25567 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOul"DINIF lrCIRTCA. PFIufITNo.
APPLICATION/PERMIT PLUMBING-MECHANICAL 25567
BUILDING DIVISION - BUILDING PROJECT'IDENTIFICATION
BUILDINGACDDRESS: � SANITARY NO, AAP1RJCA^Tg`NSUBBM�ITALDATE
0...) J Lam,/r UNITN LOTH fig_ /(1JJ
OWNC NAME PHONE COMB CTOR'S NAME' LIC NO: 6
/v� LN
�ARCfI1TTCf?NGINIJ"R: LIC NO: ADDRESS: ❑
CONTACT: PHONE, BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
BLDG ELECT PLUMtl MECEl II
PERMIT ISSUANCE ❑
LICENSED CONTRACTORS DECLARATION APPLIANCES-RPSIDENTTAL TOB DESCRIPTION
1 hereby affirm that 1 sumuni
BcerW uMer pmvisimnaaf Cluper9(communism,with
µO100 Cloo
Sccnoeluf Uirisimm3afthc Bwirca and Rofealaru Code,sed my limuefs PANELSin pAS �
C� full Tac tan eRm. tek
Q' Licrnu Clw IJc.N IIP lO 200AMP5
vEi?y INm Com.cla 201-TODD AMPS
zONZ ARCHITECTS DECLARATION OVER IoIUAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O z_O l umdcmutd my plate.shell W ueal a Public rccooU.
�yl_J SIGNS ELECTRICAL \
Q�$� Licrn..N Pmfcuinnel
KK OWNIJt�BUROFR DECLARATION SPECIAL CIRCUIT/A9SC.
ex'OaU I hereby affirm thus I stn exempt fvn Ne Cometsors License low fat the
W 3ooF followingtmxn.(Savon]03L5,Bucitrv.od Pmfeaiom Code:Any city o.uvnry TEMP.MITER OR POLE INST.
o� which reyuves a permit to consuuct sites,fir,,n e,demoli.b.a mpeif.ny ecsomme
Cm2$ piorto its issuance.Mw reaffirms the applicmn for such permit b rile.sigmel sutmem POWER DEVICES
w K OO IhM he u licenund pmxuant to the prruion of the Convacta'a I.icrnr I�w(Chapter
aax P4 g1,.ocin SWIMMING POOL-ELECTRIC
( gwlmhhectim]000)of Dlv'uim forthetlmloess utd Rofyvi.h Code) VALUATION
tKy S,iim731.ehy nya,plinuf the b.maitsrt Orest thedeaemientto MY.iol.tim of SW_
�7Y Sanian 7031..' wyuPpliunt fnrapermit wbjxuthe epplican[becivB pvWtyof O�EIS-SWITCHES-FlXNRFS Vti/v'1/�)
$'0 1Mn rive hurdrtd ddlue(5300). NEW RESIDENTIAL FT FCIR _SQ.PI'.
p ,esown Ice . ropmy,amyerryRoyeeswithwagautheirsoemtnpauaum, STORIES TYPE:CONSTRUCTION
ill WOn wvt,atd tk urvnurt Ern lnterdM aroffaed(mule(Sec.]OJ4,Buainw
Prfasiom CUJe:Tse Cmvamoks ua+ue Lew diner int spp1Y to m owrmer of
progeny who Wilda crimproves thereon,end who dea such work himwiror Wough his ROUP BPS.UNITS
employees,providedthat suchimlas sold masons imar ofdaoffetr.theownr-
balchmwwevc,mlllhve thegmimpmremem in adde Wd onemem ofmmrowe for theowrvx- TOTAL
Wilder will love the hudm a/povin{JW he did era bff m impovc for puryae of
wlc.).
❑ I,uownerallW property,vnaxcluvvelycmvactingwilhliccnml amtractaito QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
con,trvet the poc*1(Sec.](,M,Boniness sad Profeuiws Code:)The Cmmcbr's
UremeLswdoesam applyto nownaoflaopertywi Midsaimpmvesthcmmm,.nd PERMIT ISSUANCE
wWvautrcufaauchlvojecuwithvcmtnctm(Q lveresedpmsu.mto Ne Contrmtor'. ALTER (FA)
tJcrnsc L.w, FEE SUMMARY
❑ l un e.emq under Ser. .B&P C fm this ream BACK FLOW PROTECT.DEVICE, OUTSIDE
SANITARY Y N
Owner Dee URAWS FLOOR.ROOF.AREA.CONU. RECEIPT#
WORKMAN COMPPNSATTON DECLARATION SCHOOLTAX Y N
S ❑ IhembY aRmm Natlhnve•mtifcau ofcrosent to self-imwrt.maceni0cate of RECEIPT#
Wokcri Cmr nsuion In.urac ed
pc elTY tltcmf(Sec Jg00.1�b CJwhicM FIXTURES TRAP PARK FEE YN
covin MI employees oreler this permit. RECEIPT'N
Policy♦ GAS-EA.SYSTEM-1 INC. 0UD£IS BUILDING DIV ISI
Company GAS-EA.SYST -0d(EA) PANHEK E❑ d
❑ CatiBW appy is flet wiN Ne city hrapee4m diviaim. GREASPIINDUSIRL WASTE INTERCEPTOR GRADING FTE
CERTIFICATE OF EXFIAFHON FROM WORKERS' GREA$ETRAP SOILS FEE,
COMPENSATION INSURANCE
mi.semlan rml ml be covtplmd if the PmMt u for.bmvrbcd dolWs(5100) SEWER-SANITARY-STORM FA.2WFT. ENERGY FEE
a Ica.)
I ovtify that in tle pMonnarce oftbe wmk fsr which thupenit is iaucd,I"I WATER HEATER WNENT/ELECIR
not employ wy prnum in any trattnner ta,u an becote subject an tle Workers' PAID
Co emationliwa Of Celi(orni.. Dene WATER SYSTEM/IRFATING Dan, R.ipty
O Z A"11.O NOTICE TO APPLICANT.ILafur makingthie CeriOntcof Eaerptlnn,you shmld NEW RESIDENTIAL PLMIL SQ.FT. TOTAL
becuec eub*t to the Woker's Canpcnsuad. o fusion of tk LAS Code,you most
fmhwith comply with such Mvisions or lMs pmnil shMi W Asned revokW. BUILDING IEE
W z CONSTRUC ION LENDING AGENCY SEISMIC FEF.
Ihertby.flLm wt tlge u a<autrmr'Um moding.iency for the pufamenma
U O the work for which this pernu is iastd(S«.3(19],Civ.C) TOTAL ELECTRIC FEE
0 Irrdm a N.
IcnJ MECHANICAL QTY. MECHACAL PERMIT FEE PLUMBING FEE
I e miry ehu 1 mpl miL this apvhratim amd.tate that n<eWre lows
rmaam i.
rnttn�v lagrtzmrnmply with Ml city Islas]mmry ordimeea and nate law.rtlnorrgn PFRMRISSUANCE MECHANICAL FFE
�' V] railio,r.mrrvnim,and herehyaudc.iec rcpracnWtirn of this city tcemsr upm use
U Z abor<mmtioned ryoperty for impectimr puryo.ce. ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We)egret b anrc.indemnify and kap harmless the City of Cupenun agelnu
li.bilitie.jud�Pe��-� uandeaprnvw 'htmylnanyweyacmuesgsimtsaid Cit, AIR HANDLING UNIT(TO 10,000 CFM)
in on. gyme'(o(tM grai of thing. t
AIR HANDLING UNIT(OVER 10,0110 CFM)
ignore of Applicsm/Cmtmcior Me I;XHAUSIHOOD(W/DUCI)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(fO IW,000 BTU) D. Res6,
Will the tariff.,or future buffing oavfcos Hae or ha dk hemdau trweriM
av defined by the Ca,mo m Municipd Gde.Cheper 9.12.and Oe Ilulth ani Safely HEATING GNU'OVER 100,000 BTU)
Code,Section 25532(a)7
Yo E)No TILVPNATTON FAN(SINGLE RFSIU) t
❑
Will furcar udinm BOILER-COMP CIIPOR 100.000 BTU) ISSUANCE DATE
appiiranta g cµwnsuxequipnmtadcvicerwhichcmit
0Do"is it cmuminems an derived by de Bey Arae Air Quality Management
BOILER-COMP(OVFR 100,000 BTU)FIEly
/�
Yea No NEW RESIDENTIAL MECH. SQ.IT. P A I
I have read the havtdous mmm id,aNuirmomnu under ChWa 6.95 of the SEP ;�0
Cdifamia I IeMth&Safely CodeSm
, iou 25.5(15.25533 and 25534. 1 undmtadw O1Nk
if the Wildd
ing oes es ncurrealy love a taunt fast that is u my respauibmousyility to mousy ` k��
rccupmmt of Je rtquimnxmu which must he rmt Irimc to isauwtt of v Cemfratc of
tk<uparcy. I�IVu
Owneraaudtais ifgem Date TOTAL: ISSUEDBY�
OFFICE
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