S 0797 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
.CITY OF CUPF,RTINO BUILDING-EIXLCTRICAL PI?RMI'I NO.
•BUILDING DIVISION APPLICATION/PERMIT PING FROG� `fIDENTIFIC S 0797
BUILDING PRUJELT'IDF.NTIb'ICATIUN v
IfU1LDING ADDRESS: SANITARY NO. APPLICATION SUIIMI'ITAL DAfI?
-7( bies7- 4creS
OVER'S a. I ON� �0 ` CONTRACTOR'S NAME: LIC NO:
J S' 9Qr,c L����d1 �ao NlC CONI'ROI.p
• � J
RCHITF.CT/IiNGINEER: LIC NO: ADDRESS: .A ❑
C, F; LT, S J C?5DO
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Mt�FCCI1H
❑ ❑ ❑ L^
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PI7RMIT FEE
1 heathy of in o that I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WoZ with Section 7000)of Division 3 ofthe Busineaaml Praf ...CalernJmylioenmis RESIDENTIAL'
F'= in full PoreeanJeJfrot PERMIT ISSUANCE?
U F r `-ad -73 70( ❑SFD ITE ❑PLtjM 1N .RE-PI Fa.
�F.UzfI,]] I,ittnu I;� l Lmtmc APPLIANCES-RESIDENT[At, ❑ADDITION ❑PIAMtlING RE-PII'li
N6ii Data.se Ch" ^� 'T Comraclar Lr MlolT s,fRn
RAL
ARCHITECT'S DECLARATION s ❑MULTI-0NIT ❑MODIFI ATIO
F-py UP T02 MODIFICATION
Z p m Z 1 understand my plans shall be used es public records
oy�o DPTOZINIAMPS El INTERIOR ❑CI{IMNI?YRF,PA12
Fr4tW LicensedProfwslorad 201-100OAMPS IMPROVEMENT E]SWIMMINOFOCUS
YOWNER-BUILDER DECLARATION
C W Q 1 hereby.Hero In.,I am exempt from me Commctrue,License Law for the OVER I"AMPS ❑HATH RIiMODEI/RIiPAIR ❑DEMOLITION
5(:)13,U following reason.(Section 7031.5,Rosiness anti Professions Code:Any city Or county SIGNS FI.LCTRICAI. ,�OTHER
r++aW g" which requires a permit m consumer,alum,improve,demolish,or repair any soucmre FJT r I'P GIB
at C'
prior mics isxnance..lwrequires the applicant for such perniva file.signN smmment SPECIAL CIRCUIT/MISC.
F ad mut he is licensed p....a,1.the peovion.—if the Commences License Lnw(Chapter 9
W p0 (commencing with Section ANN)(of Division 3 of the Business and Professions Cock)Or TEMP.MRTERORPOLEINS'T. COMMERCIAL:
Wy e mm he is cxanpt Ihercfnnn ane the basis for the alleged caemption.Any violation nl' ❑NEW BLDG/ADDITION ❑DEMOLITION
X^ Section 7031.5 by any applicunt for a pennitsuhjecb theapplicannatid,il penalty Of POWER DEVICES TENANT ❑FOOD SERVICE
W am ore than five hundred dollars(SSW). IMPROVEMENT
^zQ ❑ 1,as Owner of the pmpeny,or my employees with wages us their sole compensation. SWIMMING POOL ELECTRIC
F+ wIH Jo the work,and lhasouctum is not intended oroffered fortune(Sec.71H4,Business El OTHER
W 3 and Professions Code:The Contractor's License Law it.,,
not apply toan owner of OUTLETS-SWITCHES-FIXTURES
propeny who builds or improves thereon,and who does such work himself or But
his awn employees,provided that such improvements arc nor intended it,offered for NEW RESIDENTIAL.ELECTR SQ ET.
sale.ll',however.the building or improvement is sold within one year ofcompletion,the SQ.IT.FLOOR AREA 5/SQ.FT.
ncolvinider will have the burden of proving that he did not build or improve for put-
an.of sale.).
1,as owner of the prtpeny,am exclusively commeting with licensed conuunnrs to I`
construct No prsjecr(See.7M4,Business and Profession,ax1eJ The Comacmds li�
cento Law does Out apply to ar owner of porpeny who bonds or improves thencon.and QTY. PLUMBING PERMIT F
who contrera Tse such project with a amtrammna)licensed pursuant nc the Communes
License Law, PERM(I'ISSUANCE?
