28140APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY 012 CUPERTINODUn.1"
DUII.DING DIVISION APPLICATION/PERMIT
.- hl.b'DRICAI.
PLUMBING.. MECHANICAL.
BUILDING PROIELT IDEW IFICAI'ION
PERMIT NO. q /�
2 8 1 4 0
DOWDING ADDRESS;
SANITARY NO.
APPLICAI'IfNI SUBMITTAL DAIS
0 0I To22E AIIe 995-34191 H IT11
LOT «
uU6 t 9 S
HtS NAME: PHONE:
S MAN_ L
RACIOR'S NAME: LIC NO:
NIC
❑
CONI Rai. N
RCIIITf:CT CCINEEH: eA`N CI.I1N :� AO RIH
.•ll Na.L
CONI'ACI: PHONE:
915-1191 QI1.
EL�CfRIC P�NA�1T
f •
FES
RUIIAINC PERMIT INFO
FILM F.LE PLUMB MCCII
KIN') WALTZ
PERMI'TISSUANCL
El El
LICf:NSED CON'TRACTOR'S DECLARATION
I herehy. al lion Lha 1 nm Iicensedalder pr.visinreof Chapter 91c.1nmencin{ with
APPI.IANCkS - REST DENTIA I.
UD DESCRIPTION
Swlioo)tkx)1 ul Pivislon3u116e Dmine..unitPr.fcssinnr C..4, unit lay license 1. in PANELS
lull fort.."'I ellcul.
License Claus Lic.«
01110201AMlS
Dae Cowrucmr
20I - INX) AMPS
ARCHI'I'Em's 11iCIA ION
1 unJerswnd my plans shill the used as pu Gourds.
OVERIIXXI AMPS
SIGNS IiLIiCIH ICAL
SQ. 19. 1-1.01314 AREA $/SQ, FT.
1
11 �A ^Ili ��
{ + Yii_
IJcenaed Pmferxional
OWNIi AR
SPEC Al, CIRCUIT/MIS
in.'N
I hereby Whon t1M n, exanPl Gum the Cummealrs 1 cense Luw for the
oo,' hunch.
ILlluwing leamn. .n )(II LS. Ihwincn and l'ndeninlw Csde AnY oily ase c.anly
TILMP. MIefER OR P( NST.
which rt. ' p[nniu„Cm.I.a.I. ahcr. il,Nnrvq Jenndish.m rautaymnwmrc
Trion sen issuanec,alw,myuimnhrurydieam for such permit mfl asi6neJewnnenl
POWER DEVICES
that III is licensed pursuant 1. the p.rvisio.r aflbe C.mractoA[.it dan lJw(CTapmr
9(.un neneiny witll5ccsinn ](MXB ul Uivisiunlof the pmima aJ sofcni.n.Cale)
Orthat Ie isexanpuhc,&.anawl1hC basis fm the dic,cO e-coplio Any violminn of
Yu1
ScOi. ]B)LSh Ilcem rosea tnubjecw then Iiemtit acivil why of
Penni PP F"
SWIMMING moraL2 RIC
OUI'LEI'S -SWIT ES I
VALUATION�—
J
nm nu sawnliveicprodollars ($500).
hundred
❑ Imuwnemllhepropeny,.nnycmpluyees syiNwN{autleirr lecompemnsi.m
NEW RI'SIDENTIAI. IiLIi tT.
STORIES
TYI'G CONSTRUCTION
.IH da he w.rk.eMldmnmcmrconm lmn eq.r. (mwle(Se .7B44,Bud.exs
w0 P1 fessiuns Code: The C.I.0 p. L w eppI to nn owner of
proper wlmbuildsurimprovesl Geon. .f_ wok Id. If. droughlik
nv pmyeea.proams.d clvew limlmnidedI e,edforsi If,
OCC. GROUP
RES. UNITS
howe,B.Imiidin{ i w1ain.rpyeirofcompl i.n,lh.owncr.
hold..,it lavethe If lwdOdsa 6uldarhnp,o M,pmpnc.f
0i
1.llil
......file emerclidvglyemnt.u.'w men .U."cestO QTY'
:fiat. r y,
sf�uMalNQ rp"!T -
S'.
FLOODZONE
APN
afiBmu she psipet (S . ..l1ent end Prnresri cud.:). CaJ,ncmrr
Lice. LawdnacxnNpp xnow,lero(propcnywh uit Jx .I., ver lhemon,uoJ
PERMIT ISSUANCE
wh.c new+a far.ucb pojxts wish ucnnvalodsl' conedpunu. U.the COntmcHMs
Lice' claw.
ALTER - DRAIN&VIWI'-WATER EA)
- FEESUMMARY
❑ 1an esenyn order Sea , B & P C for this C...
HACK FLOW PROTECT. DEVICI.
SANITARY Y N
RECEIPI'N
Owne Datc
WORKMAN C PIiNSATION DF.CLARAT'ION
DRAINS. FLOOR. ROOF, AREA. COND.
