25839r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUIL. n [ p n
APPLICATION/PERMIT PING PROJECTRCHANIFICA L J O 57
BUILDING DIVISION BUILDING PROJECT IDPNfIFlGT10N
BUILDING ADDRESS 1 SANITARY NO. AITLICAIONSUBMITIALDATE
-1o393 [u[.4 tA) . UNIT. LOT 2r 'may
OWNERS NAMI_ PHONE CONTRA ORS NAME: U NO: / l
`./ �D WC CONIROLN
R H TECf/124 FNGINF.FR: .IC DRF_ Y � � ❑
CONTACT: PHONE BUILDWG PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMB MYCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-Rf•SIDFMIAL
[❑K'L El �Sr El El
I hereby effrm Out l ecevamurrcncin
l under pmvisionso(Chmter 9(eg with JOB DESCRIPTION
��
~OOF. fall forceani.ffenion 700(o)of risionJdtbe Br.hessaM Pmfeuivns Code,eed mylim.c zein PANELS
1E¢.ZW Lic.Clan Lac.# UPTO200AMPS
y<2oo Due Contractor201-Io00 AMPS
ARCHIIRCTS DECLARATION SQ.FT,FLOOR AREA S/SQ.Pf.
I uncicommd my plans shall h used as public rewrdv OVER 10fh0AMP5
SIGNS R FCTRICAL
Qy�K Licersel Pref.iaW
iO�ulU OWNER-BUILDER DECLARATION SPE curr MLSC. /
yXL� 2t-. I hertby affirm that I am e..N firm the Contractor.Idccme law f«be GA
u13Qtn following.,(Seca.7031.5,Buam.end Prefesalooa eme:Any city or county OR POLE NST.
I=�rn .'hien reymrc.a pout to constnrct,alter,improve,demolish,or«pair any structure
%,! M to its i.csrwnce,also the licert fur such Motor file a ei swcsmt POWER DEVICES Ell
u�-_Op thuk ulicrnxd puaaat to be pmvuiors o(thc ConOxt«'a Licrna (Chapter SWMMING POOL ELECTRIC
dX9(cowerea.0tereicananB)uf hoossim Jofbeecl eatoexs.Any vers Cade)
ty_y
or must h70313 by n,apmmuddc basisfa the alk applictrou n,Anyl.ask,of
lITE
ZN Section 70313 by any applicant f«epermlt subject the applimmtoacivJ penaltyM OVRETS-SWITCHES-FIX'iIIRPS
< out man.than Gvelt n dollen($500).
F$ NEW RISIDENTIALEIECTR _SQ.FT. ST RI TYPE CONSTRUCTION
3F ❑ Lm'nwrcrnr NtPmpecXmmyemployecl wibwec!for hdrwle c«npensimsts
will dothework,ands: smunuteisnot intmdd«aw cloforale(Sec.]OM,Busiruu
erd Rofcvi«u Code,:The Conhanor's Ltanse Law don sant apply to an carer of
ptopcuy whobdlda«irrtpmrertkscan,andwindrn such wort him+Nf«through hu
employeca,povided bu.•..M1 imptovemenu zee otiotvthtlmdToed ferule.lf, UP RFS.UNITS
bavevrwill buildingancleoevemcntis.wldwithinmemldnfimvwcnn,the0wom-
buildcrwill have be Mndm mf Proving bet M1e dW nx build«impeve f«puryme of
k.).
❑ I.vsawrerof depmpemy.anmeaclusivelycontrxting withlicer.edcmtucuas to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
cmeorct be pojen(Sec.70,14,Bataan and Proksuoru Code,:)The Cone. '.
Ucrnalawdaesn«.p,Ay b u ownerapeopeny whobdlds«impmrethercm.and PERMIT ISSUANCE
whocaan.for such Peru.withnemvutor(a)Iicesed pursuant to Be Cop.'s ALTER-MAIN A WATER(EM FEE SUMMARY
Licerne Law.
