S 0852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTSNO RUILDING-ELF.CnRICA I, WTITNo 0852
BUILDING DI VISION APPLICATION/PERMIT DINGPLUPRNGC-P IVIS"CIFI1, l`�
BUILDING PRIIJEGT IDtIfMFICATIO\'
BUILDINGADDRESS. _ ^ /1 SANITARY NO . APPLICATION SUBMITI'nL UATP
OWNER'S NAME X1/1 (//(/_/I///V/lYC/ONNTRA/Q//'/1' _ IJ 1'. 1-7-
.91L�AG Yfl��9f' NIC CONBOLN
1ARCHITECUENGINI?ER: GJ LIC NO: ��'JJ�Y�� Aj L�/I - ❑
CONfnCI; ��Cli1� �yj��/� ❑ Ca.Iwnt Fw Paid by Applicnnl(Initial) BLDG HUPHONEI1HIECI PERMIT HNFO
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hammy anirm mot 1 am 1'Icrnxd amler P visi«u or Chaptn 9(co ion ming JOB DFSCRIPTION
C=Z wish Tcctim'/B(IU)MDivi.ion?of dr nuxina.vml l'mfeuium Code.vnJ my li«mcis RFSI_ DeNT�AI,:
+[1 OO PERMIT ISSUANCE
C in full Gxcc an0 cRy�!� ❑SPDWT, ❑KrLCHFN REMODIJ.
dU�j Livrnic Class_Y- -_y-IicN APPhIANCIiS-RIISIDI?NTIAh ❑ADD[RON ❑PLUMBING BITPIPE
Fi Q G Uutc�V•Jl-/�Conwcur
N ARCIIITF.CI'S DECLARATION ❑MULTI-UNfC C1 STRUCTURAL
p.n H PANUS
Z «-Z 1 undenmid mY puns nnull he uwd as public mond. MODIFICATION
OZ-0 UP T030o AMPS E)INTERIOR ❑CHIb1N131'RF.PAIR
Pit: Licensed Rnfasional 101-14X)AMPS IMPROVEMENT [ISWIMMING POOLS
OWNER-BUILDER DECLARATION )VER I"AMPS El ATH RF' IODHIIREPAIR ❑DEMOLMON
�C d I hereby.Rrm Ihal I am exempt fmm the Cominco is hittnse Law En the
p[x5,O a.U following rm ,(Section 7071,5.Business and Pmfasi«ss Code:Any city or county SIGNS ELECTRICAL OTHE
W 3 LL which requires a permit to conwuct,.Iter,inion.,demolish,or oTair any structure
_LLo� pnnoiuivuuna, amus t .plonlf s npmiuoElc.xigned wcmcnt SPECIALCIRCUODMISC.
} 0.he is leaned to the provisions M the ComonsfMs License I..(Chaper9
AGO (,Tmlmaocing.obSatiun 701Division3ofIhe11-i-tord Prof xiion,Cads)ow TEMP.MCI17R OR POLL INSI'. COMMERCIAL:
6S
a i mad he is exempt tlRrefro m and tk Iasis for the diegal excmptim.Any virAntion of ❑NEW BLDG/ADUMON ❑DFAIDLITTON
� N Sminn 90315M1y wy applicant linepermit mhjttuthe:Oppbnmmacivil penally of MOWER DEVICES ❑T ANT ❑FWD SERVICE
n«marc dun rive hmdacd dollar ISSIXB.
1..y} OTHER FJsIFVI'
d �I,uowner oftM prq+eny.mmy empluyttn with ungo vtMir mle compcmminn.
