn 7rno v o rn v 2° rn rn Z-° o �u r o a z z ^1
D = o xxrn2oNao � z �n W apo xrncnrnonvD � z
v (Zl e rn rn C C Y I1 N W v 2 O 7,;3 O
x �� 70 rn �n o o � Q,
O W c R° 2 0 r R^ �.rn_, rn n I'*1
3 m e o rr F^ n - rn m �*i z N
rno � � � � � � nZw � z � �
zo � � 70c,
m C ••t1 Iq
C a N "'� -1 rn r 70
qJ3N n CP O N Z O W
c -zC rxn z o rn o rn rn
rn
m 77ccti
2 0 0
stawji,g
m z o8
p Go
�
D 6
k
P
I
� 11 1 11
rnOwl E8
rR
ZD
YI � m 3 � ➢ �,
T O CA
c M •
N cM
A 910 E
z O
a6 n ^ s
K m S m m;
M
1 B M �O Mm
T P m mZm� Mk
!ZI
21 m m SSG)
n 3 c mn MO 67) 0n
3 Zoo' yyn nZ0 3 _�f�r��
_ c Z ~0 m �M� �2
ll�
Z CT
C)
O
� z
v
s a M =L� CA
o
m �
N S
5 \
N J _ TI.J O
Z Z
° 101n g o o
(p T
z m m m
N L _
m
oma °gig
a mMa
m 'a
1
3 s Imo, o r.". p c� r"
y07 Ir^ e D N Dt -C 7�7pp .� 1.,� N 7� 7zc� c rn
S O N O T O S 7Ao O7t r N N p y r a 70 N 1+1 T
rn
pip W 0 C C> r11 e O Z O y Z 0 + `C C D D 1 trl r a ��c
Vii, O p p v y rrn- O rC- 1'011 L O N axa Z 7A c> P �o -{ DD R^
m w r 0 rn 2° m N z m Zo r i* r^ 7d x r^ x N v' o y y c
c D �° v G1 rnrnZ rn z � m {{-� c c� D W y Z z z X {7tp1r.
m O --1 �{ D O p C1
oz � p6cn �n � cLrn � R° > G ;:5Ei ' � Z �' =' � o �" � N
7Op .C) Sp Z Z �-Nt1 Uj p 7-01 C� = D v m -N-1 Cn
im
< 7�0 v �O D o -DAY-1 hCt uW�i o o 7o Z a o
32
p mzlx*1m` 3 � N � o-1 p � � c,� � � ocn � rpo � ZDarvrt
+_ ]�Dp1
2 T 67 ht co .D.{ O QTe rn �j,7 Z M D x011 N O yT n N
x Fi O m O ? CDS rn .N O m r11 �+ A Q� Uj O N
sC _ 7�1c7t
2 Op 1*t 0 T7 7�at z v Z N T Zp
m 6 p rn rn rC C'l N N N D L rn 2 p
3 ° m_ rn z rn rn
2 9 y 2 r r �
i
Cod
m 7
f //�y/��
�� W
� Fr- 1"161�
-91 t
Ps
E l l
z x
p k
~ w
m
Fn
jig a
cr
m 111
m
o �
m � m
R IN _
N 1 A
N � Z
N J
M zm
a
6, F- U
0
yy >
9 z ; t� 6rnA00 "CN
A x Tn
z o
xe "'
R 6 c r°
�m az Q RS @ ' A Z
C yyC c 1. T
C6c 5
m F °E � 45x
� i
s �+ _
8 0 o r- on _.
v z �z ° u+ ayi � uxic �iF � NFi O • • O
A `Sm rF' ' iif E '^ cL' o O
o O m Fy m 0g7� � N zo
9a A :>:E �
c z x x o Fnc E an > D
F _
r r > > 7T
5 6
� 533
Q 3 o T m
g z
� � T
Z-
N
m T r o Z Q t5'-5"
� o F a
m
a p >
D 2'-0
m pppQ� � c
Z
cn -
m ct
v
0 p A O A
aGl G � � coc7`
= Ko
7° 0 3 c
N
AS
m pip m zo 5
NA
N Cam
m N .
zrl
m s
N
i y
mgt 70 �
pp
f'n �
c
P
m �
i