❑ Iumemmptunder Sec, ,B&PCrormismamn
ALTER-DRAIN&VENT-WATER(LA) VALUATION
Owner Date
(WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Il 1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain eCenificme of Conscnnoself-insure for Wader's Comtism DRAINS-FLOOR,ROOF.AREA,COND, t STORIES TYPE CONS'IR UCTION
smion,as provided for by Session 37W of Be UK"Cale,for the performance of he
work for which this permit is issued. FIXTIIR ES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700ofine Usti for the per-humunceofthe work forwhichtbis ticnniti,issued GAS-FLA.SYSI LM-I INC.4 OUTLETS GROUP AI'N
My Worke�(s C���oyypereatinn--��aa��0°�°°4°O°,,cunieranJPolicy vwtd'erart: p
Curtiee j,pJ:bpCp:L3�CLm.'L .Policy Na: nROG a,b KU GAS-PA.SYSTEM OVF.R4(1?AI
CBRTIFICA'rEOPL+XEtMMYI'ION 17ROM WORKERSGREASWINDUSTRI.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This section need Out be ema ned ifthe permit is foonehundred dollars(Silk) GREASE TRAP
m less.) PLANCHECK FEE?
I cmil'y that in the perfmarmiceolhe work for which this peonit is issued,1111.11 SEWER-SANITARY-STORM EA.200 fT. ENERGY
7, natio laws et employ ofCl'j�y pension i a any groan - - subject to the WOder%Compen- GRADING
C) Z Applicant o/ iO WATER HI?ATEN W/VENT/ELIiCfR GRADINGFI?H
4 NOTICE n APPLICANT':11',after ranking this Certificate of Exemption,you should WATER SYSTEM/('HEATING
a bmonte subject m the Worker's Compensation provisions of the Labor Cale,you must SOBS FEE
forthwith comply with such pnvisimism this permit shall he deemed revoked. WATER SERVICE
Q
a
CONSTRUCTION LENDING AGENCY NEW RESIUENTIAI.PLMB. SQ.FT PAID
U z Data ReceiptX
V 0 Thor which
the,.iti issued((Sec.ma?YD,
Cis,agency for the lerfamtance of
L~ the work for which this pvmtir is issued(Sec 3097,Civ.CJ
pLender's Name Eel I )TAIL:
W Lender's Address TOTAL
Ps I cenify rho 1 have read this it,denion and state that the above information is BUILDING FEET
fn correct.I agree to comply with all city and county ordinances and state Iowa relating to QTY. MECHANICAL PERMIT FEE
U huildingeonmaniriamid hereby audmrire rcpresem.1nes orchis chyme n c'upon the SEISMIC FEE
id ove-memomed pmpeny for inspection potatoes. PERMIT ISSUANCE!
(We)agree to save,indemnify and keep hmtnlem me City of CuNnino against ELECfkIC FEE
liabilities,judgments,coats and expenses which may in any way accrue againstsaid City ALTER OR ADD TO MECH.
PLUMBING Wilt
in consequence of the Starting of this permit. 0
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT AIR HANDLING UNIT(TO 10,00)CFM)
SOURCE REGULATIONS. MECHANICAL FLP s,
AIR HANDLING UNIT(OVER 10,000 C17M) CONSTRUCTION TA
Signature of Applicant/Couttador Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATIFEE
HAZARDOUS MATERIALS DISCLOSURE ^� tic
Will the applicant or future Wilding Occopatnemre orhandle hasadous remerial I MATING UNIT(TO 100,00ID BTU)
as defined by the CupeninO Municipal Code,Chapter 9.12,and the Hodm and Safety
Cole,Section 25532(a)? HEATING UNIT(OVHH IfkT,INNI IFIL)
❑Yes ONO VENTILATION FAN(SINGLE RESID) PAID
G Will the applicant Or future handling occupant use equipment or devices which ]
- - Dare Receipt q
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3W
11POR I W. OBTU)
TOTAL:
Datdct9 I
❑Yes ❑No BOILER-COME(OVER 100011)BTU)
(have reuJ the hmaNnus materials mquimcn
mts under CChapterAIR CON DI FIGS Lkr 6 9 Of the Coli- ISSUANCE DAGT.]Is
farm.Health&Safety Code,Section 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. / ^] ! 3 a r / 7
building does not camenily have a onank that it is my responsibility to notify the Occupant
of the requirements which n as,he tan prior.issuance Of.Cenilieme of Occupancy. s
Owner of apthonead agent Dam .1.0 ISSUED BY:�O �n
OFFICE
POST THIS CARO NEAR FRONT OF BUILOIN(i
CITY OF CUPERl'INO Nt). 779T
BUILDING DIVISION
" "'1fVILDINC PROJR[LIDENTD'ICATI N "•"•'
IR'11 �,NDWIISZ ,..-- 5ANI'IANrN nPPLN:,[IIUNS •• LTi
OW H'S NAMLL P.'. CUNI'HACT R4 NM NW; /L1 N
. - 'Nr(1 CUNT RULE
RCNITPLI NNGINDEk: 1.11:NIX - ADDRESS: ) - ❑
BUILDINN PERMIT INFO
INSPECTIONS DATE INSPEC. U ComWlune P..,Paid by AppueAm unuLn BLDG BLBCT PLUMB M�
: ❑ ❑ ❑
FOUNDATION/PIFRSM.D.S. INSPECTION RECORD )OB DESCRIPTIO
ly
UPER GROUND NOTE: ALL GRADING AND DRAINAGE Rpsm�AT.
