24613 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOBUILDING-ELIEUTRICki, PERMITNO,
APPLICATION/PERMIT PLUMBING-MECHANICAL 24613
BUILDING DIVISION BUILDING PROJECT THEN'I IFlCATION
RUI DING ADUHESS. SANITARY NO. A PIUCATIONSUBMfRALDT
UNIT TOT0 1
CO O SNrr, },IGgp�i N/C VVV CONTROL N
ARCHHI iCP/FNGINMR: LIC NO: A ) lYn s✓^`%C/_' ❑
CO CT: - ///111 PHONE QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�m'_pfl BLDG Ft FCP PLUMB M
,�( /Y/J PERMIT ISSUANCE 1:1 11 El
L NSP.DCONTRACGR'SDECIARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
CC7 Ihcrtby afB tlwiwliat>d ends pavisiomof Clupm9fcannercmg with
uttv 00 Salot]do 7"cot)cof i ,(}Jq�tie Busiresa C mdmylirenseisin PANELS
.� Manx Gg p:: LicY UP T021)OAMPS � L
mQy Es¢—�'I(J.(��Con. 201.HO)AMPS
'ZOyZ
ARCH] DECLA O OVER 1000 AMPS SQ.IT.Fl,(HIR ARG S/SG.14.
o Z.—a 1 wdcrswd my pen."!be used!u Public rcurde
F tnC SIGNS ELECIIICAI. Ig;^
Qled I.IcrnscJ Profeuxeel OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. r t l'... ® I N
X6rX-owu I thereby tiff.Nat 1 w esern"f.he,Contractor'.License Iuw for the 11
ul3Otn followingreemn.(Sectino 703 IS.Business ad Professions Code:Any city or county TL'MP.ME"OR NILE INST. II 0
o� which requires a permit to cawmcL alta,Imrynve,tkmoluh,or replr my structure U
�� TE R
}2 �r 0its h........ala requires the y,feu fou such perm,to Rk a signed somervent POWER DEVICES
Cooz tMt he is licensed Pwnood'.de PuAisleuMtic Ctmlrecttx's license law(Owpm
—aLL 9(conmteocing with Sectirml0)fpof Division 3ofOe Husineuod Pmfresiau Cask) SWIMMING POOL ELECTRIC L VALU ON
_y or thv he is exempt Ncre(ran sucl basis for Its,alleged expnptiorm Any violation of
Za
Session 7031 S by any WPhcmu for.Ecovolodjcrs dteapplieant too civil peomy M ODTLEM-SWITCHES-FlXTVRES
O ttwmwdon Rvchundml Jnllwa135001. NEW RESIDENTIAL EIECIR _SQ.FT.
3�F ❑ I.Use nos!sh, perry,mmycmploymwiNwogpeethe(See.cmopcmatian, STORIES TYPE CON.SIIt N
.M do Newts,and tkTloc eismtintcdde LeA dfee s.k(ser.lf-owned
end e,Iyw isms Cam Tic CommcLtFx dwho oes ares not apply lf en owner of
proPcrtY wMbuiltdwimpnvpthcmn mrd wMowea.uch outs lamxllmtbmugh his
wnmryloyebuildingordOw.uehimis odd wsertnou lmmdNmM(rnd 11,eov r- OCC.GROUP RFS. ITS
Ixidder ,r,thearse Wingurden a rent thatJwithin ot year or comple for the oweof TOTAL:
builder will have Oe burden M roving Net he db rex bWld a Improve for pupa of
we.).
❑ I,uowrer Mthcpvprny,weaausivdyentraningwiNlicenud cuntractm.m QTY. PLUMBING PERMIT FEE Fl. ZONE AM
on,trun the pmlat[Se.70,0,Burin and Professions CWe:)The Conuaturb
Iicrnsc PERMIT ISSUANCE
whnevocr.cu fusuclt pnjat.wiNtteor ctor(s)hcxnvtl pursuant to the Cmuenala
IJceo.c I.ew, AL'IT:R-DRAINR VIiVT-WATER(G) FEE SUMMARY
❑ I w evmtpl underSa. ,B&P C fou Nis reason BACK FLOW PROTECT.DEVICE OUTSIDE FMS
SANITARY YN
Owxto- Cmc DRAINS-FLOOR ROOF,AREA.COND. RECF,IPI'Y
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
11:
othy.m.dust l hese..enif tewmfrw
ofc.".self-inse. .oetieof
FlXTURES-PER TRAP
RECIMPT#
'Cnn®tient lnsuJ¢pc ec adT'ypythcr f(Sec, Ina CJ which PARK FEF. Y N
re nil cm on Igg"yDD j/ GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPFx
PWicyY n [� BUILDING DIVISION MFS
C r t0t(cb ' � GAS-FA.SYST M-0VER4(EA) PGNCHECK PEE
Q�pPCenlRWco a�rcbyr uaN.
