24983 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE.RTINO ' I. -1.1".1"C",BUILDING DIVISION APPLICATION/PERMIT IL .MECnpNc - rrknnTNo.
24983
t71,r , BBUILDINGPROJECTIDENTBTCATION.
(BUILDING ADDRESS.
�iA r• �� U'IT—✓���`' SANITARY NO. APPLICATION SUBMITAL DATE
�ObLaC0 // Yom/OOM 'q 2-✓A2
OWN'F.RS NAME: PHONE: CONTRA R'SNAM° 51.. ICNO:
/. T" NIC COM'kOl.p
1ti +J �. SLLI d
tCHITECTIENGINBER: LIC NO: F ADDRESb: 19
CONTACT: PHONE: a'A � v '' �ea^''�- BUILDING PERMIT INFO
BLDG E EcT PLUMB MECII
PERMIT ISSUANCE
LICENSED CONTRACTOR'SDECLARATION AppI,IAINCFS-RESIDENTIAL ,,,,, ES {'
700 Ihereby orfrmthat ion3.fcenudunderprdI'mfinsi...Code,and(commencing
museisin pp-- ;^� F L
JOO Scnion]IXgµlr Divisiun3of,be Business and PruPossimnz Code,and my licmuis in PANELS
7w= full force and effect.
CZU Liccnsr Claz Lica lIP T0200 AMPS
< Dom Convmc 201-1000 AMPS
—wz, ARCIIITECI'S DECURAT N
OVER 1010 AMPS SO IT.FLOOR AREA 5/SQ.Fr.
In' 1 uMcrstand my plms shall be used as Public record.
F u SIGNS ELECTRICAL
Licensed PmfessmrmI
YIce< OWNER-BUILDER DECLARATION SPECIALCIRCUIVMISC.
eby
7i0 1 ng mason,
affirm that 1 oro acusis from the Cosions Cs e:Amy law fordo
_poi fnlloxgng rtasoa(Section]OJLS.Rosiness and Professions Code:Any city or county TEMP.METER OR POLE(NST.
< which Mquirts a Permit to consvun,eller,improve,demolish,or repab any structure
to—1 priorto its issuance,also requires far supplicant forsuch permit to file asignW structural POWER DEVICES
Y<O (hat he is licensed pursmat to the provision of she Contractors License law(Chapter
C SWIMMING POOL ELECTRIC
e� 9(mmmcncing with Section]fg0)of Division Sof Nc Business and Professions Cade) VALU
,•ty or Nat he is exempt therefrom and the basis for the alleged exemption.Any vioI dm of
_ZT ScNon]031.5 by any applicaus,for a pari,subjects the applicanuo.civil pnWy of \ OUTLETS-SWITCfIES FIXTURESC7 S /�yr)6
T= r mon than five hundred dollars($500). NEW RESIDENTIAL ELECIR _SQ.FT. �•/��
a: n❑ I.azowncroflhepropeny.ormyemploymawithwagesnthcirsolec.miens.don, STORIES TYPE:CONSTRUCTION
will dothrwork,and the suuaure is not inendmmufficred rorsale(Sce.]041,Busixss
and Professions Code:The Conamewe,License law does not.pity to an owns of
property who builds or improves Lcreon,and who does such work himself or trough his
OCC.GROUT' RES.UNITS
employees,provided prove improvementsarenot intendedmoffend facade. r.
however.thcavete brdenofementissat hedidnone t build o(cmareve foron.pteowncn T 1
builder will have the burden of proving that he did not build or improve for purpose of �1�� _
salt.). mvu.a rf ':'S-^,.e PLUMBING PERMIT>sT+ti�`,,'°y 4^.VFEE L'riF FLOOD ZONE APN
❑ I,u roof NepmpenyamexdusivelyconmcdngwilblicensMeonuacwmto QjY'^el:it{c: v,+x-ser„3`
construct thenproject(Sec.]DSC,Business rad Professions Code:)The Convecmrs
License Lawdeses not apply to anownerof property who mildimimpmveathemon,and PERMIT ISSUANCE
whoconvacts for such pmjmv with a continuous)licensed pursuanlw the Convectors
Littre Taw. ALTER-DRAIN&VENT-WATER(EA) 'nF"lis4;:,y.y:L,.FEE SUMMARYf',,`,i`I olst
❑ I am exempt under Sec. .B&P C for this recon BACK FLOW PROTECT.DEVICE out SIM FEES
SANITARY Y N
00,73'em
DRANS-BOOR.ROO RECEIPTMWORKMAN COMPENSATION DECLARATION 5 11 TA% Y N
I hereby affirmeal l have emitificme of commit,to self-imus,or a cerdficalc of Fl%TURES PER TRAPRECEIPfp Compcnm,ion loaner or a certified copy thereof(Sec.3800.Lab C.)which R Y N
.overs ell employees under this pcnnia GAS-EA.SYSTEM-I ING4 - S RECEIPTp
Policy k I UILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER4 EA .ANCHECK J.E
❑ Cedifid copy is hereby furnished.
