25407 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPENO APPLICATION/PERMIT PLUIBBING-MF.Cf1ANICAL PERMIT NO.
BUILDING DIVISION
N A)m"y-gsC}'W'AITCpUILDING PROJECT,IDENTIFICATION-.fr*P,aJY:?ISY?3 -` 2540 1
BUILDING ADDRESS: �•j� SANITARY NO. A�PPISICATIIOOINS�UBpMG`17ALDAI
;?oo6o STL✓/z" CR4, ZLVAD+ UNIT# LOT# X
OWNERS NAME: PHONE / CONTRACTOR'S NAME: LIC NO: NIC U CONTROL#
kI/AJ B2 iN7tl2.c14TjoNkL 770- /Z6/ Ac/F/G j3 /.UD. 07IS(7 �•7 /r`y��'
'. SHITECT/ENGINEER: LIC NO: ADDRESS: 410 q /hra4 / 3 1
,SA IAX, A�1617bo7 o R,i6#Z4 'WE CA, 92(-Z6
•- CONTACT: PHONE: pTs�ut;Y:, A S \p�g�Ipp y-! carat Via:
5%FLFFE,1 '7/3 We l TRY lm arm% �tixt,2'fp n3:+' w 'S?l ELECI`c
Ikfe / BLDG ELECT PLUM / — '
t.a 23— Ga 3/ 3 � PERMIT ISSUANCE _f�—gs,
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JO DESCRIPITON
Q=Z Ihereby affimt that l an licensed anderprovisionsofChapmr9(commencing wiN
WOO Section 7")of Division 3 ofthe Business and Professions Code,and my license is in
��— full force and If 7
<Z License Lic.0 / SO - r,AMPS Z� \ . . :1
yell• Date. Canmc s/,(��, WI-1000 AMPS Vs/x-V
Z�yZ ARCHITECT'S DECLARATION SQ.FT.FLOOR AREA S/SQ.PT.
DVFR IOOOAMPS �^/
OZ—IO I understand my Plem shall be stud m public records.
6 J 6J Q
F-y�+,1 SIGNS ELECTRICAL
ce'=< Lianrd f4ufeuiond meg/
X�S'< OWNER-BUILDER. SPECW.CRNIT/IASC. ��
EMU 1 hereby Wfimt TMs 1 sues exempt fiwn the Conaecmr'.Llama law for the
m 3 a ya following region.(Section]0313,Bush.asW Prole siom Code:My city w couvry TEMP.METER OR POLE INST. 6
7RLL'Ow.S which rep ima a Permit to construct,alta.improve,demolish.or repair any aweture POWER DEVICES •� ` ([�
} prior to its issuance,also regWres do applinnt for such permit to file s signed Summmt
Se C C Oz Diet he is lianud pursuant m Ne pmvisiom of Ne ConmW's Liana Law(Chaps.
A. 9(commencingwiNSe on700o)ofMi im3ofR BminevWR tmiau Cade) SWIMMING POOL ELECTRIC ALUATION
Www or that he is exempt therefrom and the ba.is for the alleged exemption.My violation or
F•Z� Secuum 70313 by any a N.,for a permit miry o the epplimnlmecivil pemlry of DTI-EIS-SWITCHES-FIX'IIIRRS [ll,
<
not more than five hundred dollars(S500).
y� p ❑ I,uownaofNeproperty,wmyemployeawiN wegeuOSe'vwlecompematima NEWRPSIDENTAdLRLECTR _SQn STORIES TYPECONSTRUCTIOI•
y00 willdo the workand Neswctom is not immndWorofferadfdrade(Sec.9044,Business
and Profeuiom Code:The Connector.I .law does not apply w m owner of
proprny,who builds or improve thereon,auto whodoe such work himselfor through his ------6!CGROUP RES.UNITS
employee,provided Wtsuchimpmvemenuerenmimmdedwoffemdfmr S.If.
however,Ne avedWg wimprovementuwld wiNinone Yeuor impron,f.r p Sp..- �r
builder will have Ne bwden of proving pro he did mI build w improve for purpou of
sale.). - x a' vx' TF� \ .as' FLOOD ZONE APN
❑ I.0 ownerofNe propenty,am ucluaivelYcanowting wiNlicemedconowmnma ra:v8T ai, -
construct the project(Sm.7044,But.and Protectimu Cade:)The C mxuoaa
Littme Law docamtapplY tom owmrofpropeury wM1obuilNwimprove Numn,and PERMIT ISSUANCE II .
who cat.cut forsuch project ilheronuwmr(s)Bwnsdpunuamlotla Conuuto/a _ y
license Law. - ALTER-DRAW b.VENT-WATER(EA) /
❑ 1 are.comp soder sec.' ,B A P C for dins reams BACK FLOW PROTECT.DEVICE SANITARY - Y .. N
OwnerDau DRAWS-FLOOR.ROOF.AREA.COND. : 1 RECEIPTS!