SCHOOL TAX Y N
❑ thehy alfirm nh111tr ennifiemc.(comm�uo ulGimum,m aceniEcnm of
An Is •nwlin urwme ase a.enilied copy lhertofl5tt.lgaB, Lab C.I which
In allwnpinyerulderlhir 1.
Policy
Policy N
FIX 'IORFS-PIiR'fRAP
GAS -EA. SYSTEM I INC. 4 OVfLETS
RECF.1 N
PARK FEE Y N
RECr If -
111111 ODI ISION FEES
C.'n a ,
❑ Certified copy is hereby famished.
GAS -BA. SYSTEM OVER 4 UA)
PLANCI IECK I
GRADING .
❑ CnlilieJ copy is hleJ with the city impenion Jivi.ium GREASIYTNDUSfRL WASTE BIG ERCEPI OR
CERINFICATEOFIi%EMITION FROM WORKERS'
ORHASHIRAP
5011
COMPENSATION INSURANCE
17Nl: :E
(This seainnoced lmtbe: ...,,land ifth. permit it for.. hundrtd dollars UMOtB SEWER.SANITARY - STORM EA. 200F1'.
to lev.3
l.cnily that in din do.nwmeof tlm work I., whicWhislennil I, Issued. l shall WA IIiR IH;AI EH W/VEN'1'HLUCTR
not .ngdoY any Lemon in any nwnna so as 1. become r.bjc. m the Wmkcrri
PAID
Cmnpensalinnl.awsof Cddomia. Data
WATERSYSTEMTREAI'ING
Une Receipt
Applicant
TOTAL:
NOTICE TO APPLICAN F.lf,nRa amkinphis C.nifiam rd'EsenFion, youshould NEW RIiSIDFxrlAL PLMD. SQ. IT.
hcw.e subjcn m the Worker's Compcnsutiu. prnvirims of the LnWr C.J., you muss
forthwith.mnply with such provisions or this permit shall he dcemcd,evoked.
BUILDING FEE �e
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby allinn list[ IWre is a M..twelion lending a{ency fur the perfwmunce of
the work for which tnis pn til is issued (Sec. 3W7. Civ. C.)
TOTAL:
ELECTRIC IT �•
Ic,xlw's Nm,w
-
-
LenJdsAdJ,ess QTY.
MLl;HAN�CAL P., IMIT �.
FEE
PLUMBING F.
I ecair t 1hd I have tad this opplicalion and Mum that the above L.O.C.H. is
Co... IagmebnvogJy winhull oity.wl moony ordarinc.aulmme lawsnlmi, m
PER MIT ISSUANCE
MECHANICAL. FL'
CONSTRUCI'ION'1 %
h.ilding conal union. and hereby uulho,ize representatives Of this city la enter 11 Ishe
abovementioned pro'c"Y far inepectinn purposes.
ALTER OR ADD TO MECIL
I Wel ugly m save, inJcnulifY it keep handless Ne City of Cuparti.0 agninio
licehilitis,jwlymm�...casuundCspvC.,wniI on 'R:R voyac... c.,doo.id City
AIR HANDLING UNIT(IO IOJXX)CI'M)
m Con.'.C' ;t Iw'ranlin. I. flit cm'.
a«a ,J
AIR DANDLING UNIT (OVER 10,(MCFM)
PAID
'S,nctoof it App inunlcnnuaao. Use/ EXHAUST HOOD W/U11C1}
HAZARDOUS ERIALS DISCLOSURE
III: IINI'f (TO 111B,1NM1 p'f111
❑m. ReceiplN
It '
Will roc applicall or tome build., nvvpao Mort Or handle baewd.us lnwerl.l
as J, ineIIbyfCG..pertin.Mt icil"'I Cole. Out,., 9.12, ould'a health ad Safely BEAT! INC, UNIT (OVER Its) had D'I'U)
Code, Section 23532fa)I
❑ Ye. be.,
V1 MOLATION FAN (SINGLE RESID)
DATE
WilUhca licamrlmurc builJin nose.. ui forJwic.s whichcn111
ser «Occaren y proal
IMzwdnus it mmaminunu use Jdinnl by the Be, Aren Ai. Quality Munugenwm
Mark.?N
❑Yes ISN°
BOII.IiR- COMP(311POR IBBOX) BTU)
BOILIiR- COMP (OVER B10.00) BTU)
NEW RESIDENTIAL MECII. SQ. FT.
01 •j9Mark.?' Ju i
I have mad dm Ilaradou5 nwmrids rt'y.irelnems older Chapter 695 Of the
C.10"O i. 111141h& Safety Code, Seminar 255(15.25533 and 25534. I .O&,stund hin
VVI tiA
CITY UF
itthe GuilJin1h nw lyhaveamnun Inns itis Iml.00 It . mnotify nhu
lied' It to
Omcupum use @c Icy., work which non n n prim m irsuuncc ase n Cenificmc ase
c.11pal,cy. G i lr
ISSUED 8Y<:-
Own.r or nu urieeJ ugem115Dae TOTAL: