24520 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB ILDIN.-ELECTRICAL PERMITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. _ 24520 A C 2 O
�y/ya��j/�� BUILDING PROJECT IDENTIFICATION G L� J
BUILDING ADDRPSS: ' �,/ r' V SANITARY NO. APPLICATION SUBMITTAL.DATE
1 S UNIT# LOTH l �'
OWNERS NAME: , 1 ]p�E: C( Cf :S Al
LI"ry1779� NC CONIROI.#
RCHITCT GINEER: LIC NO: I/q0l�'kImAmEs;
S.S: ❑
j CONTACT: PHONE BUILDING PERMIT INFO
ELECIRIC'�W FEE
BLDG ELECT PLUMB MECII
PERMIT ISSUANCE05" � � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESID AL
pCZ Ihereby arfirm Jur lam Uansed undm povisicnsofaapa9(commerwingwitn JOB D^ESCRIPTION
=OF fulfane]eMJ MeffiFOA:R�fHCIPS
BwirussW Pmfeadnna Code,and mylivrnteisin1PANELS
1P TO �� �
¢Z V Uc.N
vFi¢y Cm.a
Z O,,Q DECLARATION V AMPS REA $/SQ,FT.
c z—W I urtdauud my plans twl l><n.se m pabr tttmda A L. I N
G SELECIRICA
¢ M� wMPafa.jSe PECIALCM
PUTER
�yae¢ OWNER-BUILDER DECLARATION R
XdXowu 1 hereby aff m lion 1 aexempa
len die Carim
nns Ucerue Law f
am tM1e
following tsan.(Scctim]0313.Bminem vW Profnabu Cade:Any cirymmanty INP. )R IF.INiT.
t_t'--C which rtaN'va•pemdt m a#utraL user,improve,devrolish,or repair anY wpaure
fyWW 7 prim w iter iauurce,aHa rearyires die.mlicam fa such Perish to nk•aigrd stuamenr POWER Y J
vl
,<0 p Jur M U IittnaM'entant to tM1c Pmvuiom of the ContrectNa Licmre Isw(CNpa
yXmyy.in SWIMMI POOL F,LECIRIC
ts. ( fwiNSatinn]000)of Uvisim tofthe BuunenaM Profesaiom Codel VALUATION
W_y orJw M1e iseaemp Jrrcfmmard tM hada for de allegMeascol" n.Artyvialetionof I
FZQ Seeiioe]0313 by any applicmt for a Permh subjccn Bieeppiant tie civil pcnnityof OIfILI:I'g-S CIIFS-FlJ(NRFS l� r�
h
Tont mine Nen fisc hatches]dal $50
W ( 0).
KETAL ELECDt . . ` (J
ce ❑ 1.no mrofthepapeny,mmyc Wymwithwegcsm NcbsdecomMrn , NEW RFSIDENSQFTSTORIES TYPECONSTRUCIION
y3— win do Jsc wink.udc: he Carhismnintcdcdasawcloce,ma Sec.to an owner
erd Rvfessi«u Code:The Cawacrda Lircue Law daa mt apply to an owrra of
prcp ywMboJds mimpava dsrtm,,vM whodonauchwvtM1imrellrc Nroughhis
omatiploym.pmvidW thntaach impravasnuuc mtinreMedorofferM fa sale.IL
GROUP RFS.UNITS
however,the W Bding m improvemeN u.dd wi,hin me lcvafcampledon,Neowr,.r- TO
buJ will hove rhe burden of proving thin he did not bdW oc itnpave for purpose of
ak).
❑ I.mo Nffiepopery,amexNwivelyca tingwiihlicamiconv w QTPLUMBING PERMIT FEE [o APN
Nwaruct rhe rojest(See.7W.Busucm erd Pmfeaionx Code:)The Coo.her's PERMIT ISSUANCE
l�reme Iron doer Tont appl Y to an ow tier o(InopmY w M bui Wx or mpwa Naeon,and
who canhaen fon such pojeeta withaconew,"s)IiatLad p rauwr to the Coweetess ALTER-DRAIN&VENT-WATER(EA) FEESUMMARY
Livrna law.
❑ 1 am exempt order Sec. B&P C fon tM1u raven BACK PLOW PROTECT.DEVICE OUTSIDE
F
SANITARY V N
b mr Date RECEIPT#
DRAINS-FLOOR,RUDE.AREA.COND.