SWIMMING POOL ELECTRIC
O will Pr ole wo ns Code
The ewm i.not intern.I'vv N fon risk l9ec.'I ar msocir.n ❑OTHER
t ta.3
and ar�y horn.Code:Tim oes lvarvo land se I.dw divas tint WRAy to if om�ner of OUT1J.cfN-SWRCHES-Fla"NRES
pmpmty wM build.ns improve thcrem,and vera dos.such wnh himself«Nmmgh
his own enR'Fa1tts,povidM that such imrynvrnems uc not intcMN or nRcncd for NEW RESIDENTIAL ELECIR SQ Ff.
xidcJL Mrwevcr.the bullJine tut lmpnrvameu ix,mld within uric yearnfmmplctinn. SQ.PC FLOOR AREA SISQ.PL
IIIc
.,turdilm will have the burden M paving that IN,did int huild or improve for P«-
qxe of vola)
1,ex owner of the pogeny,am exclusively m obmung with licensed«mv.mon to TOTAL_
co., pmjcet(Sec.IBkJ,Boor. it Pov7T .i-Code:)lin Comtraa«'s Li.
rise Lw does oat apply to vn owner M pnpmy who lwids or impmvax doentonuml QTY. PLUMBING PER FEE
whomntmns forauch prow,withvcontrxow(.)licensed pumunim mthe Contrxtols
Liccnm law. PERMIT ISSUANCE
❑ I an exempt under Sm. .R&P C for this rrssm
Ovvaxr Data ALTER-DRAIN&VENC- 1 VALUATION
WOR muKERnder
COMPENSATION osaron DECLARATION BACK 140W PROCECI'.DEVICE �Y�11 o
1 hereby�mI uridrr pcmlty of perjury uric M the follaving decl.rwiom:
�IM1nveeM will mainmineCenifcmenf Cnnsem lnmlLinxu¢f«WoAer'a Compem DRAINS-14008.ROUT,ARP,A.CUND. SIGRIES TYPECONSI'RUCI'ION
sudom,x likh nal Toon by Section BJq)of th IuMr Calc,f«tha perfmremx of the
w«I;Rr wM1eh Nis.periost i.icnled. II%l'URF_S-PER TRAP
I have erld will mummin Wmlaf.Compen.svtion I.r,as rcyuinM by Ssetim
nftbe Prior Code.f«the cifvnnu nfRm x'«kfm which Nfs pmmiOnisstcd. GAS-HA.SYSIEM-IINC.40 ICC.GROUT' APN
My Wowk In aria) �c lereth Policy wwlAgrl�)nw GAS-FA.SY SYSTEM-OVER4fFi
Cvrn«: Palley No. � L�/OO
C,..UM ATEOF 13%H MON MOM WORK13R5' GRPASF4NDUSTNL WASTE 11 RCEPRIR
COMPENSATION INSURANCE BUILDING DIVISION 17:Y
(This.ttnion need!tint M1c crmtpmrd fthe Permit is for on,hurdred Mit,ISIW) GREASL'I'RAP
or leu.) PIANC FCK IPP.
lernifyihat in the perf«nrcmeof Ne work fmwhichthis Emnit iaiswcd.I shall SEWER-SANITARY-SIURM .A._
mr employ any pervn in any manner wI as m necvnle subject to TNI:WorL rv'Com,en- EbIERGY FEET
zZ union I,-of Cdifrmie.Data WATER HEATER W'NEN M-I;CIit
O Applicant I GRADING FEE
y NOTICE TO APPLICANT:If..Rn nuking this Cenihcam of Excmptim.)xar should WAT1:R SYSTEMICUREATING
besubjccl Ia the Worker,Comwt
pnion pmviaimx of doe LoMr COdc,you moM SOILS IT,
Obard lll..,Ay with.wch provisions oe tido pcmit shall he damned mvokal. WATER SERVICE
DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC. PAID Data eeipN
U O I hnebyalEnn this ntc
there is a mrsttim lending age for the perfoma
rnM
Oma. the work f«which Nis permit is i.awW(Sx.71097.Civ.C.) TOTAL:
I•-' 1<rtrrn Name
O U i<Odcr'x AWd ,
1 1 rarity that 1 have read this applicvian and cute thou the above information u BUII.ITING F'I:I:
N correct I agrec to(Tianply with all City.trJ Tommy ordimnec,mrd stain laws mewing Io QTY MECHANICAL PERMIT FEF,
U Z bungcmvmetion,and M1crtby eulh[rl]c repeenutiveS of Nis city to emerupm Uic SEISMICIEE
above-mention i pmpeny for ins,,¢tion pmtio c. PURNIIIISSUANCE O
(We)agree m asse,indemnify and lett,hartnRzs Ne City of Cupertimt ain
ga . ELIiCCRIC FEF.
fiabodticn,pxlgmcros,uw vmf cxprn cs stitch may in any w.y.'emcsi'mri -0 City ALTER OR ADD IU MSCI I.
in cncyurncc of the L-nm,of this Isorm, PLUMBING FEIi
«
APPLICANT 'NDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT TO 10.000 CEM)
ILA S MIiCHANICAI.[TIT
SOURCE. I . /�A//f� AIR HANDLING UN (OVER 10,000CFMI CONSCRUCTION TAX
t CA/']ROu(-1-USMATERIALS'INS DISCLOSURE?U �J Disc EXHAUST HOOD CATMUCT) HOUSING MITIGATION FIDE
IfA
Will the,appl'Ieultm frame building omulvntstmeor handle M1u.Nmin modomw HEATING UNIT CEO 100.0tq �
BTU)/� a•�
as defrwN by the Cuptminn Mun ip.l Cade,Chapter,9.13,and the Health and Safety
Coin Section 255?3(v)'! 1117NI'ING UNIT(OVER 10).(900 B'I'U)
(]Yes VENTILATION FAN(SINGLE RESID) PAID Dam RcaiptN
Will the aplAkent or future build «r
ing ap ut use equipment or devices which
emit Nuurdaun air covoominonn mdclit"by the Bvy Arca Air Quality Mwwgcmcnt ))OILER-COMP(JHPOR 1000101CU) 'COTAI:
LDISWCC. �/�NoROILF,R-COMP(OVER 100Sq)RTU) ju
., /-
AIR CONDITIONER
ve mad Me huvrdommau'andn�uilemcmv uNcn C Nar 6.95of the Cah- ISSUUAANCCE IJATIiN&Safety Cde.Scclioxu 25,585.2551?wit 25511.1 unknwM that i(thcNEWRESIDENTIALMECH. SQ.P-Lhave a trrmnt that it is my mEstnsiniliy m nut ythcwcvpant yhe api«miaruvrcc Mal:cpi� dfley(jy/agent !/ ��a-D(ae 1OTAL: ISSUED BY:
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'ERTSNO RUILDING-ELF.CnRICA I, WTITNo 0852
BUILDING DI VISION APPLICATION/PERMIT DINGPLUPRNGC-P IVIS"CIFI1, l`�
BUILDING PRIIJEGT IDtIfMFICATIO\'
BUILDINGADDRESS. _ ^ /1 SANITARY NO . APPLICATION SUBMITI'nL UATP
OWNER'S NAME X1/1 (//(/_/I///V/lYC/ONNTRA/Q//'/1' _ IJ 1'. 1-7-
.91L�AG Yfl��9f' NIC CONBOLN
1ARCHITECUENGINI?ER: GJ LIC NO: ��'JJ�Y�� Aj L�/I - ❑
CONfnCI; ��Cli1� �yj��/� ❑ Ca.Iwnt Fw Paid by Applicnnl(Initial) BLDG HUPHONEI1HIECI PERMIT HNFO
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hammy anirm mot 1 am 1'Icrnxd amler P visi«u or Chaptn 9(co ion ming JOB DFSCRIPTION
C=Z wish Tcctim'/B(IU)MDivi.ion?of dr nuxina.vml l'mfeuium Code.vnJ my li«mcis RFSI_ DeNT�AI,:
+[1 OO PERMIT ISSUANCE
C in full Gxcc an0 cRy�!� ❑SPDWT, ❑KrLCHFN REMODIJ.
dU�j Livrnic Class_Y- -_y-IicN APPhIANCIiS-RIISIDI?NTIAh ❑ADD[RON ❑PLUMBING BITPIPE
Fi Q G Uutc�V•Jl-/�Conwcur
N ARCIIITF.CI'S DECLARATION ❑MULTI-UNfC C1 STRUCTURAL
p.n H PANUS
Z «-Z 1 undenmid mY puns nnull he uwd as public mond. MODIFICATION
OZ-0 UP T030o AMPS E)INTERIOR ❑CHIb1N131'RF.PAIR
Pit: Licensed Rnfasional 101-14X)AMPS IMPROVEMENT [ISWIMMING POOLS
OWNER-BUILDER DECLARATION )VER I"AMPS El ATH RF' IODHIIREPAIR ❑DEMOLMON
�C d I hereby.Rrm Ihal I am exempt fmm the Cominco is hittnse Law En the
p[x5,O a.U following rm ,(Section 7071,5.Business and Pmfasi«ss Code:Any city or county SIGNS ELECTRICAL OTHE
W 3 LL which requires a permit to conwuct,.Iter,inion.,demolish,or oTair any structure
_LLo� pnnoiuivuuna, amus t .plonlf s npmiuoElc.xigned wcmcnt SPECIALCIRCUODMISC.
