19778APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro;M Identification
Building Addrt,n
I'FRMITNO.
19778
nsr. �e
CITY OF CUPERTTNO-BUILDING DIVISION
' APPLICATION / PERMIT
O O
or'a Na : N
ArthitM/En rcer. Lac No,.
BUILDING -ELECTRICAL PLUMBINCMFLHANICAL
CATTSGORY
CON ROL #
QTY ELECTRIC PERMIT. FEE
BUILDING PERMIT INFO
/�
Address �(
PERMITISSUANCE-
O ❑ ElLENSEDCONTIt
CEOR DECLARATION
(herebyICa RlrmtlutlamlkmaeduMerpmvblaruol Chapter9(�
IngwthS n7OD3)of DINNon3dthe Bua and Pmfeselons e,andmy
Wense V In died.
APPLIANCESRESEDENML
pB N
.
PANELS
Lkx C Ica
—
Date Contractor IfIL-,-
UP TO 2DOAHM
�^
—
-I DDD AMPS
ARCHITECI•S DECLARA DN
I urderatand my plans shall be used a pubBe mcarda
OVERIODOAMPS
SQ. Fr. FLOOR AREA
f/SQ. Fr.
SIGNS ELECTRICAL
Licensed Profeanlorul
amr3aLCB(CN7/M
OWNER -BUILDER DECLARATION
I hereby affirm [tut I am a=pt from the Contractors Lknnw Lw fm the
m,(p METER OR i
folluwbg maeon.(SMIon 70315, Business and Profnebns Code: Any city or
c ntywhkhrequimapermittommimgalter,Improve,demo h,orrepab
'
any stmdun prim m Its Ls>tsame, alto requlm the appbunt far such per W t to
file a aigned atatement that he is licensed pursuant to the prodsiora of the
Contractor'.Lkeme law(Chapter 9(osmmenMg with Stolon 70(0) of Divi-
slon3 ofthe Business and Profmbra Code) or that he Is exempt therefrom and
CES
GPOOL ElE
TY
r
VALUATION
the huls for the alleged exemption. Any Halation of Section 70315 by any
apph.t fora permit sub*tz theapplkant too d l penally d not more than
IN
Rundmd dolWs(S.SM.
vL1,
STORIES,
TYPE CONSIRUCMN
as owner of the properly, or my employ. with wage a thetr Bole
NEW
mmpmurtlon, will do the work and the etmdure a ort Urentled or offered for
orb � 7064, Bos.hand Pmfe os Code: The Cmuradora I.J. law
Y"
'
does ort apply to an owner d property who builds or improve ththeorem,and
whodoeeuchwork hM�elf orthrusgh hbownempIcyoes, provided that such
OCC. GROUP
RFS UNITS
Improvements are wt Intended oroffered for sale. I( however, the Wilding or
Improvement issoW within arrcrcyearofcompldbMtheowner-buBderwlB have
TOTAL:
tlle_paMen of pmWng that he, did oot build or improve for parpnee ofaale.).
11 1, as owner of the property, am exclushrly mntraning with Ihmxd
to mMrud the project(See 70K Bodes` and Prd®lora Code:
QTy. PLUMBING PERMIT FEE
ppgM1.1. ISSUANCE
FLDDD ZONE
APN
The Coruraaor'a Lkeme Law does our apply to an owner d property who
bands or Improvva [heron, and who metra,,ta for ouch ErWoms with a
eq,If.cmr(s)Itaroed pursuant to the Can``'dor' Llamas law.
Lj I am exempt under Sec B h P C for this renin
ALTER -DRAIN 6 VENT-WATER(EA)
FEE SUMMARY
BACK Flow PROIDCT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, CONE,.
SANITARY Y_ N
RFLmT a
Avner Dee -
WOR KMAN COMPENSATION DECLA RATION
Eemby affirm that I have a cerHBcate d eoment to rU-kwrt, m a
3900LabC WorYen('Cooper`ua(l'l�mtivuruimaacertlfled mpytherto(f5ec.
]g W, Lb CJ'11Y ��`# 1�
CoPo]m v ar'�r�ld�YJ�n—mss �l
FIJ(TIIRES PER TRAP
eA{DOL FAX Y_ N_
Y— a
GAS EA. SYSTEM -1 WC4OLTLETS
PARK FE Y N
N—
RE{FSPpI
GASFw.SYSTEKIOVE1(4 (F.3I
BUILDING DIVISION VISION FEES
m— pyb hereby faumlahed'
CertBlad ropy is flied with the cfly InspMWn division.
W
GREASE/INDusIRL wnsrE wrEltCFproR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF E'%IMITION FROM WORKERS
COMPENSATION INSURANCE
(('hisaedlonneednotbecomplded ifthe mmttisfmomhundmddollen
PAID
Date RCC¢( t#
SEWQLSANITARY STORM EA. 700FT.
(5I00)mlma.)
to gythatbthepedomancedthew kforwWd W.pe isbeued,
1 shall not employ any person N any manner ro as to bemone subjed to the
Wmken'Compematbnlawaot Callfomla. Date
WATER HEATER W/VENT/ELECrR
ENGRGYFEE Y N
PAID a
WATDi SYSIF]s1/TREATING
Applicant
NOTICE TOA]'1'LICANI':IL o making this C¢rd pmofEumptbn,you
e.Mfsu th Workers Comperuatk..,thlonsofthe Labor
• Date R¢oei t#
NEWRESIDEKIIALP[MR SQ.pF.
-
TOTAL
Cha,y h
Cade, you rtake fcethwith mmply with such pmvlabro or this permit shall be
BUILDING FEE-
deemed revoked.
SEISMIC FEE
CONSTRUCEION LENDING AGENCY
IhembyafBrmthattMmre amvmolmleMmgageryforthepeffarm
anceof the work for whkh this permit b issued Sec. 3 ,CW. C)
torAL:
ELECTRIC FEE
Lenders Name
Leeds`s Addma
1 certlfythrt I love rad thisappllotbn grid wtethat the above Informed.
ism`red.Iagrtetocomplyw aUctyandmuntyordinanmandgatelawa
QTY. MECHANICAL PERMIT FEE
PLUMBING PLUMBING FEE
MECHANICAL FEE�tf/
PERMIT ISSUANCE law
FEES PAID
relating tobulWing mnatmction, and hereby authodrss mimmentatives of this
-
&y to enter upon the abovo-mentbrcd pmpery for WpedWn purpose.
(We) agate to neve, kdeinnify an d keep harmleas the City d o
Cupertin
ALTER OR ADD TO MFCII.
DatC Rttei t#
SUBTOTAL:
against llablhtln, Ndgmerds, coanaM expenseswhkh mayln anywayamue
a ni t I City lr.sequena ft grading dth pa t. ALL
AR6HANDLING UNIT(TO 10,000CFM)
AIRHANDUNGUNIT(OVER 1o,DDOCFhn
CONSTRUCTION TAX
SjVmIr of Appecanst/Contractor
E)CHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUSMATERIAL D CL.OSUR
HFATING UNIT (TO IW,ODO BTU) r
Will the appllom or future buOdingamspan stcurmha rdous
material ae defined by the Cyyp�eertlro MuNcipal Code, Chapter 9.17, and the
FleaithaM Safety Code, SpEion 75537(x)7
Ye No
Date RCCCI t#
HEATING UNIT (OVER 100,DOO BTU)
TOTAL:
VENTILATION FAN (SINGLE RFSID)
'
ISSUANCE DATE
W the applicant or future Wilding oc vpant use Nulpment or devices
whkh emit havrdoue ab renymirardaae deRned by the Bay Arta Air
EZ=
BOILER -COMP DEEP OR 1W," BTIn
Q.allly Maragemem
4 Yn
BOR-ER-CO.V.P (OVER IDO,000 BTU(
ars{No
havemad the smaterial. requirements under Chapter 6,95 of
the California Health h Safety Code, Stolons 25505, 25533 and 75534. I
NEW RESIDENTIAL MEQ(. SQ-Vr.
urAmtard that lithe building don not airmotly have a tenant. that It is my
mponslbWty to notify the aacvpant of the mqukements which rtuM be and
- -
prory uaruc da Certitbtc o! party. 9
i\WV^}'P31Keerl
ISSUED BY. �✓`a /I N•lLY)�M-Q.l
authc,Lmdagent I Dam
TOTAL
OFFICE COPY