24539 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
[ARCTH
TY OF CUPERTINO •- � RICA]. PERMITNO.
APPLICATION/PERMIT %N'C PROD CT IDENTICAL 24539
BUILDING DIVISION BUu.mnc PROJECT IDEMnFlcnnoN
LDING ADDRESS: SANITARY NO. APNACATIIONSUBMITALDATB
Orz r UNITN LOTN
NER. AMG: PHONE: CONT CTOR'S NAME LIC NO: a
C /� N/C CONTROL
:CT/FNCWEIR: UC NO: ADD RFSS /C
ElCONTACT: P IONIi QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
CH
/O�—,7Q"/ PERMIT ISSUANCE BLDG ELECT PLUMB MEl
LTCFNSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
pMZ I hcchyaRrored l mr,lion,edtnderpmvi,'umn(Creeptc9(amnercin8 with JOB DES CRI N
+1100 S¢lion7")of Division 3oftle Bari.srad Profeui«u Code,mrd rm been.i,in PANELS '-k)
/ �
{FQ.-�'I W 'ull�gaCrce cRal. � N UPT02IXIAMM -\J\,,,�
(�V=y De. Cmtrectu 201-I(I(IO AMPS S 1.1.11.(NM AREA f/SQ.FT.
ZOIv'it3 ARCIIITIiCI'S DNCLAkA'1'ION OVER 1000 AMPS Q
p z_p I urdcatard my plana,hall he weed u Public acad,. �•�a
SIGNS ELECTRICAL V /� L � !� a
lisbad Professional r IIv
g OWNER-BUILDER DEC ContraON SPECIAL.CIRCUIT/MISC. It rI, _
O�yF 1 heresy alum tMl 1 am ascent from the Contractors Licrnm Taw for the Y) U r R
W'LLy following re.(Schon]031.5,Bu,i.and Profesimts Code:Any city or county 'ITJHP.METER OR POLE INST. I�N � 1
h- ,,15 which require m pert to wnsvuct.War.improve,hneleh.or rtlar my muctme
fnY7 peon.^,isuwtce,Ww,•9uf lhe.pliicanl far mch permit to file..igned,eand t POWER DEVICESDAT-
ppC tMtfti in licwN pursuant to the Woeinicew of the Cootncrof Licence Lew(Clupttt SWIMMING I't")DI,FIF.CI'RIC
m LL 9(c„ re
neeeing w,in Section 700( f Dlvlaion 3 of the Business enol Iii,( ,iau Code) VAI. ATION
Et, or than he in excerpt therefrom md!the hasi,far the WlegM exception.Any violuion of
FZS' Section 10313 by any apptieanfor.permit subjects the.pplieanl to.civil prnmFIXTURES
lty of OUTLETS-SWLTGHES-FIXR
�'0 no r.Nm five hurrdfN dallmn(fX)(). NEW RFSIDFNIIAL FAF.CfR _SQ.FT.
C $ ❑ I,v,owmofNepmpcny,wmycmploYca with wmgcs.sthcirhalerompeuatioo, STORIES TY NSIRUCIION
LLLL]] will&enc work,and the prwewec in nor me�ed orofferm formic(See.'1094,Bush,.
., sed Pretension,Ce,k:Tec Contranur',Li.Law doe not apply to an owner of
pmpeny whobuJdsor ingrvvn thvmn,ud whodm,uehwark him,elfcthrough hu
owa,ar,nyee,,Minc,intiatwch impmvrnnddiin.ivcddaoRcNfmuk.lf, OC GROUP NILS
befiWar ,ill avidin,eimlwvcmrntishathwithinto yearofcmrvefo,theownn-
buidnwlllFavnheM1urrknof In that he did nm build or im for f TOTAL:
peau , peeve purlwsco
sded.
❑ I.uowrcr Mthc PeolMY.mcxci"nlycmtr iingwithlicveadmumctmto QTY. PLUMBING PERMIT FEE FLOOD SANE APN
.,Ie project Dec 7ND,Bushes and Prohard.Cory:)The Conu...s
Liana Lawdoa mtapplylomtnwecrofTmperry Puha Molds orimprova them^.and —T-
I PERMIT ISSUANCE, -7 SL
whoeontmcis for such projects with acom,ecror(.$)licensed pumuanl to the Canlmcaa
L;,cn.,a lsw. ALTER-DRAW&VENT-WATER TA) FEE SUMMARY
❑ I un exempt urdc See. ,B&P C for thio cease^ OUPSIDEIPES
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owoar Dm, DRAWS-FLOOR,ROOF,AREA,COND. RE 1PTX
ftGASWORKMAN COMPENSATION DECLARATION SCI IDOL TAX YN
e,ne m certiGcam of RECEIPPWakvs'Cmprn,uion l,tsuaraxa.ccnifiW ropy thcrmf(Scc 3g00.lab C)which FIXTURES-PER TRAP PARK FEE YN
,m Wl Y 's uMcthis pe +It. -EA.SYSIF,M-I INC 4 OUTLETS RECEIPT#
_ ppBry� BUILDING DIVISION FIJ3
C�,otPanY GAS-BA.SYSII3M-OVER 4(EA) PI,ANCIIGCK I'LL
❑ CMefieI mPY^M1erebyf mlehM.
Certified copy i,filtdi with the city irepection diniciose. GREASEJINDUSIRL WA.STT!INTERCEPTOR GRADING FUH
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASETRAP SOILS PER
COMPENSATION INSURANCE
(Ihis,ection recd nm he modeled iftnepmnit i,fi,rone hunJai&dItr,(IINd S17WER-SAN]TARY-STORM EA.2Mfr. ENERGY FEE
or leu)
Iccnify thu in the perfomtu .f the wart for which thu permit u i,mcd,I shall WATER HEATER W/VEJN`DEi.ECTIk S•�
ror con loy my perm^in any mvmef m..to Isco a.object to the Worker, PAID
Cmnpenaivnl.w,efc,lifomie. Dode WATER SYSfEN/1'RI?nTING Dale RociptN
O z Appbwam
z O NOT ICE TO APPLICANT:IL after making thu Ccrtificue ofF emgion,you mania NEW RESIDENTIAL NAB. SQ,FT. TYTPAL
1,0 you recent
� - fm�ihwith comply with cach proviu'mnject to chic Worect «uih,s Pvn,tdall domed revoked. BUILDING FEE
W Q CONSTRUCTION LEADING AGENCY SEISMIC FE!
I Mchy aftion drsL there is a contrtetion lending agency fee the perfamana of yymZ•S FIECIRIC FEE.U p elf work for which the,peit u iswd(Sec.309"1.Cin.C.) TOTAL p
PLendef,N.D-' U Lender',Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I comfy Thal I have nailthi,.,kationmtd,or,e teal the ohne information is MECHANICAL PIKE
conal.I agree to amply with all city and county or,linuncc,sed Vnlc laws relating to PIRMIT ISSUANCE
F' buildingcrosvu nes sed hereby mathorica reprerntrovesofdd,city u rote(opener the
(J Z .hove-memimM pepeny far wpection puToa. ALTER OR ADD TO MF,Ci. CONSTRUCTION TAX
(We).gae to,Yve,IMmv,ify end keep h.rmlan the Cly of Cuperl'vto egminn
liuladitic„jwdgacnu.ueo and expense,which may in any way aarvea,ati mid City A I R HANDLING UNIT PO 10.000 CFM)
m,eytrerce (the,bodfIh' perm11
o ` AIR HANDLING UNIT(OVER 10,"CFM)
, IAUST HOOD�'matu,e MAppli��veva DDuar,ere PAID
I/ IIA%ARDOUS MATERJAI S DISCLOSURE DISTING ON jr,(TO 100.090 BTU) Data Ri ciN 0
Will the mpplicuu or firma building occupant ume a LuMlc lar rdou,muoLd HEATING UNIT(OVER 100.000 BTU) TOTAL
u helloed by the Cupertino,Municipal Code,,Cheper 9.12,sed elf Health sed Safety
Cade.Senior 25532007 VENTILATION FAN(SINGLE RJESID)
❑Year 11 No
ISSUANCE DATE.
ces which e1NBOILER-COMP(311POR WK),N) BTU) P A
Will Jia applicant a fururt bulJng ocapMl use eyuipmem or devil
ser cnmWtinant,to defined by the R.y Area Air Quality Mamgement BOILER-COMP(OVFR 100,000 BLU)
Di.lricl)
❑Yc, ❑No NEW RESTDFATIAL MECIL SQ.FT.
I faces cool the hee,mloces mvteriaH aquirtmcros under Chagc 6.95 of de DEC 10 1992
California HeaIN&SWery Cade,Se,aima 25505.25533 sed 25534. 1 urdcmand that
if0e buddies,dors rot cart live nowt,than it it ery respwuipllry to notify the CIIY VF CUren 1111%
occupml of tk mgaircncro,which must ba near prof m ivuance of.Greif a of
Occupancy. ( ' �r '
Wna or wthuizcd.,on, Duc TOTAL: ISSUED
OFFICE