23568 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldir,,Proed Identifiutiw
8ulIA"Addtve: , 1'F7IMITN2 3 5 6 8
�- �Asv�atevvicw C'v ss ern vo
/ r• esj 0 CPIYOFC'UPERTBNO-BUILOBVGDMSION
Cwtndue.N. . IJc.No: APPLICATION /PERMIT
O BUIIANGd0.'IRICALPLUMUNGKfSCHAMGL CATEGORY CONTROL#
Anehlteet/Pngneer: Lie.Na
WING
Irt.:,u;wasn�m;y;,•,.: U3 �PFRF149'aNFO� ^
r_.. ELECTRICBAIIYITE .asass ..
'
Add.
PFRMITISSUANCE ❑ ❑
LKENS ED CONTRACTOR'S DECLARATION
(hereby .70that tam B.3.f B prmbloruo(Clupter9(eonunmc APPLIANCES-RESIDENTIAL JOB InBwlth9e tbn7fMD)d DMfenct. lhe8udroe.nd Rvle.Iw.Cade.nd �,�
Ilwnr bin fu8 fora and dfN. PANELS �` VGa Lae
License Cha LieI
Date COMactm
ARCHMCrS DECLARATION
q�+�0yu Z I.ednwnd eny pluu,hall be urd u public rcaad. OVER 1000 AMPS SQ.FT.FLOOR AREA --I/SQ.
yj'ZZUO Lion HdesbNi SIGNS ELECTRICAL
Q OWNER-BUILDER DECUBATION SPECIALCIRCUIT/MIL
F. Iberebyaf8rmthatlameumptfr the Co&n es Uoe Uwfmther ^
following reason.CSecron 70315,B..iner and Po(,rune Cdc Any dty or TEMP.METER OR POLE Il... ,RK•
wuntywhkhrnprimapm wwn Mh ter,tmpm dm lbh,wreptlr
qqq any.hucture prim to lb lruuev,also requireet the.ppliaot for meh pemdt to POWER DEVICES A.
d 5 Ne.eigne l Matertwn that he Is licensed pursuant to the pwWlon.of the
inContnctor',L&oense Law Chapter 9(mwrcndng with Section AIM)of DM. �'O'U'BNG POOL
. n3ofthe Butl ma Profmb Cde)ortluthebocmpttkr mad m.AyLLuC M VALUATION
< the hub for the alleged Beets ter. Any violation d Selly o 70715 by any Ali 15_9V.7�E�FC(TURFS V �a7
ppVaat fora pemdt subjects the appVant to a dull penslty d not moat than V
>. 110
red dollars RS001. L
1 uowrcrof the Property,mmy empty,,wth wageutkk.oe NEV.'R®QJ77AL ELElIR SQ'E7' RISS CONM N
wllldotkworkandtheMr mbeat Werddorofferedb
O b Sec 7IK4,B.at .rd Pr mi.m Code:Tk Comndoea Ileem.IAw
B dere.not apply to an.1 dpopMy who WIMa or imptv,e thertaR and OCC GROUT' RFS U=a whodoaauch Mm�Ifmthrarghhbw trnplaympro that,udr
Improvement are rax Inbnded oroffeml fmaae.IL haveser,thebulMNg m TO
' ImProvemem b.oM VNhln omycardcampleOOM1tk owner-0ullderwW kw .,�r
t raenaprodngthat hedd nabuud orlorpcoveforle rpmeofule.). (ny: P�;[j/y{gj(.jG,j> [yQ'I', r Cj�; -- icy
LJ C a.owner d the property,amac
ehWvely contracting with Ilmnaed FLOOD ZONE APN
PERMIT ISSUANCE
contreet.to wmtrud the prole¢(Sec 70K Suaieer and Prderbru Code:
The Codndors Umar Law dca not apply to an owner of property who
bund,or Improves thereon,and who conrtrads for such pW*ft whh• ALIE"RAIN(c VENT-WATER MAI
op{[�Rm(a llaneed pument to the Cwtr.dor.Llmm.LawF6E.SFJMMARY�
LJ I am e.empt under Sec B 4 P C fm s thio rm &JtY F[nw PROTECT.DEVICE
rea -
=qlnp Mee
DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N_
Owner Data RECER'T a
WOR KhFAN COMPENSATION DECLARATION
❑I hereby afllnn that 1 haw a mni8ab of consent to.elf-Irwn,or a FDCAJRE4 PER TRAP SCHOOL TAX Y _
mdl0ated Worken'CompeauMlwl�wranm maaM(ed oopythereol Sec. RME3PT
Lab CJ GAS-FA SYSTEM-1 INC,OUTIHM PARK FEE Y_ N_
fay kY a— GAS FA.SYSCE7.TOVFR I(U) RI3rELr1'a
many BUILDING DIVISION FEES
I ICenmed copy b heavy L,ml.kd. GRFASQ/INDUSIRL WASTEINTERCEPTOR PLANCHECK FEE
Lh�JI CenNed copy Is filed with the ed,Impedbn dtvlYon. .l7
GREASE TRAP L
CERTIFICATE OF IXEMPTION FROM WORKERS' PAID
COMPENSATION MSURANCESEWER.SANITARY-STORM E.A.700FT. Date Remi t#
(I'hla.eodon need not be cmrpkted V the pemdt Is fee oro hundredde0n
a
0I00)ar le..) an wWATER HEATER W/VFN'f/E7rCR ENERGYFEE Y N
I
I aruthattothe parawwedtk was NNthis hued,dell mR empty any IA w b any wenn an r to b.wme.ubled to the
WWATER SYSTEM/IRFATWG
Workers* mpematlun lAw.dGllforNa. Data PAID
O = AppOant NEW RFS DEMIAL PLNB. SQFT. Dater Recei H
Z !? NOTICE TO APPLICA.NT:H,.ter madly this Certificate Of Exemption.you
,hold become subject to the Wor4npemwvbla
s'Comation pns of the Labor TOTAL
WN Code,you roust forthwith cunply with eh provbbnu or this pemdt.hall he_ BUILDING FEE
> deemed revoked.
CONSTRUCTION LENDING AGENCY SEISI
d IharebydBmt tkttherab a comemctlon ledingagercy for tk doer. TOTAL ELECTRIC FEE
Z anmdtheworkfor which ehb pmNtbbsud bee 30Y/,CW.CJ pe
() O Lader.Nameg PLUMBING FEE
IL LedersAAareas QiY: bIECF1AiVICA4;PERINIT ,. FEE
O WIcertifythat t kw read this application and w
stare that th..be mformad. ,-. . MECHANICAL FEE
IL bcorren.l.gree to complywkh all dtyad county odlmnmand tlate law. PERMIT ISSUANCE FEES PAID:
>_ IL re]Miylo WlMingwmmdiman Mrebyauthorkereptanudva Mthly
dty,
Z to enter upon the above-mmtbmd property for lnsERH.
pedlon P. ALTORADDTOMEC
IWd.gee ro WenWry an d keep l unni.the Clry&Kp" Date Rece1 tp
.g.tmtlhbwdee, a mA n,,open.wh,,,nvyln anyway.. AIR HANDLING UNIT(TO 10,01DO CPW SUBTOTAL
-
as. I m enerdtk grtmly dtNa pormk. AIR HANDUNG UNIT(OVER Ik000CPM) CONSTRUCI7ONTAX
turcdAppltont/CwtrnRtm Date Ep Iwf75'THOODD(W/DECCONSTRUC170N TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the ce huturn WVding omepant More or handle haaardw. HEATING UNIT(TO 100,000 SDI) Date Recei [M
nWerLl u ddlnd
by the CupertinoMuddpal Cole,Clupt.r 9.17,and the
Heath ad Safety Code Sedlw 75537(a)t HEATING UNIT(OVER I K000 BTU) TOTA .
qYee No
ul the:pptaMw tore Wudingar ,ant use equlpment m d outer VENTILATION FAN SINGLE RESID) ISSUANCE DATE
whkh emit has dons air owbminama ae deBnd by the Bay Am Ak
aAbFlty M..g.e em Dunrict7 BOIIERLIDMP OHP OR 100,000 BM
Y.-a No
kve red be hu.gd wtcrlb requirements u oder Cha pier G95 of BOILFRCOh1P(OVEIt 10()," u) e• /4
the California Wath 4 Safety Code,Sedbns 75505,25513 Md 755M. I A[k�
rd car dthatifthe Wlldlgdmandwrrentlyhave.ten.nktktltbmy NEW RESIDFNIIAL MECH. SQ17
ponebllty to notify the oavp.m of the requirements wtkb trust be root ^l/r lir ,•.
prior to lmuance daCeniOcatedOmoprry. .a /`,1JU)
Owner or authodad agent Nit— IS5MDBU
TOTAL'
OFFICE COPY