26308 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINONC.-RLE�'R A PERMIT O.
APPLICATION/PERMIT PLUMBING,-MECHANICAL 26308 O+ O p
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION O
BUILDING ADDRESS: SA ARY NO. APPI-IGTIONSUBMITALDATE
llNffx LOT♦
O ? SNA .: PH A;R'SN ��� C 3035
R NC CONTROL 0
• ARCIIII' IENO LIC NO: DDHFSS: • I
CONTACT: PHONE QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLOC ELECT PLUMB MECH
PERMR ISSUANCE El El D
LICENSED CONTRACTOR'S DECLARATION APPLIANCTS-RESIDENTIAL LOB DESCRIPTION
OC7 1thereby affirm that I am Iiecn.sed under rovisioni.f CTn(nrr9(comrnencing with
ado (Section J000)eof fWviaim Jof the Boomers roadPmfessi«v Code.ad my licencuin PANELS 5 �
IVOR`
I1ull ones, `
......ZW Li Clcy,• I.Ic.0 UP TO 20rt AMPS v
Vr<Dr C. .cmr 201-1000 AMPS
Z Oy% ARCIIIIECTS DECORATION FT.1000 AMPS t B IT.FLOOR AREA VSQ.FI'.
dZ—t] IUMnauM my pbmn dWlMvsdvpublic rsords.
SIGNS ELECTRICAL Air _
¢,ec� Lsed ProfessionalProfessionalOWNER-BUILDER SP
DECLARATION ECIALCIRCUIT/MISC.
�j�' icen3 u IIdFFy.... 1 hemby.fr Bou 1 em exempt from tis Cm tromns Liave Isw fm Ne
4oQ following revers.(Sewn]0313,Betimes ed N.Itssiom Code:Any city an court, TEMP.METER OR POLE INS).
which rtqu'va a Pamir w conwuct,aim,impmve.dnrolislt.or mpd'r.ny suunurt
c �c[n} prim to its issuance.also regal=the applicant for such punt to file a signed stutrmrnt POWER DGVILTS
1y Y O that he is licevd punu.nt to the poviv«n of the Canoed«'.License Lew(Ch rpmr SWIMMING IMMMG POOL FJECITUC
e.ax� 9(cmttnrncing wilt Senior 7")of Div Bim 3 of the Budneas nil l4mfrni«u Cods) VALUA'p[y
W�H
or that M is exempt ttertrrom and tIm be.i.for Jcc ellegrd exemption.Any violation of 'X CSL.
FZY Seet4tn 70312$by tiny ii diceru for a Permit subjects the q ic'un to e civil perulry of OUTLETS-SWITCHES-FUCTURES —
< not mart Nan five hurdmd ciollen(SSW). —
� o ❑ I.mowrcrof the pmpcnY.«mYcmploymwithwagmmtheirademmperuatieo, NEW RESIDENTLAL ELECER _SQ,FT. STORIES TYPECONSTRUCTION
n3°= will doted wtrk,mdthc nnrmoeumtintntdeimnReted r«ale lss.)OW,Builds
ad ProfLtisions Code:Tice Contractor'.License Law doe M apply to on owner of
pmpcny wed builds m imposes thrrton,ud wed dom such w«k himself«thmugfi hu
empbycn,pmvldedtlut such lmpovtmauue mrimeMed«.(feted fmuk.If. OCC,GROUP RFS.UN111
however,Inc Mildingm imptovet«nt u sold within one yes of complain,the ow er-
huilAerwillloN
vethebuertofpM tem ovitgthu did build impose for pug of TOTAL
e c).
❑ I.mmvrcro{ohs poputy,amcacluslvelymnrrectingwim lkrn+m cnnuacmn to QTY. PLUMBING PERMIT FEE FL ZONE ql'N
«atoned the Itroject(See.7019,Boron.utd Professions Cade:)Tlie Conoserms
Li«nw luso Jon not apply to enowterafprupcnywMMllds«Imptovm lMnrm,and PERMITLSSUANCI?
wMdermosu f«wch Per t)"wiN acmtnnwls)hismasN pmauant to the Conmclols
U.Uw. ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I un exempt under Sec. .B&P C f«Nis eemm Om.l5rFITIT-
BACK FLOW PROTECT,DEVICE SANITARY Y N
Owner Not DRAINS-!LOOK ROOF,AREA,CONU. RECEIPTN
• m WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ Ihercby vffmm thatlhnvcaanifrcncnf rnnanu to self-insmc.m.anificatc of FIXTURES-PER TRAP RECEIPrN
W«km'Cmtprnsetivnlmumna mocmificdcapy Ncrosf(Sm.JP W.Ub CJ which PARK FEE T N
m W cmpbyce'.under ted permit. GAS-FA.SYSTEM-]INC.4 OUTLETS RECEIPT P
Polity N BUILDING DIVISION RTS
Company GAS-EA.SYSTEM-OVER 4(EA) PIANCHECK FEE
❑ CeriifiedmpylsherebyfumisMd.
❑ Certified copy is fled with the city inspection division. GREASPJINDUSTRL WASTE IN'1ERCEFTOR GRADING FEE
CERTIFICATE-OF GXEMPOON FROM WORKERS GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This action need m bc cour ilcted dust permit is for orc hundred dnllm(gIW) SEWER-SANITARY-STORM FA.20017. ENERGY FEE
«Ica)
I anify this in the perfmwcce ofthe,work for which this permit is iu«d,I shell WATER HPATFR W/VFNT/ELF,CfR
roil cri any person in any m u m Isecarnu subject to the Wmkm' PAID
Campnn.uuiso uwsof Caliromia. Dae so WATER SYSTEldb REATTNG bone ReceiptN
O Z Applicun
,z 0 NOTICE TO APPLICANT:IL arta making this Ccnificamof Esem,mor,you should NEW RISIDEiNT'IAL PLMB. SQ.FT. TOT
F r!) demos,subject to the Worker's Ctmtpmatim pmvisi«u of Use labor Code.You mss
fowall ai with such pwisdon s«Nucmt
pit shaed m
ll be deemated. BUDDING RE
4 Q CONSTRUCTION LENDING AGENCY SEISMIC FEE,
U z IheeM1y affmm tMtlM1ere isecmlanlKlion lending agenry for the pcH«muec of TOTAL: ELECTRIC FPE
O wer
Nc work nichtbla pmit is issued(Sec.304E Civ.C.)
Inder's Nems
OF' Lemkri Addres QTY. MECHANICAL PERMIT FEE PLUMBING THE
L7 1 cmify Jw 1 Jesse nail tau"lic.Jon W.0tm the.Moe inrmowion is
�"' 4 con«t. tepee to
comply
ell dry mtl county«dirumea and sum laws reldingm PERMIT ISSUANCE? MECIIANICALFEE
Mildin,modruniedrund yaudwriee teprewnmtivm ur Nis city lornterupon due
U z .bwe-mentionedWcind
quyoscs. ALTER OR ADD TO MECTL CONSTRUC IONTAX
( )egae keep M1ennlua the City of Cupmivo egun,
I' 'I
-i SowldcM1 mayinany way accrue gautus.id City AIRHANDLINGUNIT(TOW,000CF1,I)
mJt.
AIR HANDLING UNI'((OVER IOAW CFM)
mco;7c,,�H-rmdo
onnKl« D FXFiAU51'1I00D(W/DUC� PAID
AZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO L00,000 BTU) D.R ReceiptN
Willst or future Mildin,occas ,ams or hudle harerJous materialIIEA)ING UNR(OVEtIW,000 BTI) TOTAL Municipl Coal Chgwr 9.12,and Joe Hcalth.nd Safety
Code.5mi1125532p)t
11 Ya 13 No VENTIIATION FAN(SINGLE RESID)
BOILER-COMP(3HP OR 100.000 BTU) ISSUANCE DATE
Will tM1c sppliant«fmmc building by dic B,Acis Am nrdcit,Miahichcmit P A I D
District?
is,emumi"""s m defmrJ by tM1c B.Y Am Am Quality M.nagerrcnt BODER-COMP(OVFR 100,000 BTI)
� Dw ei
❑Yo ❑No NEW RESIDENTIAL MECII. SQ.FT.
I hove maid the Javrdnus materiels requiremrnu under Chsptc 695 of the APR 26 1994
Califtmnia Ilr lh&Safcry C«k,Smtlom25505.25533std25534. 1uedemud that
if the hu,"tyconnot caaertayh.ea mount.dutitismyrmpmanlirymtt«ifythc CITY Ur- Vur[LII
'cogent of ted rcquircmrnu when man tc mot pita m isswnta Ora Ccnifia¢n( —�
(kcvpmcy.
Ower Or outht-ml agent Uwe TOTAL: ISSUED BYUW I
OFFICE