S 1033 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINORtill.DING-ELF,(TRICAL PHRMI'I NO.
BUILDING DIVISION' APPLICATIONWERMIT PLUMBING-MECHANICAL S 1033
RUILpING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE?
4s4s / 1d-is r�
OW ER:S N(p ME YHONIi: CO, CONTROLfOR'S N ����yyyy LIC NO:
�� S3- /..U� NICCONTROLN
. RCI( CUBNGINIJ:R: LICNO: AI)DRF'q� �y r 2i /fN�( ❑
CONTACT; PHONE: LGr�[ BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELT PLUMS MECH
❑
LICENSED CON'ntAcTOR'S DECLARAI ION QTY ELECTRIC PERMIT FEF,
1 hereby affirm Elul 1 am hanssd under pr ci one,of Cm pmr 9(,o n encig6 JOR FSCRIPPION
OctZ with tiectiam]gNl)M Divitim JMtle Hoo.imv wW Pmfesldm,Co.le,mW my liaaoc i, RESIDENTIAL
W 00 t PERMIT ISSUANCE
C u:F in full force and cRm ❑SFT)WI. ❑KITCI113N kIiMUULh
aUU Lkcnsc Class L.ic.N APPLIANCES-RESIDE!MTAL [I ADDITION ❑PLUMBING REd'IPE
F Z u] DCommcl
mho
❑MULTI-DR ❑STRUCrUkAL
F-D4 ARCHITI=DECLARATION
PANELS MODIFICATION
ZO`r�Z luadcrwd my Plato still lx trod a+pnMkawrords UP DO 21X1 A
OZ�,O A1PS ❑INTERIOR ❑CHIMNEYREPAIR
H. Lkansd Pmfcasiomal 201-100DAMPS IMPROVFMEST OSWIMMINGUUsTUS
ay � OWNER BUILDER DECLARATION OVER Iqp AMT'S ATHRF.M0DLs1tFPAIR ❑DEMOLITION
a
�y'tY 1 heby M.thea 1 roan e,empi From the CIEVaat«,Ix<nse Law for rhe
x O L V following aamn.l.Se,11.70313.Boone.tad Pme.inm Curie:Any airy or curry SIGNS ELECTRICAL. (TRIER
til 3 V.♦n which reyniees It pemit to ammurvcl.aIle,improve.clot h,or repot any structure
F-�05 prior to its imaroat ,atria entire the applicant for such peanit to file a nigddl4mcmcen SP'ECI AL CIRC UI TIM ISC.
nor he d Px
is I canst^"' to ON,lmvisiau of the Conrd«s aLiceaee Law(LIol9
YS+ <E COMMERCIAL'
c. lcat he
ro En Section]tl(Ifl)of lint,nr hale Buroi asnwJon,Any
Cak)a TEl M[:TEk OR I'OLIi INST.
d Nm he is cacmin mlw�efnmm uaN Nc Buis fu Nc allc8d cacmginn.Any vinlm'xm of ❑NEM'PLOG/ADDIIION ❑DEMOLITION
Send.7031.5 by anyepplicmd ft ape.it subjaata the upPlicam no a evil penally of POWER DEVICES 0TENANT ❑FOODSERVICE.
CZT ren Ewe than five hlmbed dollar,1S5001. IMPROVEMENT
< DLusowrcrol the qupeny.or mYeaamployeea w'ithu;mgwmtMir Wcenmpeammtiem. SWIMMING POOL IJ CTRIC
F�0 ,dl du a
the wk.a,jlit,.,.,a is aulmdda
coRcadca d for-In 7(W.Basi ❑OTIIER
a4 and Pmfenimm,Cod,:The Cornncmr's License Lnw dean nor.,yo an,—of OUTLIES-SWITCHES-FIXTURES
c,'3 pmperY who bell,er;misoves natation,rand who docs such wort himself er thntuBh NEW kFSIDEMIAL EI.I;CfR SQ FT.
his own croPE."s,Provided BW such inymmvcncas aR wt intcndcd a ofeml fa
mle.If,hwvcver,the hoi HintUt,mlrurenwnl is wild wilmmona yearot msolocaa4 the SQ'Fr.FLUOR AREA ESQ.IT.
rat bidder will base the burden of fmrving that be did not build or imperse for put.
? A
❑ I,Or,owner of tie pmier.M exclusively committing with licensed contractus to
msini the psoj,O(Sm]I w,Business mW Poofcuions CWe.)'III Contractor's LI-
crnmLaw Nesnniapplytoanearip Pp y who M1uhdsa improve lh,,,O.and QTY. PLUMBING PERMIT' F' �� N(�
a0mconmets for roucb Pojta,w;N,aunorctrr(s)licrnwl pu.00rma Ctmmxt«s OCT D
L'acnm law. PERMIT ISSUANCE.
I am axcnyn under Sec. .B&P C for Thil ru tun
ALIER-DRAIN&V ENr-WATER Ess) A
Owarcr Dae a ` 0-x!1
WORKERS Crty(A COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 7 [/ll
�- Ihcabyallinn ua,kr penalty err perjury one of the follewinB Jalumiuns:
❑ Ej
Ihuvc and will!few by SXtio lfraam of Ithe set&l for on Wndcrsve of the DRAINS-!LOOK HOOH AREA.CONU. STORIES TYPE CONSTRUCTION
,croon, r fmsvidd few M Soria a. of ale IlEax CMc for lM pertaxnuau'c of the
work have
which thisprima;,Worth. FIXTURES-PER TRAP
1 have will ln a'r mInsurance.ss an by Sation
3100af NCLaM.Goskhome IsticmurmofNc weelk for which lhi,prmdtIn
iced. GAS-IIA.SVSTIiM-I INCA OUTLET OCC GROUP APSE
MyW esCn I mane - vWPnikya b GAS-FA.SYSTEM.OVER 4 EAU
Cure nm ^1 m q+licyNa:'M?n60/
CEKfIP CA'IEOFEXE PIION FRONT W.:[KS' GREASFANDU. fRI.WASni]N :RCIiPIDR
COMPENSATION INSURANCE BUILDING DIVISION FIkS
Rbis.acma.redoor beewnpletedif Bepennia ix fm um hudral ddlea GSl(X11 GREA.SETRAP
a las) 1'LANCIIECK ITE
IcMi I that in ma,NO..of the-sit fa which this permit is i,suN.I xbWl SEWER-SANITARY-STORM PA,200 FP
nth cntEaluy any penin in any manna an w m bnvna suhpo th
¢a e Werke"Ctmmpen- ENERGY FEE
Z ,than LEE.,of Cabral Da, WATER I I I i IHR WIN ENTIELECR GRADING EI?li
Q Applicant '
NOTICE TO APPLICANT.It,after making this Ccouncerre of Eiampaiem,you sMuld WATER SYSTE1,1/IRFATING
a , he,cma.xuhjcG In the Faker's Com,ru rO m puu IM Lr
ovininI tMCoda.You mea SOILS FEE
fambwiNeadply with mchpmvisionsordispernot Mall hcd¢ncdrevdeed. WATER SERVICE
7 Z
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PIMB. SQ.FT. PAID Dare Rtdpt N
UO (hereby affirm ma Bort is a eoatmchon knding aeanry fa mac perlummarme of
VO — the work fa which this Permit is issued(Sno.3191.Ca.CJ Ir eat N. '1(TI'AI,�
y, Ladar, as
'n Aald , TOTAL;
!' as I ecrify that I have rtW this Wheaton and route Its the above information u BUILDING IFS
tTT""" to currceLlutlrccmamniply with Ell city and county ordimammn mm3,cmc laws rdmimp In QW.. MECHANICAL PER FEE
U Z haddingcaoamution.end M1eabyroumerire aprs-.amauves ortnin ebr renter ar t selsnur.1,1411
'� crime-mcaimed pmPwEy fa an action lwPl II!RMIr ISSUANCE, /
(sac)agree to vvc,hademnifY and keep harraims rime City of Cupertiam andent FSECTRIC IFF.
71
Iiahilitiu,judgmmtils,cnln and cx,,erwa,which nay in any way accrue ayainv.said City ALTER OR ADD TO MECH.
PLUMBING FTii
in cunsequeree of the granting of this permit.
APPLICANT ENDS TANDS A ' IL COMPLY WITH ALL NON-POINT AIR HANDLING UNR(Tf1111,0(XICUM) MECHANICAL EEE!
SOURCHREC A NS.
AIR HANDLING UNR(OVE)t 10,"CTNU CONSTRUCRON TAX
'17Sigel AfRlicenuCmmarvcor Dare EXHAUST HOOD(W/DUCR HOUSING MITIGATION FEE
IIAZARDOUS MAfERIALS DISCLOSURE
Will the applicant or future bai Hing occupant qna or handle hvaaddwematcrial H EATING ON['P(TO 100.000 BE U)
a defined by the Cupcn;na Municipal Cde,aslo r 9.12,and the Health and Safety
Coda,Section 25532(,)? HEATING UNIT(OVER 1011(p BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESIDE PAID
Date Receipt X
Will Ne a,lieam or fumm building nmpont.1 eyuipnrcnl a dee'vicwhich
-emit ltvsrdonm„ir comaanirunms an, ali by Ne Bay Arca Air Quality Mamaeenent NOII,FR-COMP I3HP OR 00.OE0 BTU7 TOTAL.:
LLl)wnct? ❑NuBOILER-COMP(OVI?R Igk1MXl BTU(
aad N,hvardmroas malaials ayNacnrm,urate Clapta M1 95ofte,CaliAIR CONDITIONER ISSUANCE IJATE
&Salary Code,Nation,25505.25533 ad 25534.1 uaNdmvamd dui if Be NEW RES IDI'NfIAL M ECB. SQ.ET.dm amamtylwvaa erwnt.that it:,mr rcrpruiNEhywraify Bra acvlamtri which muni he incl prior tem isstarcc of a Cenitvam d(kralwn y.mmd,l:em Date TOTAL: ISSUED IIP:
OFFICE