1 WORKMAN COMPENSATION OECLARATON SCHOOL TAX Y N_ -
i ""� Ihemby affum Nut Nv<acatiflau ofcaswmmml(imure,wa mbflete of (DCRECEIPTIS
orken Compcns mlmurmceorac fiedcopythereof(Sw.38W,LabCJwNch FlXT13RES-PER TRAP - v ' PARK FEE Y N
.,•,; mvcaallcmPlaya'suMa Nis pcmtih•r''ax q)1�,�/// o ` I RECEIPT0
Policy . - '• •✓V //�/X J 7 cAs-EA.SYSTEM.]INC.Wc4 oVDElT BUTLI)WGDIVISIONFEES -
❑ CmifiM Copy is haebY fumishW. 'l i�� �J— GAS-EA.SYSTEMAVFR4(PA) PLANCHECK FEET e T
❑ CertifiN copy is filed wiN Ne city luupecvm division. `, GRHASWNDUSTRL WASTE INIERCFPfOR `4 y' GRADING FEB
s CERTIFICATE OF EXEMPITON FROM WORKERS' GREASE TRAP - - - :•: SOBS FEE
COMPENSATIONINSURANCE
('M3i done mtbecompieWifthepemtitisforonehundr &ilm(SIWI SEWER-SANITARY-STORM EA.20(1 [j. ENERGY FEE
or le )
Icmifydwfuthe pedomuna of Ne work(w which NiS peunit iaiuued,IshW WATER HEATER W/VENT/ELECM q i, •'
rot emPlay anY person in mY manrcr so u m boons,subjc"w Ne Wwkvi _ PAID $' 2 3z
ZCompensation laws of California. Due A Y Date Receipt# ,n. •. ;+
Applicant
'.z NOTICE TO APPLICANT:IL aper voting WS Catifias,of Exemption,You should NEW RESIDEFIT7 PFA1 S TOTAL Z2 v�
In become Subic"to the WorkclS Comp St sties providom of the Tabor Code.you mus: r.
; foMwiN comply with such provisions or Nis permitsM1dl be dames mvokeN �Vjr — BUILDING FEE ^
a Q CONSTRUCITONLFNDING AGENCY OL SEISMIC FEE t
-A z IM1ertby etf tiro Neeuecauvuction lending egenry for Nepeer.ceof - ELECTRIC FEB
O Ne wouk for which this permit is iawed(Sce,3097,Civ.C.)
D" (; LemiUnder.AEEIeaa . . .p s Name
PLUMBING FFR �" ,.d-,4••c i+r�'„"w/
O V 1 tees fy Net I have red W..ppl a an uW nue Nu tlx.have wamudm 1. " s 4 d
..t " Ida coram that
I havyead dlciryudmunryoudiuunaaavd slue law.rtl.tlngm , PERMITISSVANCE Ski �-� s
'IE•' buildin8comtmction,andhvcbY OUNod¢seprtunutiveo(titisciry mentaupon Ne CONSTRUCTIONTAX
L) Z a1iove-seentiow4 property for uupection purposes. ALTER OR ADD TG MECR. '8'
(We)agree to uve,unsoundly dly and keep harmless the City of Cupertino age. e
list,I'tia.judlim -.trot andexp whchmayinanyweyucmesgdmt.dd Cly AIR IIANULINO UNIT(TO IO.OW CFM) _ j
in,
nc Nae tin8 .pemJc Apr HANDLING UNIT(OVER 10,000 CFM) r
i a-Z
SiSgn�of ApplicanVCon r e Due EXHAUST HOOD(W/DUCD PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100!010 BTU) Data Receipt IS
Will the up,licmt orfumrt budding occupant store or handle hmeudau.material HEATING UNIT(OVER IW,1IW BTU) TOTAL:
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Health and Safety
Cala,Saban 25312(87 - VENTILATION FAN(SINGLE RESID)
' ❑Ye No
f �
ISSUANCE DATE
Will Neopplicanmrfumre building occupant use eqme
uipnt ordevice which emit BORER-COMP(3HP OR 100,000 BTU)
i' —ndis dr conNminwu u defmN by IIs,Bay Arte Air Quality Mwgammt BOILER-COMP(OVER 100.000 BTU) ).
/aV. Cl Ye XN. NEW RESIDENTIAL MECII. SQ.FT.
'-' PAl
1 have red the hateSafety
Coe,marcrtt uequiremenu undo 34,Chapter1 un enta d the D r
if
iHealtho s safety Cale Stehave
-b ard,th 23533 and responsibility
1 ity W rund that
if the buildingII Joe not in- 1,vy Tuvea Tamm,NmAis myutemer.f. mnotify Ne DEC
Ou ars of N ait 'u whicf t be ma n o issumce of o Cenificem of �7 ^
ccaPanc a a p :��111I y �
Owner hn...sJ agent Dena TOTAL: ISSUCOe`I: