21116 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
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Building PR ed Identuketiony A 1' PERhUTNO.
Building Addrta: 1'&T
1010 s we o PLAP l I&J fzEv 1 2111
m ams: G-Re� ^ Nr.
&M1LaY C17Y OF CUPERTTN68UILDING DIVISION
• nst Mame: IJc.Q1d�� APPLICATION I PERMIT 1
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A / r: •C'� JL � QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
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LICENSED CONTRACTORS DECLARATION .L/J
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file a signed standard that he Is Bansd pursuant to the provisions of the
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F•75�1 si Icithe Businmmd PRGabmCade)orthdhebem."O.Rfmma d ��q VAWATION
�<.•77 the bask for eMalkgedexemption.
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B� R ndrcd e, us ofth500). my NEWRESIDENTNLELECTR SQFr. SIORIfsS TYPECONSIRUCTION
�rs �aaowvwdthee work and thesempkyrn wNhwagautheredir fo
C�93 aa(SM 70Kw11&.anmk,andon,Cad:Theme Is Coor mendedaoaemdlw
� ale lSre 701E Bualr�and Ptdessbm Cade:The Codrado/e Llameiaw
ORB danmtaPPlyban owmr dpmpertywhe builds w imprwmtherms,and OCC.GImUP RES UNITS
whodorsinchwwkhim lfwthtmghNsownempkye pmvW dthatinch
ImpmvemenU am not Intended arofated fasale.IL however,thebulldingor TOTAL;
improvement bald within amymrafcompldfo4the awner-buiWerwlB have
lbaboden of proving Out lm did al build or hrpmve fapurpaeWNlea QTY. PLUMBING PERMIT FEE
LJ L as awNr of the property,am axehWve y omtmeBng wbh lkmwd FT'DDD 7<1NE APN.
tmtrsdona mmlmdlhe pm)mt(See 701{,Buslneu and Prafsba Cady. PeRMRL%UANCE 'l 0
The Contmdoe.Limine law does rea apply he an owner d property who ALTER•DRAEN k VFM-WA1FR ffA) y4
builds or Improves therms,and who mmirsdd fa matt pm)em with a
WWlada(allIlamM pursuant to theconbaadaLkdme Law. BACK FLAW PIO7BCL DHl7CB FEE SUMMARY
LJ I am exempt under See B A P C far thin mason
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Owner Fra DRAINS.RODIL ROOF,AREA,COND. SANITARY Y_ N—
WORKMAN COMPENSATION DECLARATION RFZFJrT
❑1 hcrtby aBbm end i lave a atdfima of caned to mj&fdama,ne a FIKIURFS PER TRAP SCHOOL TAX
arlNateof WorkeR'Canpenedlmlmurumaacmlfkd mpythemW Oee. ��9
330QIab C1 , CAS EA.SYMM&I WC{OLITLEIE PARKFFE Y— N
pa ky d CAS EA.SYBTIM-OVM4(EA) RECEIPT
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OCny BUILDING DIVISION FEES
edNed miry b hembytumbhM. CREASE/D•NUSIRI.WASTE INTERCEPTOR PLANCHECK FEE
❑C&Q ropy b filed fu thevis mY Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' IGREASETRAP PAID ..
COMPENSATION INSURANC11 SEWER-gANRARY-SCORN BA 20EFr. 5a—tc Recei t
(Thbsection need ad be completed Btho permit b foram hundred dollars
OIOWaldsl WATERHFATPRW/VENT/ELBCTR ENERCYFEE Y N
I artifylhat In the pedu
ornnoe ofthe work forwmthis permit b blued, —
1 anuli ma empby any person b myy manmr m u W beams mb]ed to the WATER SYSTEd/TREATING
O Aor�CompemdbnlAwso(GOfamh.Date PAID
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NOTICE APL'LICANP:iL after msWng thbcedBhaleol Etettrpdon,you NEWRFSIDENTIAL PLMIL SDFT. Date Recei ted
FN shmidbeoamemb)rctbtheWodk 'CompemdbnproWsbmofamiabor TOTA .
Code,ym swat Whwkh amply withmeh p"imwwthb pem*shallbe
> demand Rwked. BUILDING PER ng
CONSTRUCTION LEND=AGENCY SEISMIC FEE 1
CL IheRbyaftlrenthatthem ItamatructionkMingegenryfertheperform- ELIiCI'RICFEE
M Z m thewwkforwldehlhls permit bhmed CSm3fi97,CIv,C1 TOTAL
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F PLUMBINCFEE
LL. F Lender.Addmm - QTY. MECHANICAL PERMIT FIE MECHANICAL FEE
O W I artlfythdlleawmisithbeppihatbnandebtethdlh,:abwelnbrmatlm �y
Nomndd.lq.wcomplywithaUdtyarA=Rtyodfmm mdittelaua PERMIT ISST)AN'CE �TW
} N adding rebuilding construction,and heRby mthafamproom ailumofthb ��ryal /NF1
F Z dlyto enterupon the ahuve-aendomd property for hupedon purposes ALTERORADDTOMBCFL' and d-i
(We)agme to Nve,4dem i and keep hamdeu the City d Orpediro IK(eeCC011 IIRR
eS.Inud film ms,metsAnd aeawhkhtmyliaywaymorm AIRHANDUNCLINITCTO10,000CFLO SUBTOTAL:
a of bgdthbpemdt.
AIR HANDUNc u Nrr KwER lggoocpho CONSTRUCIION TAX
SIgN1uRdA met/Cont a EXHALSTHOOD(W/DUCD CONSTRUCTION aPAATARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building omrpant lore or handle haradms HEATING UNIT CIO 100,0008TW Date aeterblade0md by the OtpertlmMumdylCodkChapter9.1;and theHeaNhand SdetyCde Sedka75. (a)? HFATINCUNIT(OVER1o0,0110BM 1
((''''J]Yes r]No
TVBltheippllmM afutumbuildingaaupantuseequlpmem ardevkd VENTILATION FAN 6'Iw(n CRESS ]$$IJ,A�T(f�A'1'E
whl I emit haradmI air anambrsnts a defined by the Bay Am Air 'w/�'u
tLraJlNy M.Ngerrumi DTW'IM7 BOEER-COMP OFE+OR 100,000 BTID
• ThaYve madlhehaaTma meadaa requlmmena underChapter G95 of BODER•COMP B)VF7F 100,000 BTID
the OlBombFWMh ASafetyCde,Sedbm 75505,25573and 7553{.1 FV
understandllutlfthe huEdbg does riot mrrendy NveatenanL llul henry NEW RESIDENTIAL METH. SOFr.
respommllNy a mllfy the wwpm dlhe mqulRnedawhkh ram be east
prior to Issuance of a Certificate ofOccupancy.
Owmeoraunhor oat agent Date 7DTAISSUEDSV:
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OFFICE COPY I