25091 APPLICANT TO FILL IN INFORMATION WITHIN,RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOAL PERMIT NO.
BUILDING D1VIISION APPLICATION%PERMIT - PLUMBING-MECHANICAL n C O(�
- ;p«,•rs1;xBUILDING PROJECI'IDENTIFICATION• GJ J
BUILDING ADDRESS: Q Q ^•A: I; 'y�'u ._ d(y' 30
/�/ �� SANITARYNO. APPLICATIO�N�SU�BMITTTAL DA
LG 'f�/ •�/+erI F/ v_ _ /'f'/NUN`IT7x. / .. LOT / x1644q ` ix L}1tg9.
�OWNERSNAME:• PHONE CO R'St•I E: J `V
IWARCHITECTBiNGIN 'LIC NO:
. . .QTeY �A t I+ ELEC,I`R'p. >• ,�/N,Cy4M' � ' . /}kl i ❑
'ONTACT: PHONE: .. 16 PE
_
"BUILDING PERMITBVFO_."r':"=.,
`: •�'• ;•' •_ ,°•' ': ' "'- BLDG ELECT PLUAI ME
PERMIT ISSUANCE �� •L��/.
LICENSED CONTRACTOR'S DECLARATION .APPLIANCES-RESIDENTIAL TOB DESC ION
CCZ I hereby affirm Wt l ate licensed under provisiomol'Clipter9mm
(cacmingwiN
WOO Section 70001 of Division 3 of the Business and Rvfessiom Cade,and my license is in .PANELS
FIs;- v\ )
CU� full force and ef�fe)tf?Jf./
<" License Clam_Lm# - UP TO 200 AMPS
Injy Dae /-��_Conlra. p' 201-IOW AMPS
-ARCHITECT-SDE TON SQ.FT.BOOR AREA 5/SQ.FT.
OVERT"AMPS
02:-a l undenund my plans mall ns,used as public records, J.
SIGNS EI.ECIRICAL ` 4-,v
YE" Licensed Profeuiowl
�paz¢
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. �h2.
Wi nereby n.(Se tim I am exempt from she Conmacs Co License Lam.for Ne 4�� /
1- C'ss whichoo,ime d.Perii Socaus S,Businusandone.deiolu Code.Any city surals iy TEMP.METER ORPoLF,INST.
I_LLOQ whichreaussu npermit acconstme eller.improve,demolish,I.[,a siig ed s ..a.,
f�Y tpric'mhat
its icamenteursunt to the
Neapplinsofurnish CopemtoCs Licoaignad uatemmn POWER DEVICES
C `p Ihut he is liccnscd pursuant m the provisions of the She Bu dors License Lawns Ccdcr
aX�L 9lrommcncing with Smion]000)of Division Jof the Business and Profasiom Cade) SWIMMING POOL ELECTRIC
VALUATION
u^y
or he7031.5 by yapplimand the bermitsbjShe
ctsalleged the applicant
Anyviolation
peewee of OUTLET'S-SWITCHES-FIXTURES
FZQ Section 7031.5 by anyapplicantfor apermit subjects the applicantmacivil penalty of L. •�
'2p film
nm m1.eownrofhe TodMlan(SSW). NEW RESIDENTIAL ELECTR SQ.PT. STORIES TYPE CONSTRLMIU
`z[-•-. ❑do
wrk, dteproperry,e,Find ploymxwithwaguusheirsolecompematiem,
will Pr Newon.Cde;'phe Structure,Find imm�dMofa.4 an a,],raide on
owner
IIcea � q
rviciess
and iry who
Cada The Cluves the rem,License Law doh not apply lf,t owner i.
propenywho huildsorimprovcs Nemoa and wM1od«ssucM1 work nimaelforNrougM1 nice OCC.GROUP RES.UNITS
ho%emplos,building
ori Wauchimprov wild
wit ase ne intend to mpletio d thm ow, rL
however,Ncavethe burden of prtemuhat he idnoeeyw or improefar purpose
T T
i builder will have the burden of proving that he did not build or improve for puryose at
mlcJ. Nv; "a:;f y. wa-av¢rxpy.argK r�„�,..a ��yy
dda' PLUMBING PERhllT-•.•'�-%' FEE;p„' FLOOD ZONE .\PN
❑ I.uowncr ofthe propcny,atm eaclusivclyconanneing with li«mdcon=,Omto kyr.>r. >.x���aa•am,:x z^^r:"x+iN_` '/'--
common,the project(Sce.]I)se,Buins.and Profieriau Cade:?The Carivactm's PERMIT ISSUANCE
License Law J«snot applyro wowncrofpreperrywM1O Euildsmimpmves Hereon,and'
who contracts forsuch projects with occultations)IiceueE pure maSto W Contractors _
_ License Law. ALTER-DRAIN&VENT-WATER(EA) ":+a,:''' �i,l,FEESUMMARY:.'': �:•s�'a;)•'i
❑ 1 am exempt under Sec ,B 8i P Cfor this rtason BACK FLOW PROTECT.DEVICE I I1 SIDE FEE5
_ SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
_ WORKMAN COMPENSATION DECLARATION. - SCHOOL TAX YN
❑ IrebyafmlM,lhveacrnfimwofconsettoself-insumma«atific-s_to.,oL AS ..S�TMIR--AI pWCf7 y I RECEIP
T#
Workers Comtionhuu «macmificdcopJeraf( PARK EE Y
N
RECEIPT
8TETcoven al employ«'a under this penL BUIDIViSJPullcyx ON FEE
S
Company
PLANCHECK FEEis
[ICenifN copy is hereby famished.
