25034 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINOUILUJIsti-hlKGI KICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING \IF. ENCHASICAL 25034_
BUILDING DIVISION BUILDING PROJECT IDTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE.
O z UNIT♦ LOTH J/' 3
WNER NAM PHONE CONTRACTOR'S LIC NO: V
_ WC CONTROL
CIIf1ECf/QJGINEQR: IJCNO: ADDRESS: ❑
( _
'CONTACT PHONE TY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
`4.:'• Q
BLDG ELECT PLUMB MECH
PLIRh1I71'ISSUANCE 0 R El
LICENSED CONTRACT OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
FI0Z Ihcfcby affirmcostlmnlrrnsduMn and
ivmaof sCome, (dmy]te se
00 fullrocCmdefDirisiwJ of the Nurmaaand Rofeea'ions Code,ofd my]tense is in PANELS (�••�
yw� full rove effort.
Ia.Zw Iiuna Clac+ Lk.a UP T0200 AMPS
y 4 y Date Co t.o,, 201-1000 AMPS FLOOR AREA FT.
T. 5/SU.
7ONZ ARCHHECI'S DECLARATION SQ.F
I undnswid my plea shell M used a.Publicr cards. OVER I"AMPS
OZ— I
0tn(= SIGNS ELECTRICAL a ^ N
� F„ Li¢naud Pnormiorw
H< OWNER-BUILDER DECLARATION SI'HCI AL CIRCUITMMI Cf—
�°Oo. 1 hereby affirm that I em exetp from the ConwctaY,Liceroe Lew fm be,
followin,reaaon(Section]031J,Busifm and Prufe,fva Code:Any city maumy TEMP.METER OR POLE IN as ( I� L
which"none,a pemeit w ansnun,alter,improve,d rcolieh,or fepir any.xanurt
}� prior mica ivuvec.vt•^fryuke the appficvufu.ucbpenino Rkaaipd auwtnnt POWER DEVICES rl del
wzpp that he is Board pmauant to flu,p wiwons of the Contras«a Li¢nse l�w(Cheptn SWIMMING PIX>I.ELE TRIC 1��
6 X6Xo�C 9(commecei ng with Secdon WWI llivi,ion 3 of Ne Baines end lkokadora Code) VALUATION
yl^,o, a tion h u exempt thcfcfmm end be buiafor be alkBed exeropion.Any violation of
} Sction'IHJI.S VfLE13SWITCHFS- NURFS
F•3Q bRy any applicant�ornpmtit subjate the arplicmxtoecivilpwlny of O
oRGvenanartd ddlm gsoo).
Eo fthepopn,y,armyemploya,wiNwegeotkiradecwnpnmmtion, NEW RESIDFMIAL FJ.L'CIR SQ.FT. E5 TYPE CONSIRUCD
yII nhcw«k.vultM re stmnuis nximnrdrl neofrvedr�aek[Sa.906C.xn,incu
Pmraniom Cole:The Contnnofa I_icm,e law door non apply to an,cwrcf or
papeny whn build,m imlaoves 1Meon,cath who dove,aeh work himalf a through his
entployec,, os Wed that such impruverncncrvc not intendedaoRend fmssle.If, OCCROUP kinq,UNI[S
hmwcrn,the buidingm imposemem u rood within oat yev ofo0mpletion,the ow.-
Wildnwillnevetiedudesof that he didnm build m ion for f TOTAL
porins pore rama,ea
ek.).
❑ I.uowrcrofNnpropeny,uneacluvvelycontr.ctinywiNlrrnacdconurnanno QTY. PLUMBING PERMIT FEE FLOOD ZO APN
comtrun the Project(Sec.'1039,Bu.inea W Pcof ssmo,Code:)The,Contractor's PERMITISSUANCE
Licrnselsw doefxx apply tuwawrcrof)vopeny wlu build,arimlv.rve,thcavn.W
ljc.oLaw. - T'-racu for,uch pmjenawiNacmtfactm(s)lic=tud pmuann to tie Contncnala ALTERDRAIN&VENT IJFEE SUMMARY
❑ I am exefnpt uMn Sec. ,B A P C fm Nu reason1 FE
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Ihte DRAWS-FLOOR,ROOF,AREA,COND. RECFIYI'♦
WORKMAN COMPENSATION DE ON SCIIOOLTAX Y
❑ IhmbyarBfmthvlhaveac fitenofcar,cnttoxlf-ir .macinifinteof RECEIPT.
WmkenC avian lnsurvmz ornani0edc FIXTURES-PER TRAP
' ornPc^ ofry devaf(Sa.JXtp.lsb C.)whkh PARK FEF. Y N
cn,va all anpbyee'.mder this Pemul GAS-EA.SYSTEM-1 WC.4OUTIE S RECEIPT0
Polity♦ BUILDING DIVISION RIES
C—Puny GAS-E.A.SYSTIIA-OVER 4 EA) PLANCHECK FEE
❑ Gaited copy is hcnby fufmaltM.
❑ Ceified copy is GIM with the city ircWtion divi.ion. GREASEpNDUSI IL WASTE IN'T'ERCEPTOR GRADING R:E
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE.TRAP SOILS IEE
COMPENSATION INSURANCE
(Tldaaal{on ftad mtbe compinMif de pcmnit Mor.hundfad"Ifert IM) SEWER-SANITARY-STORM RA.200FE ENERGY FEE,
or len.)
I ccnify that in the perfofmwice of the work fm which Ni.permit u ivucd.I dudll WATER HEATER W/VENTIEIECTR
roof employ any ponos in my mama.o as to beconn mb ev no the Workm' PAW
z Comrcmvion lsw.td Glifomia. Dune WATER SYSTEM"EATING Woe Rocipt0
APrI'.t
O O NOTICE TO APPLICANT:IL ahen making this Ceificmc ofF nrtption,you,hould NEW RFS]DFNTIAL PI.MB. SQ.FT. TOTAL:
hscorm,mbjen to the Worker's Compcn.vion povisour,of the labor Code,you mo,l
foMwlN comply wlN ouch povuianm Nu p:mtit.hall bed may i BUILDWO FIE
0
(] CONSTRUCTION LENDING AGENCY SEISMIC FEE
L) z I hmby hie then elan is a=ed(Se,ion lmdCi,C.nny fm 0e perrmwn,c ar
U U Newonk fm which Ni,pmnit is issued(Sa.309].Civ.C.) IOTA11ECTRIC FEElear'n's N=nc —
0 L) 1<„degddtrn Ql'Y. MECHANICAL PERMIT FEE PLUMBING FTE
U U I cxnify that T nave mad his city
asst county
and awe the an aboveaws od,tian Ie
confect.Inenc to comply wiN all 1marrid cwnrymdinanofvd wee uw,nuxnyw PFJtMRISSUANCE MECHANICAL FEE
othme-gcauom Posafd hvcby vuhmiufr,rwe,wives ofNucirytoetaupontin CONSTRUCTIONTAX
Uz nbOveWe)Wne to sanyfumnepathr lone,
AhTTA ORADD TOMECII.
(We)ayce to urc,Gdemifyand hie my
be,City yacofseso=aey.iw
linbilitia,judpteno.coua std apcma which may in any wyaarue ageinv aaH City AIR HANDLING UNIT(TO 10,000 CFM)
jSAu
- egnntingor Ni Formil. Y/�
`l AIRHANDLINGUNR(OVER I0.000CFM)
fAppli.,Camnutm Dane EXHAUST HOOD(W/DUCn
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) 6ae Rcalp 0
Will tk applimm tr future bu1h11ng orcupau.fone or hafdlc harmdau mudenel WATNG UNIT(OVER 100,000 BTU) IDTAL:
u def�by the Cupniw fli
MuciMl Cade,Chap=9.13,and the Heand llh Safety
Code,Savi25532(q]
0 Yo ❑No
VENTI•ATION FAN(SINGLE RISID)
BOIIJ:R-C'0MP(3HPOR 100,0110BTU) ISSUANCE DATE
WII Ne vpplicant m��l�n huildin�acupent oecquipmat adevicewhichemil
hvudow au eovamtiftau n defml by the Bay Ane Air Quality Mata{emel BOILER-COMP(OVER lw,0(gl BTU)
DichinT
❑Ya ❑No NEW RFSIOEWTIAI.MECH.—SQ.ff.
I have fad the haoaNOu,mvniels mqui.offs under Chaps 6.95 of he PAID
Ctdifomia Balch A Safcry Code,Sections 25505.2553]vd 25534. 1 uodnwM the
ff/ ooctledtildfIs, ,.tdcnmently mshoaveatefNcnoc, cit,toits my o.of.Celity to fntifythf MAY -4 1993
spam of the regmrtmats which man be met prior In iesuencs of•Ceniliate of m(1
Olsmc�
Owner or stuluuun! caDLC TOTAL, G/1 f vl P
ISSUE HY: � 1 d