�II1A Cmifd copy is fkd with to city inspection divisiwc ORGSFANDUSIRL WASTE INTERCEPTOR
Tl GRADING ETJ;
CI?R'DFlCATE,OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEB
COMPFIJSATION INSURANCE
(This senors red not be emtPletd ifthe pewit is fororc hundred dollars($UK) SEWER-SANITARY-STORM FA,2UIFT. ENERGY FEE
on I..)
I certify that In Ne prsfomwtcc ofthc work fa whkb his perot is issued.I.hall WATER HEATER WNENT/ELECIR
not empltry any Pension in any m m to become abject to Ute Workers' PAID
z Cwe'rosurion Lawsof Coliform. Doe a WA DER SYS-IEMORIATING Date Receipt It
Awricuml
OQ NOTICE TO APPLICANT:If,after mating Nu Ccnifacof Escmption,you shwW NEW RESIDENTIAL PLMB. SQ,FT. TOTAL_
F" beet subject to the Worker's ComperolOon Pmvisimu oftbe lvhor Code,you mus
C > Forthwith comply with such pruvisinm w this Prmtit shall IN,deemed revnkeol BUILDING FEE
d (� CONSTRUCDON LENDING AGENCY SEISMICFEE
z IM1nehy.ffnn but mere is.ron.tratmnlendingngcncy for tb ,crfimwmenf
U O the wart far which Nis penNt Is uwd(See.3097.Civ.C.) TOTAL ELECTRIC FEE
0 I<dc's None
Lend eAtdre.. QTY. MECHANICAL PERMIT FEE PLUMBING FlF.
i
Icertify rho 1 hove read Nis epplialon end souse Naz the aaow information Is
corm.Iagusto comply rr,md with altndhond cauntyadiwresmd uate4wsreluingb PERMIT ISSUANCE MECHANICALFEE
(� building conwixtimb ad hereby eu0onzc rcpmx wtivp of this city to enmr upon the
[� z nbov(We).urxdp fwounify mr!ko5Poscs. ALTlJi OR ACC TO MECH.
CONSfRUCT10N TA%
(We)n e 'rod K W resp hmmlps tk City M Cupen'vo.galeas
IiaMliticr,jd t.v esu expenaew h myweyacr eagain wed Cty AIR HANDLING UNITHO 10,000CFM)
in couucyucn c t •granting of Ni.pc I �3
AIR I IANDLINC UNIT(OVER 10,1100 CFM)
Signature of AppIEc t/Ccmtmctor Doe ❑(IIA UST I IOOD(WNUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,IXp HTO) Date Repiptx
Will tie opplicuntrrfuwrcbuddingrcupart mac or Mmllchverhm.mmcial BEATING UNIT(OVER 100,000 RTU) TOTAL;
us dcfireJ by the Cupenbtu hfutdcipsl Code.CTeyter 9.12,mrd the Health ad Wsty
Cade.S ElYes q? 0N VENTILATION FAN(SINGLE RISID)
WilldsepplicstufwurtbuilJlegocarpanluurywlmveadevips whkt emit BOILER-COMI'(3HPOR 100,000BT1J) ISSUANCE DATE
bmmNona
it atntwitunu v defined by the Bay Arm AU Quality Mma,ereat BOILER-COMP TOME IOO.gxl PTU)
r IhWicY:'
AID
❑Yp ❑No NEW RESIDENTIAL MECH, SQ.FT.
I huvc new the hs7uu rs nutcnals rryuhemcnts uMer(Taft 6.95 M the AN5 1994
Calif Troia I IedN&Safety Code,Seebaru505
25 ,25533 ad w
255M. 1 rdvduststmd
if the building docs rot currently honest scrum,thu it is my mspoosibility to rwtify the
'cupunt of the re,uiren,enu which mart Ne mct pow o Iutuna of a Ccnifrate of Tllti
txetrparmr, V 11
(Tuner m vuNonzd agent Doe TOTAL: ISSUED BY:
OFFICE