PADISET BACK-CERT J SHALL BE INSTALLED TO COMPLY WITH CJSFDWL L]KITQIEN REMODFl
THE APPROVED PLANS AND CITY OF CIADDI'11014 Ci PLUMBING P&I'm
GARAGE SLABSIPREGUNITE CUPERTINO STANDARDS. 0MUIIfId1NIT USTRLCrJRAL
MOOIFlCATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN'SIGNED TO ARRANGE INSPECTION 0INTERIOR ❑CNIMNEY RPPAIR
UNDERGROUND/SLAA CALL AFTERNOONS (I:BU PM aan vM) IMPROVEMENT nSWIMMING PG015
tlAl MOUtlUHP,PAIR CN DFMOLMON
PLUMBING 777-3228 MONDAY TO FRIDAY 24 HOURS BE- FR
-ELECTRICAL FORE REQUIRED INSPECTION, JOB ADDRESS
DONOT.POUR FLOOR UNTIL.ABOVE HAS:BEEN SIONP.D, AND PERMITq AR NEEDED WHEN PHONING. -...
COMMFRfIA!:
PI,UMBING ATTENTION CONTRACTORS: 0 Kfiw BLDGIAUDITION oN
MECHANICAL NO PERSON(S)SHALL PERFORM WORK ON CIT NANr DSPRVICE
1'H1S IUB SITE WITHOUT BEING IN COM- LDOTHERELECTRICAL PLIANCE WITH WORKF-RS'COMPENSACION
FRAMING VENTS INSURANCE REQUIREMENTS.
INSULATION
INSPECTION SPECIAL INSPEC71'IC)N REQUIRED Q DATE INSP
P1ACE NO SUBFLOOR UNTIL ABOVE HAS BEFSN SIGNED' ----
ROOF SHFATH/DIAPHRAM
PLUMBING '
TUBS&SHOWER PAN T
MECHANICAL -..-
ELECTRICAL/POOL BOND
AMINC/STAIRS/E.EGRESS
SULATION VENTILATION '•-
'COVER NO WORK UNTIL ABOVE HAS BEEN
EXTFRIAL SHEARMOLD DOW N
INTERIOR SHEAR/HOLD DOWN
SHEETWROCK/SHEEIROCK SHEAR '
EXTERIOR LATH/WSCRFED
SHOWER LATH
NO TAPE OR PLASTER UNTIL fiAOVF.;FIA5.8P.EN.SiGNED'.
SCRATCH COAT
SEWERIWATER _._.- ....,
TEMPORARY APPROVALS: .
OCCUPANCY
ELECTRICAL
GAS
GAS TESL'
GRADE -
FIRE
HANDICAP
FJ-F('TRICAI '•
PLNG -
F.CHANICAI.
A60WEROY
N vAI,NINAI.ONLY --_ ....-- CERTIFICATE OF OCCUPANCY IJ
BUILDING IMPORTANT: Iss1JANcr.uAT6
OCCUPANCY OF BUILDING ISNOTPERMITTED PLEASE READ REVTRSE SIDE BEFORE.
UNTIL BUILDING FINAL IS SIGNED BY BUILDING CALLING FUR FINAI, INSPECTION!! • ''�
INSPECTOR.
Zd Wdvo:£0 666T 9Z '9ad ZES0£40300 : 'ON BNOHd WOad