❑ Cmiriloic i,filed wits the city inspection division. GREASEUNDUSTRL WASTE 4-RIEFtIM GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERSSE TieR SOILS FEE a �'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is forces,hundred dollars;(SIM) SEWER-SANITARY-STORM EA.YWIT. ENER E �x
or leas)
I cenify that in the performance of She work for which this permit is issued,l shall WATER HEATER W/VENgELECM
not employ any person in any owners so as to become subjcn m.N<Workers PAID
,Z Compenntim La of t Da¢ '— —�`� WATER SYSTEM(BEATING Dam ami 1p I
Applin I
Z2 NOTICETOAPPLY ^ d f Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
^ become suhjenmshe Worker'aC Ilan provisionsof Ne LaboaCode,you run
forthwith comply with such provisions or this p<mit shill he deemnd revoked. BUILDING IEE
0. (] CONSTRUCIONLFNDTNGAGENCY - SEISMIC FEE
z 1 hereby affirm that there is a enmmoeion lending agency for the perfornance of
Ne work for wh<h No permit is issued(Scc,fA],Civ.C.) T 1 ELECTRIC FEF.
as
lander,Name 1 / - ._ toss,':.'i..• ruts.:r:xs u- a y +y,�a 24" .}r' PLUMBING FEE
F Lenders Adders QTY MECHANICALPERMIT A i1,wIFEEi+Jk
V 1 certify Net T have reed W pplicm end sum that Ne valve information is y`”� •..:*'vmen ,axwe t -
�” fJ-1 correct I agree to comply wish all city and county ordinances and sum laws mlaung to PERMIT ISSUANCE MECI IANICAL IEE
F" building comauctioo,and hereby authors.repnracnutiviesaf this cityto cmeropbn the CONSTRUCTION TAX
U Z above-mcmianee pmpcpurposes.,rty for inspection puoses. - ALTER OR ADD TO MECH.
(Wel agree to save,indemnify and keep harmless Ne City of Copious,against
liabilities,judgmenu,cmuandexpeam which may in any way aeemeagainst sod Ciry AIR HANDLING UNIT(TO 10,000 CFM)
ncome4ucn lin ofdYa mdL _
t - I AIR HANDLING UNIT(OVER 10,000 CFM)
Sp
Si,nanhczrAPV.VCmmxctmr Data EXHAUST HOOD(WMUCC,
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100.000 BTIA Dae Rcram'#
Will the applicant as future building occupant nem w handle hazardous material HEATING UNIT(OVER IW000 BTU) Tf" w-`
as defncd by the Cupenino Municipal Code.Chapter 9.12.and the HdN .
and Safety s
Code,Section 25532(x)?,,,���JJJ VENTILATIONFAN(SINGLERESID)
❑Yea 14 N
/ BOILER-COMP(3HP OR 1W.000 BTU) ISSUANCE DATE
Will Neapplicanwrfummhuilding«cupanmeq
seuipmemadeviceswhichemil
arardoas dr.mnumivnu u defined by Ne,Bay AmAB Quality Management BOILER-COMP(OVER IW,000 BTU)
sdo?
❑Yee, ��No � - NEW RESIDENTIAL MECH. SQ.FT.
a: 1 love read the It�jaaarrd�w`a material,"sinal under Clupar 6.95 of I ]
Culifom a Hands&Safcry Code,Sections 25505,25533 and 8516.'.1 andeeend That
if the buildingd«snot curnen w haveam be Writ is mymunce.iliryenficat Ne
jut
Oma oncl�i ..•� Z�'�s3 -
Oxnam'.wN6rr2 eel. Y Dae- 'LoTiOl. ISSUEDBYOFFICE
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