WORKMAN COMPENSATION DECLARATON SCHOOL TAX Y N
❑ em' dBrm JutlMreacrniticoreacl co,, twaclf-imu31aardf tech FlXTURIS-PER TRAP I RECEIPI'N
Wmkcn'Compcnurian lwunra:emaccniEM copy themf(Scc.38fY1,lab C.)which PARK FEE Y N
cover,all arploya'a under Jda prmiL GAS-TA.SYSTEM-I INC.4 OUTLETS REC7EIPT#
Policy Y BUILDING DIVISION FEES
C Y GAS-IA.SYSTEM-0VER 4(EA) PLANCHECK FFP
CeniBM mpY u hcaNy famished.
Cervi fed LWy is TIM with Jse city inrpecdaa diviairm. OREASP/INDUSTRL WAST:INTERCEPTOR GRADING FEE
CERTPCAI'ROp F.KEMMONFROMWORKFRS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This wctimrml oabeconsplaMifthe pcmtit is formmhuMrM dallan(glD(i) SEWER-SANITARY-STURM EA.200FT. ENERGY FEE
or Ern.)
T cmify than in the Pcrinrmwax of Jc wart rah which 11his peri,is isauM,I tall WATER HEATER W/VINTA?LECTR
ma employ any pnan in any manner ser as 10 henna: suhject to the Worker: PAID
Coni, a ationlawanf Celifnmk. Date WATER SYSTEM/ PTING Dele Raeip♦
Q z Applicant
NOTICE TO APPLICAM:IL akc,aAing thin CcniOwtcnf liseooa ,pm elnuld NEW RESIDENTIAL PCMB. SQ.FT. TOTAL
[n b ctubjectto the Worker'.Compena...to awn Moxa of the lad.Cade,you man
a > fuMwitn comply won such povisimxmthit permit shoal hedmrcJ rtvnkM. BUILDING FEE
Ft1 Q CONSTRUCTION LENDING AGENCY SEISMIC HE ' �'
z I hewhy efina tnv tMre is a caam coon lending agency ftx the pmhmru cof ELECTRIC FEE
U Q the work for which that ltemiir is inns)(Son.31)17,Ci,C.)
Icn asNwu
Lm Mr's Addret QTY. MECHANICAL PERMIT FEE PLUMBING FEE �w
W 1 ecnify,net 1 have read,bis applicmion aM ante thea the.hove information is MECHANICAL FEE
cnrrccL lagrarowmpy with all city eM n,anty mdinar,cu Wamtc lows releungto PJiA11T ISSUANCE, 7
_ huildingmnawction,and hereby vuWwis nprnemmivesorthls chy mens,upon,he
UZ above-rtmtionW praperry for inspectionry
Puoees. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We) ,one to save,irdemNfy"keep turmlem the Chy of Cup:nivo against
Iiabilitics,jWgmrnu.amUW espevawhich may in may way a arueagunn avid City AIR HANDLING UNIT(7`0 10,000 CFM)
In consegwn a of tM grm,dng M thio perm AIR HANDLING UNIT(OVER 10,(100 CFM)
Gtracc oa�G(�itkn2tt��
ignamrtof Applicm,t/Contnctor Due EXHAUST I{OOD(W/DUCn PAID
FIran,I.OUS MATERIALS DISCLOSURE
HEATING UNIT UM 100,000 BTU) Dena
Will tbePe Cuammo M unkiJdineacupw atuemheMleharardun mamriu HEATING UND(OVEe 100,000 BTU) AL
u blared by the Cuprnim Muucilvl Cade.Clupa 9.12,erd the lielth W Safety
Code,S ich 2533210] VENTILATION PAN(SINGLE RESTD)
❑Yet ❑No
ISSUANCE DATE
WEB Jrgglivv,torfuswe bullNrtgmvpantua equlpmrnt ordeWm whichmdt
BOILER-COMP(3HP OR I W,E00 BTU)
M1nrmdaus
aur co namirunta to bane l by th Bay Ata Au Quality Mvugerruru BOILER-COMP(OVER 100,000 BTU)
DiLria?
❑Ya ❑No NEW RCSIDENTAL MECH.—SQ.FT. j q
1 Noe red the M1vardav nraiu mil,mp,i.te uMer Chapin 6.95 of t1he {p�f' 6J
Ccalirmni.rkwn&SeretY code.satim.t vws.zss33 w zss3a.I nMcrvvtl ova NOV V 24 100
Weca;Mingdoe notcurrrntly neves n,M5 5. itumyil MNL
lim wmtifytial
ocvclatat of tate raalaircmcnH which must be met prim to imumac of a Ccnifiaew of /.
OcaaAarY VEL ) �. 1
Owr,cra auahodwl agent That, TC JSSUFDBT' �n
OFFICE