❑ 1 mer cacmp under San. ,B&P C fur this maaon oLjT9BACK FLOW PROTECT.DEVICE l
SANITARY Y N
Ow«r De¢
• Wohm'Conynlr.utmta«acmified ropy tlercof(Sx.3800,Isb C.)which FlXl1RES-PPR TRAP RE FIPfX
WORKMAN COMPENSATION DECLARATION DRAINS-FLOOR,ROOF,AREA,COND. SCHOOLTA% Y
N
❑ RECTPY
PARK EFFY N
con ailepnyce's
order thio permit. GAS-FA.SYSTEM-1 INC.40lITLE1S RVISI X
Ydiry DI
X BUILDING DIVISION P£PS
C Y GAS-EA.SYSTENUOVER 4 JIM PLANCHECK FEE
Cmifid copy is hereby furnished.
❑ miffedmpyu filed with the airy ingctim divisimL GREASEANDUSTRI.WASTE INTERCEPfOR GRADING FEE
CT3HTIFlGTL OF EXEMPTION FROM WORKERSGREASETRAP SOILS FTE
COMPENSATION INSURANCE
(his sevum nml of be romplded ifthe permit.f««c hutdrN cultures($100) SEWER-SANITARY-STORM FA.20t ENERGY FFP.
or l .)
I anify thm in do perfartrwet of be work for whit tM1u Permit is inesi.I stall WATER HEATER W/VENT/ELECTR
of c mle,any p N any mourner sou b became subject to be Woskai PAID
Compenvtionlawsof Califomiu Dote WATER SYSINWG? TING Date RecelptX
Q z Applicant
z2NOTICE TO APPLICANT:If.shier making this Certificate of 11orrTiun,yco should NEW RESIIIENTAL PLMB. SQ.IT. TOTAL
p: CA baane whJat to the Worker's C«npenvnm pwhipu of be Iebor Cade,you el
a > forthwith comply with such prorio«u«thus permit shall be,deemed revoked. BUILDING 117E
L1] Q CONSTRUCTION LENDING AOENCV SEISMIC ME
zIhercby off con buthese isocomtnu:tioalmding egixyf«the pefftmwmed TOTAL: F1ECfRIC ME
O tM work f«which this permit is mued(Sec.Jfl9],Civ.CJ
Lenders der's Name
0 F LerderS Addrm QTY, MECHANICAL PERMIT FEE FLOWING FEE
U I certify that I have rd this appliatism and sane that the above information Is
>. corme, ayecbcmrrrply with al)city and county wdinnee and swelaws nladngb MECHANICAL FEE
PENAUT ISSUANCE
I^ buJdingronsntctim,end hachyautMv<refavenuuveraf thio city to corer upon the CONSTRUCIIONTAX
UabovementiemW propmy fan inspersion pueposes. Al TER OR ADD TO MECH.
(We)agmc to save,inkmoiry erxl keep bannlen the City of Culsrd.+gainer
Iia Iues,judgmen..cos.zed esperae which may in any way accrue agaiut said City AIR HANDLING UNIT(1'010."CFM)
hf of the erunng of bN pervut. 2 AIR HANDLING UNHT(OVER 10,000 CFM)
Si t rs« ❑ EKHAUSTIIOOD(W/DUCI)
PAID
HAZARDOUS MATERIAhS DISCLOSURE HEATING UNIT GO I OU.IXXI it put IAu RttciptX
Wil me,.,icaromfimn Wilding occvpur son err noodle M1.avd«u material
as df d HEATING UNIT(OVER 100.000 BTU) TOTAL
eby be,Cupertino Municipal Codand
Code,Chapter 9.12, the Health and Safety
Code.S ion 255320)1
El ye, Cl No VENTILATION FAN(SINGIE RFSID)
ISSUANCE DATE
Will thenpplimnrmfutre Wildingoccu,aw use eyuipmem«Mvias which mut BOILER-COW(3HP OR IIXI,0aX)BTU)
harsrulwi air uuntaMwn.as defined by be Bay Area Air Quality Munagemmt BOILER-COMP(OVER l(K."BTU)
. Dian]
Cl Y.Yn C3 No NEW RESIDENTIAL MF.CT4. SQ.ET. pAD
I It...reed tht hand u materials rec uvurenta under CMpa 6.95 ml.the, DEC 131�T
Celifurom Health&Safer Code,Scti«u 25Nt5.25533 end 25534. 1 undcmud bat /g[�
if be building ones not currently have.smarm,that it ix my resp«..ihility to notify be ' 9,
occupant of the meyuucments which oust be,net prize to issuance of.Cerificate of
trot y. O Lit-
Pace
h r J
I
Oamcr«authorized agrnt Due TOTAL ISSUEDBY:
OFFICE