S 1977 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTIN(l HUILIIINI:-ELRCPRIGI. FI:R�ITr"° 1977
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �`J
BUILDING PRIIh:Cr 1DENTIFICA7LION
BUILDING ADDRESS: / SANITARY NO. APPLICATION SUBMFITAL HATE
O Z T,.mow v� r o r-�Iy
OWN'S NAME, PHONE, CON' A )R'S NAn1P LIC NO:
N/C CONT RULs
ARCHFTECLIENGINEER: LIC NO: ADDRESS: ❑
COIRTACI': PHONE: �Z 0 BUILDING PERMIT INFO
❑ Co1L4allanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME(
o '996-zi ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
I Hereby orient Inas 1 on itan.sl ander pnwlekw'or enarmm
ler 9 faneelina JOB DESCRIPTION
IO1�a1IYZ wish Sernm700(b.l Divisive J oflhe 9usincse at Proh,.ka,Code,rad",blies I RESIDENTIAL
FcB in full lM1ree nd effect. !n /J � r[^ PERMIT ISSUANCC 0SI1)WL ❑KI ME[]IN REMODEL
ZUU Liccn.v:Cuss�LieN_-. 7 J .J APPLIANCES-RESIDii C1 ADDITION ❑PLUMBING RE-PIPIT
a a Ir Ie cwlm,Iao
ARCIII'DICTS DECLARATION ❑MULTI-HNIT ❑STRUCTURAL.
7.ONZ IuMaamM my planuh.11 bcuv.IioPublic mcnrds PANELS MODIFICATION
OZNa UPT0200AMPS ❑INFERIOR ❑CHIMNEY REPAIR
W Limned Rofi—o�nu1 201-IIXXIAMPS IMPROVEh1ENT C]SWIMMING POOLS
%Y�J OWNER-BUILDER DECLARATION pyliR IIXXI AM1115 ❑RAID REAIODHI FPAIR DEMOLITION
C w Q I hereby uMoa nim 1 um-ro"fmm ole Comrai I.Iccnse U.forOa
lL a U fdhrving ma s .(Section]0)1.5.Busireas and Profexdau Cod,Any lily or county SIGNS ELECTRICAL ❑O'fIIEH
1x13 LL y which rcyuin,u peraot to earoo,abet,improve,demi i.n,tr mpr any.Petro. C
FLLaS Moro,its ix5vance.a.,myuirtnlhe opplinnl lm.mch l+Trout,file axigreAaatcmcnl SPECIAL CIRCUIDMISC. `
ft�}� tMIMi.BacnseJ pmwavmthc pmvisima Mlhe C'wtna«nFiceme law lCMlraV
�ap1 (cmnnicicing whh Section 90X1)ofDlvidan 3 ofmc lluxlnns aM l'rorc.imts Coc)tr TL' IF MEI'ER OR PILE INST, COMMERCIAL
a a o IY that he k emmpt therefrom end tM Iasis or the dleVil exeronaim.Any violation of ❑NEW I31.D(JADDH'ION' ❑DEMOLITION
x a' mm�
Sm ]1111.5 by any appliaatr aemtxuae aPlkan
n lot pitbjrcthe acrvll perah,of POWER DEVICES
aI-may ❑TENANT [I FOOD SERVICE
Zi not mxe than for huMmd dollars(5510). IMPROVEF P.Yf
F] La.nwnernuhe progeny.nr my anploym wiN wn�nmlhnrsdernmpcmvion.i SWIMMING POOL ELECTRIC
fF� win do the wor4.urld l M:nmmmr,isnot alandcd and fclaW for iala(.S4o,]IILI,Bronx. ❑0'1}IER
W> and Profccal Cody:The Cam «
xtx LiEss
cense 'does nes apply to an owner M OVHJTS-SWITCHES-IIXTURFS
lou,arty who build,or in,00,.Ncrvnm,ar.l no downs xueh wo,k hilmdt'or Ihmugh
Aix own cmployccx,eremitical that turn innrawmnu are Nor intntdal m nBcml for NEW RESIDENTIAL ELECIR Sit PI'.
rale,If,Mwe\v:r.the Wiling oriWrovemenl is sol within col y=of emrlpletion.the (.FT.FLOOR AREA S1SQ.IT
erMiiWcr w11 Mve the locco of proving Ihat be did tel W nJ or improve for pun
pare of,ale.).
❑ L:a oftb,pn,,ria ulunivciy a,olaala,w llh ki,rvM mnlaonts ,, TIYCAI„
aalelNCl ILK P.ker(S+�704-1.Basin,,and Prafexsitms Code)Tho Cono.is Li-
mclmwdt,notapplyoranmmruI oeray wW hot ldvoein,,oci detain,ata QTY. PLUMBING PERMIT FEE
wMl conitnetx fee such projects with a,ontactoi liremed Panora to the ComrucmEn
IJce.Haw. PERMIT ISSUANCE
❑ 1 no,cx,a,it ender Sea. .B R P C for Ia,reaaoo
0..mr Date AUTE-DRAINey VES'-WATER IEA) VALUATION
WORKER'S COMPfiJSSAI'ION DECLARATION BACK 11-OW PROMCI'.DEVICE
Thereby ullient under p<or of pcUo7 o^e n(dm rolik a.,dealarallo . Z b� A
❑ ompen- DRAINS-ROOR.ROOFAREA.COND. STORIF Tl'PECONSfRUCTION
wion,ar prmided for by,sliw 3]00 of the i�Cade,fm the Icff,nnaree of III,
wink fur which Ihie pcnnit'o i�u.W.
FIX'I'URIS-PER'I'RAI'
1 helve earl will nminuin Wei Canpensnn,n boar res,as rryuirtd M Swain
3]1X1Uflnf LaM Gdc.Gn the rfnnnarwmfthe work lorwnich Ihie lie
, pe Mmis+oed
GAS-EA.SYSTEM-IINC.d OU`U. S
XC.GROUP AIN
My Wa policy zS
y . _P
GAS-EA.SYSfEA1-0VER1EA)
CERTIPCATE 01:GXI3MPHON FROM WOkKI',RS'
COMPENSATION INSURANCE GREAMERN)USfRL WASTE INTERCEPTOR
BUILDING DIVISION FEESTo.,vctiun nuJ txae hcomplmM it the panel,is Grant hroWretl dollars(S IIX)
or lay.) GREASE;TRAP
PLANCIHP.CK LEE
-
in
lhatmlhe a flM wink fm which this permit uissueil,IJWI SEWER-SANITARY-STORM ITA.200 IT
nm employ vnty remmi ymfRmr ru nr to h'cune nuhjlx'I mtW Worl.en'Coinpam ENERGY FEE PA
ZO rtplµu f WA'II:R IIF.ATIJI WNI:MI'll?LI:CIIt GRADING FEE
h NOTICETO ARPJCANT: .ell nvling thin CcniOcam of 6cmpiun,you sMwIA WATER SYSI f;M TkIiATIN'G
h" ; necom snbjea to IM Wei C ntpenvtion provision\of li Labor Code.you maw SOILS IEE
Wfonnwiln comply with at¢h pmvisinnannhia prnnit nnull WJttmnl rcvnknl. WATERSIiRVICH
a0
7Z CONSTRUCTION IJND WOAGLNCY NEW RESIDENTIAL 14_4111. SQ.17. PAID
V p Ithereby hi,htmlh�IM,is rod(Sec.3( lemling v5ercyfm the pertntmuce of Detc kneipN
the work be which Ihlr p:nnil is icuM(Sec.3(S7.Civ.C.)
F' lamkfs Name 71YTA I,:
Landch Adhca TOTAL. IBUI EDING PEC 6
(~ I elify that 1 ro,rtvd Inas applicmon nM at,that the a1Nwu illaouunaxt t,
N corrtcLlegrtemmmply with ellmD and cwmy oNitlarccsvM wvclm mlmingm TY MECHANICALPIERNIIT FEE
u z buihling annntnetim�and Wrehy uulnnns nynaxmwffvcr of thi.city trwntcr upm lW Q SP,I$ IC 3 VICI�
,hove-mcmiwM ptnpm,for impcctitm Furryea. PERMIT ISSUANCE
(We).91.move,imlenmify mod kap hamde,x the City of Cuperdno nEdmt IC FTE
Iiabiliiics,Judgrose ,anus"esRTscs.halt may i n troy vay acauc ag'.i ro,.ad City ALTER OR ADD'REM FC1 I.
in amryuence of the granting of lW,permit, V P pMBI�5P EFA III XS!
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO 10.IX(CI4p
SOURCE REGULATIONS, t MECHANICAL FTE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUC190NTAX
Signatum lCAMlkunaWasmetm D.te EXHAUST FOOD(WMUCT) HOUSING Nil UOA510N FEE
HAZARDOUS MATIB IAIS DISCLOSURE
WHI lheit'liavnerr future WiWins tecuPaat..or handle hazardous material HEATING UNIT(10101,000 BTU)
to.dclimvl by Ile Cupcnitm Munlclryl Coca,Chapter 9.1:,and the Ilealth and Salty
Coda Selliw 23532(.)9 HEATING UNIT(OVER (10,00)If ai
L]Yes 0N I I'AIIJ
VENTILATION PAN(SINGLE RCSIM will RcaiplN
S
Will IM a sFic-art,or fiandre Wilding..,aaru lac rytripncnl or dcviie%which
a
rollbal cVa,en cwtnmmunherrclibyIle Buy Arca Air Qualhy Mwavcnent 11011.Ek-COME(31111 OR IIXLIXXI B'M)
District I o
El Yea, FI No HOII.ER-COMP(OVER 100,000 BTU)
AIR CONDI HONER
I hove read the h^,a^I:u nwteridx rtyuitentvn,uvla CTvlxab45 of the Cdi- ISSUANCE:DATE n
4miu Health h Sufvvy Coda K,,wra 25511.5,25333 and 25534.1 uvGarmand dot it be NEW RESIDENTIAL ME-CIE. SQ.F"F
Wilding ticn MM awrtnlly M\c.tenenL lMl ilixmyner,, .ibllilylo nMify lhC rccvlsmt I (f
of the rty Arcownls which must W neat priorin lxewci nfv Cmllicne oflkculurcy. ` a (�
Owmt oriablur eJ ngem Ilse TOTAL ISSUED HY:
OFFICE