❑ Ccnified<opY is filM with the ciy inspection division. GRUSFJINDUS WASTE INTERCE IN
CERTIFICATE OF EXEMPTION FROM WORKERSGREASE TRAP SOILS FEE
C'OMPFNSATION INSURANCE
(Dusunionnecdnot hecompleted if Ne pari,is routine hundred doll.S t00) SEWER-SANITARY-STORM E,.201 ENERGYFEE
or Is".)
I ceniy that in the perronnana of be work for which this Permit is issied,Ishidl WATER HEATER W/VPNT/F.LECTR
our employ any person in any mumu so ns to because subject to Ne Workers PAID
Compensation laws of California. Dam WATER SYSTEM/BEATING I Date Remipra
Z Appliesnt
NOTICE TO APPLICANT:If.after making this Certficamof Exerapin,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
2 rex become b,.,,.the Worker.Compervedon provision or the labor Cade.you mus,
forthwith comply with such provisions or this Permit shall be clamed revoked. BUILDING FEE .a.
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE L
J
1 hereby off rm that Nem is a construction lending agency for the performance of'Z, TOTAL: ELECTRIC FEE
1 O the work for which this permit is issued(Sec.3097,Civ.C.) _ -- ..-o .. _ - `4 - 1
Lender's Nun. w rte; U "" ' + "a_4 ' PLUMBING FEE
F lender's Address QTY.11 1 MECHANICACPERMTT�'" n 1, FEE
Q U I ani that I have rad this application and carte re an above w,rmmion is °1d'`' IT S'` - — -
' � co N PP MECHANICAL FEE
�
correct.lagrcc to amply with all city and county ordinances and stem laws mle,ing to PERMIT ISSUANCEh
h buildingemonmelhon.and herebyaveoriae npmmudvesofthis ciy rocnmr upon Le CONSTRUCTION TAX
Z above.memioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)ng.m save,int arty and keep harmless Le City of CuPcnino against
liabilldes.judgmcnv,costar .'rueewhich may in any way.e.c.gun,said City AIR HANDLING UNIT(TO I0.000 CFM)
conuq of rand gof Lis permit.
14 AIR HANDLING UNIT(OVER 10.00(1 CFM(
Si umo Ap icmVC mmclor Dale EXHAUST I{OW(M'/DULT) PAID
HAZARDD SMATERLALS OSURE HEATING UNIT ITO 10J.”BTU) Date Receipt is
Will the applicant or future building occupant store or handle harardus material TOTAL:
its defined by,hc Cupertino Municipal Code.Chapter 9.12,and me HeaLN and Safety HEATING UNIT(OV FR 100.000 BTU)
Code,Section 255321x)? VENTILATION FAN(SINGLE RESID)
❑Yes ❑ No
ISSUANCE DATE
Will the applicant or future building occupant use equipment or devices which emit BOILER-COMP(3HPOR 100.000 BTU)
cc
. unbus air contaminants a defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,0111 BTU) f
icl^.
f ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I have mad the hazardous materials requirements under Chapter 695 of the APR �lI '►95�
Cahoon.Health&Safely Code Sections 25505.25533 and 35534. I understand fou [�
if dm building di nor curmaiv have a tenant.Ih:e it is my m,,a,ibilin m nmify,hc
cupun,of he requirements which rano,be mem prim to issuance of v Certificate of V ( UI. \^Ur GTs
Occupancy.
Osa'nefor authorized agent Dam TOTAL: ISSUED BI?/�� a /