S 0487 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OP CUPF;RTINO 1 F,C
BUILDING.ELFRICAh PIRMITNO
BUILDING DIVISION \pl'1'LICATION/PFRMIT PLUMBING-MECIIANIGI.
S 0487
BUILDING PROJECT IDENTIFICAHON
BUILDING ADDRESS: SANITARY NO. APMICALK N SUBMITTAL DATE
9-)0 ly - g�
OX AM6. PHONE:
sz= CACTOrRS NP
r NIC CONFROI.0
t106") SEC NO:ARCIRIIICUlaNGINCER:
❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FJ.ECT %DMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby affirm Thal l am Barred under prm;ei�of Chapter 9(eommei
enng JOB DFSCRIPTION
�aZ 'th Sation](q(Bvf UiAkioe 3 oflhc BusitcraanJ fTnfariwu Co.k.suni license is RESIDENTIAL
Woe, ori PERMIT ISSUANCE
F,_ in full fence and cffw, ❑SFDWI. �❑qKITCHI3:RE\10UI3L
tV�j Licrn.¢Crus Loa.if APPLIANCES-RESIDENTIAL. ❑ADDITION {T%.UMBING RI PIPE
ai Dam comrmmr
F7H ARCHFU:CF.S DECLARATION I'ANLLS []MULTI-0NIT ❑STRUCNRAI.
Z O t2 Z 1 understand my Mans shell be used n pontic ree rds MODIFICATION
OZ-o UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
gy aqIJeensed Pro(eeaesel 101-110N)AMPS IMPROVEMENT El SWIMMING POOLS
OWNER-BUILDER DECLARATION
6 I hereby off.—that 1 vm corm%from the Comm
roin-,Licue Low for IM1c OVER IMOAMPS El UATII REMODEI/ItEI'AIR DEMOLITION
°x'O a V fdlow;ng aasca.(.Sariun'loJ LS.Buximv arM Itofcssims CcJc:My city or mmnty SIGNS ELECTRICAL ❑OTHER
ly 3(r-I-' which rcyuira u M1'ry-,it 1.,...mad.uhn.im,neve.deem h.to,rtPur any swnurt
�jE0 pear to its immmc,alar routines tleopplicam forauch Prrmilm File—ii,rcd m0emmm SPECIALCIRCUITIMISC.
zt2> now he rs license pormanot the l ovivirnn of dm Contractor's Brame Law(Chapla9
1 SC0 aomnwneinp elm Section 7000)of Di vision 3v fl he Business and Prefeowns CUJc)r TEMR METER OR POLE INS'. COMMERCIAL:
athat Im ix exempt Internet.and IM1c haix fill the allege c.empmn.Any vidm'nu of NEW BI-MADDITION [I DEMOLITION
Seen.7031.5 by any epplicenl fora permit subjeetslhe applicant on.civil perary of POWER DEVICES 00ETENANT ❑FWD SERVICE
N nave than rive hundred!dollar.155(X).
I-ZY n' IMPROVEMENT
=Q Q l,oa ounce of Be pr structure
re is emPbym wilhwngnulMi(rale contrcnsBusiness SWIMMING WR)I.EhIiCIRIC
I sits
yF
9 will dalhewttk,garde int Conoaelor s erdecc oRitate, -k,(Star.It)an owner of ❑OTHER
1'3 and Iany wine,
b Cork im cvnolcmo1 ulwt Wwdace rixrk himlfrwnaof OI1lLETS-SwIICHIS-FIXTURES
his own
end Wilde pr impmva t mush i mW wMr dies euro work d d or or through
him"wn ooseve hit pmvidet shut such oseiil cold arc ria intended on Nfacd for NI:W RF_SIDPv'rL\L ELECI'R SO FT.
safe,If,however.IM1c Wildin6 orimlxnvenuntnxdt within nteywofcompleti..n,the FT.FLWRARP 5/SO,FT. +
aaan W ilder will Msc I e huNrn of Isn't,tool he did rot build or improve loons,
"f `l) SEP 15
❑ I,�t owner of tri,pory 7fla B,eemaivdy cmmc sirwer who etc vN enam d is B, ll)rnL: D[p1�
a.Lst Je es on i(,Secs]f NJ.Budr.1 mW Rofas'vn d,or irWorses iondshcrenn.wl QTY. PLUMBING PERMIT FEE
wrcerm,rectR«HochPmjalswithn<on.mcert(glicvneepurvunnnnthccrmtracmr'n CITY Ur cur RTINO
n Ian,Ise. 1'I?EMIT ISSUANCE
❑ Lein eaemptunder Sec. .H&PCfee this rramm
o.ner DateALTER-TRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION ofthafRl.in, BACK FLOW PROTECT DEVICE
1 IKrdtw vlBor under trallyof ile.f my crit of 0,hJlowing d ereser iron:
❑Ihove mdwill mor try ScCenifcem of Creed,,CadF ode,rauefor Woorma Crmpen- DRAINS-FLOOR.RWF,ARIi\,GOND.
SIURILS 'IYI'Ii CONSTRUCTION
satin,,ter which ti for by Section]](111 of IM1c IsWr Code,for tW perhrmm¢c or he
workfor whichOtis Peron is Issued. FIXTURES-PER IRAP
ED 1 hand will awillill maideneff Wafted, amoc oft a d,for c,h o, con by Smite
3'Iy Woo sGlok,(nrIM1c pvrGmmmcc nflhcwvn hosv'M1kh lM1n p,mti,is i..wed. GAS-EA.SYSTEM-1 INCA OUTLETS OCC GROUP APN
M1fY N' CoCg�tesatbe roar rcc and l'olicy'numbrr vrc:
Cunir' Sly- / PoIicY Na: GAS-PA.SYSTEM-0VER4(Ek,
r CERTUICATE OF FROM WORKERS' GRFASPIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCIi BUILDING DIVISION FEES
(This.mOtiou rrceriol hermnpRte ifBr permit it frr on,hundred dodder(SIM) GRESSETRAP
or hes') PLANCHECK FEE
Jecrlifytbd in rte perfomurccoOlr work furwhich rhixpermit isixsaed.I shall SEWER-SANITARY-STORM EA.200 FT.
rex employ any p,ram in my manner so as to home sahcet to the Waken Compete- ENERGY IEE
O z s tkn lama of Celifnmia.Dom WATER HF,ATIR WNENUF.LECTR GRADING IEF.
z Applicant
y NOTICE TO APPLICANT:It,after making this Certificate of laemplion,)m dead! WATER SYSTFAVIREATING
a ' IMosubject In rhe Worker's Compenxmion nevokiom of the Labor code.you inunt SOBS FEE
fowi.h comply with mvah provisions or Hes permit stall Mhcnedrevoke. WATER SERVICE
a �
GDNSTe is aro N' actimLENDING AGENCY NhIV HESIDENIIAI,PIJN11. SO.FI'. PAID
= Z' Ihaeby affirm WttMrc is aconmrvnim lending vgcrcy for Nc perf0rmargeM Oam RcailnN
C.) _O rhe won for which this Nmil s issued(sa.Ay)].Civ.C.)
w (~ Lcrukfx N. 'ral'AL:
U Lender's Adders, TOTAL
I certify hit, rent t I ho,s This application and euro thud IM1c aMrve in mronem is BUILDING FEE
rjj const.lagrtemrnmply wiN sll city arW roomy ordiner¢a ant vac lawn rdatingw QTY. MECHANICAL P17RNIIT FEE
U Wildingcroslmnlon,nnJhembyoutM1urvc repnsen.ativernl thiocirymcnmrupon de SEISMICFER
aWvcmentinmd Force,for inepmkm purpo..es. PERMI f ISSUANCE
(We).,mem save,indemnify and kap harmless IM1c City of Culce int agaimm ELECTRIC IFF,
Iimbilitiesjuri,doescorm,tied espen.se,which may in any way aarue Art said City ALrERORADDTOMF.CH.
in rnn.aNuence of rhe granting of this pencil PLUMBING FEE
APPLICANT TINDE- STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10010CI'M) MECHANICALFE3
SOLI (lULAT10
G _�I� AIR HANDLING UNIT(OVER 0,000CFM) CONSfRUCr10N TAX
Signe�ppliann Imchr �� Oam EXHAUST HGOD(WIDUCI
HAZARDOUS MATERIALS DI,SCLOSIIRE HOUSING MITIGATION FEE
Will the alplicosm a future Willing acca,eme arae or hanJk ba ushems mammal HEATI NG UNIT(TO 100,000 BT U)
as defined by IM1c Cupertino Municipal Cite.Chapter 9.12,and IIIc H'WW ural Sultry
Cede.Section 25532(.)+ HEATING UNIT(OVER 100,000 HTU)
0 ye, ❑No VENTILATION IAN(SINGLE RESID) PA10
Oat, Receipl0
Will Ile applicant in(mare Willing byvaccusumB areas Air uordeviceswM1icM1
emit hvmdnna air aumininvns ur MGne hY Ile Bay Arta Air(pelilY Mamgemcnt BOILER-COMP QIIP OR M."BUT)
aDM.:
ITeWn'!
Dyes C)No BOILER-COMP(OVER 100.000.000 BTU,
I have road Ne ha+:udue matcrinls no,mrceens order ClwlNn M1.95 of t he Cali- AIR CONDITIONER ISSUANCE DATE
Tomo Ileilrh&Safely Cale,Secliom 25505,25533 and 25533.I unlaumtl Nn if the NEW'RI,91I)ENIIAL MECH. S0.IT
Wilding Joe'not currently Mvc..count.Net it is my mxHruibility ru n"tify me
of Be rtquimements which mum he mer prior w i.uuame of a Ccnifieme of Oem,omy.
aanenm sumnimd agcnl Hoc TOTAD ISSUED BY:
OFFICE