} 0.he is leaned to the provisions M the ComonsfMs License I..(Chaper9
AGO (,Tmlmaocing.obSatiun 701Division3ofIhe11-i-tord Prof xiion,Cads)ow TEMP.MCI17R OR POLL INSI'. COMMERCIAL:
6S
a i mad he is exempt tlRrefro m and tk Iasis for the diegal excmptim.Any virAntion of ❑NEW BLDG/ADUMON ❑DFAIDLITTON
� N Sminn 90315M1y wy applicant linepermit mhjttuthe:Oppbnmmacivil penally of MOWER DEVICES ❑T ANT ❑FWD SERVICE
n«marc dun rive hmdacd dollar ISSIXB.
1..y} OTHER FJsIFVI'
d �I,uowner oftM prq+eny.mmy empluyttn with ungo vtMir mle compcmminn.
SWIMMING POOL ELECTRIC
O will Pr ole wo ns Code
The ewm i.not intern.I'vv N fon risk l9ec.'I ar msocir.n ❑OTHER
t ta.3
and ar�y horn.Code:Tim oes lvarvo land se I.dw divas tint WRAy to if om�ner of OUT1J.cfN-SWRCHES-Fla"NRES
pmpmty wM build.ns improve thcrem,and vera dos.such wnh himself«Nmmgh
his own enR'Fa1tts,povidM that such imrynvrnems uc not intcMN or nRcncd for NEW RESIDENTIAL ELECIR SQ Ff.
xidcJL Mrwevcr.the bullJine tut lmpnrvameu ix,mld within uric yearnfmmplctinn. SQ.PC FLOOR AREA SISQ.PL
IIIc
.,turdilm will have the burden M paving that IN,did int huild or improve for P«-
qxe of vola)
1,ex owner of the pogeny,am exclusively m obmung with licensed«mv.mon to TOTAL_
co., pmjcet(Sec.IBkJ,Boor. it Pov7T .i-Code:)lin Comtraa«'s Li.
rise Lw does oat apply to vn owner M pnpmy who lwids or impmvax doentonuml QTY. PLUMBING PER FEE
whomntmns forauch prow,withvcontrxow(.)licensed pumunim mthe Contrxtols
Liccnm law. PERMIT ISSUANCE
❑ I an exempt under Sm. .R&P C for this rrssm
Ovvaxr Data ALTER-DRAIN&VENC- 1 VALUATION
WOR muKERnder
COMPENSATION osaron DECLARATION BACK 140W PROCECI'.DEVICE �Y�11 o
1 hereby�mI uridrr pcmlty of perjury uric M the follaving decl.rwiom:
�IM1nveeM will mainmineCenifcmenf Cnnsem lnmlLinxu¢f«WoAer'a Compem DRAINS-14008.ROUT,ARP,A.CUND. SIGRIES TYPECONSI'RUCI'ION
sudom,x likh nal Toon by Section BJq)of th IuMr Calc,f«tha perfmremx of the
w«I;Rr wM1eh Nis.periost i.icnled. II%l'URF_S-PER TRAP
I have erld will mummin Wmlaf.Compen.svtion I.r,as rcyuinM by Ssetim
nftbe Prior Code.f«the cifvnnu nfRm x'«kfm which Nfs pmmiOnisstcd. GAS-HA.SYSIEM-IINC.40 ICC.GROUT' APN
My Wowk In aria) �c lereth Policy wwlAgrl�)nw GAS-FA.SY SYSTEM-OVER4fFi
Cvrn«: Palley No. � L�/OO
C,..UM ATEOF 13%H MON MOM WORK13R5' GRPASF4NDUSTNL WASTE 11 RCEPRIR
COMPENSATION INSURANCE BUILDING DIVISION 17:Y
(This.ttnion need!tint M1c crmtpmrd fthe Permit is for on,hurdred Mit,ISIW) GREASL'I'RAP
or leu.) PIANC FCK IPP.
lernifyihat in the perf«nrcmeof Ne work fmwhichthis Emnit iaiswcd.I shall SEWER-SANITARY-SIURM .A._
mr employ any pervn in any manner wI as m necvnle subject to TNI:WorL rv'Com,en- EbIERGY FEET
zZ union I,-of Cdifrmie.Data WATER HEATER W'NEN M-I;CIit
O Applicant I GRADING FEE
y NOTICE TO APPLICANT:If..Rn nuking this Cenihcam of Excmptim.)xar should WAT1:R SYSTEMICUREATING
besubjccl Ia the Worker,Comwt
pnion pmviaimx of doe LoMr COdc,you moM SOILS IT,
Obard lll..,Ay with.wch provisions oe tido pcmit shall he damned mvokal. WATER SERVICE
DZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC. PAID Data eeipN
U O I hnebyalEnn this ntc
there is a mrsttim lending age for the perfoma
rnM
Oma. the work f«which Nis permit is i.awW(Sx.71097.Civ.C.) TOTAL:
I•-' 1<rtrrn Name
O U i<Odcr'x AWd ,
1 1 rarity that 1 have read this applicvian and cute thou the above information u BUII.ITING F'I:I:
N correct I agrec to(Tianply with all City.trJ Tommy ordimnec,mrd stain laws mewing Io QTY MECHANICAL PERMIT FEF,
U Z bungcmvmetion,and M1crtby eulh[rl]c repeenutiveS of Nis city to emerupm Uic SEISMICIEE
above-mention i pmpeny for ins,,¢tion pmtio c. PURNIIIISSUANCE O
(We)agree m asse,indemnify and lett,hartnRzs Ne City of Cupertimt ain
ga . ELIiCCRIC FEF.
fiabodticn,pxlgmcros,uw vmf cxprn cs stitch may in any w.y.'emcsi'mri -0 City ALTER OR ADD IU MSCI I.
in cncyurncc of the L-nm,of this Isorm, PLUMBING FEIi
«
APPLICANT 'NDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT TO 10.000 CEM)
ILA S MIiCHANICAI.[TIT
SOURCE. I . /�A//f� AIR HANDLING UN (OVER 10,000CFMI CONSCRUCTION TAX
t CA/']ROu(-1-USMATERIALS'INS DISCLOSURE?U �J Disc EXHAUST HOOD CATMUCT) HOUSING MITIGATION FIDE
IfA
Will the,appl'Ieultm frame building omulvntstmeor handle M1u.Nmin modomw HEATING UNIT CEO 100.0tq �
BTU)/� a•�
as defrwN by the Cuptminn Mun ip.l Cade,Chapter,9.13,and the Health and Safety
Coin Section 255?3(v)'! 1117NI'ING UNIT(OVER 10).(900 B'I'U)
(]Yes VENTILATION FAN(SINGLE RESID) PAID Dam RcaiptN
Will the aplAkent or future build «r
ing ap ut use equipment or devices which
emit Nuurdaun air covoominonn mdclit"by the Bvy Arca Air Quality Mwwgcmcnt ))OILER-COMP(JHPOR 1000101CU) 'COTAI:
LDISWCC. �/�NoROILF,R-COMP(OVER 100Sq)RTU) ju
., /-
AIR CONDITIONER
ve mad Me huvrdommau'andn�uilemcmv uNcn C Nar 6.95of the Cah- ISSUUAANCCE IJATIiN&Safety Cde.Scclioxu 25,585.2551?wit 25511.1 unknwM that i(thcNEWRESIDENTIALMECH. SQ.P-Lhave a trrmnt that it is my mEstnsiniliy m nut ythcwcvpant yhe api«miaruvrcc Mal:cpi� dfley(jy/agent !/ ��a-D(ae 1OTAL: ISSUED BY:
OFFICE