28214 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOB DDINO-EkLUrRICAL PERMIT NO
BUILDING PROJECT]DEN'rDTCATION . ^ a�
APPLICATION/PERMIT PLUMBING-MECHANICAL LyV( L
NUIhDING DIVISION
BUILDING ADDRESS; SANITARY NO. APPLICATI
ON
SSU13MIITAL DATE
LOT
O J'„N � M µ PIION�_ ^ M' Clll :S N M�` 1 SJJ O J
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AR IIT �IJGI EI UC NO: A RF_SS �m•I,J,J �kV. `�• 1J I I �
CONfACI':/ CH
//']�/�} /�./T/�..// PHOONI_ QTY. ELECTRIC/PERMIT FEE BUILDING PERMIT INFO
f0eVE I I y4Zz&1 7 PERMIT ISSUANCE B� F1F❑l PLUMB ME❑l
LICENSED thanwasCONTRACTOR'SDE
ions of RATION APPLIANCIS-RFSIUENI'IAL OB DESFR}Pf10N
GKZ Iheaeby.rtlrtn Wil am licensd under pmvlsln,CLARApter9(csmmrnnng with `PDE
r�00 Section]0(0)of Dtviaan 3o(the Biuineas std Prefnciau Cede.and my lieeroe uu PANELS
�— Teri rtxee and art«r. p .�
tEG� Lianea Clas 1.ic.# UI'T02W AMPS
<..
vs7y Dale Cunvvcior 2UI-IM)AWS SQ.IT.BOOR AREA SSQ.IT.
Z FOyG ARCHITECTS DECLARATION OVER LOBO AMPS
07—Cl l utNdrstmd my plain shall M usd n publk rcasrdc
y h W SIGNS ELECTRICAL
6Y�Kj QeerneJ Pmfe.csarml
i'1+1U OWNER-BUILDER DECLARATION SPECIALCIRCUMMISC.
KOa 1 bemby.!firm that I.m exempt fmm the Conmctor'a Lice.law fm the
1+131'-rFia following venison.JS oa]0315.Btnirraa malRafcaaiom Coo:My cuymroumy TEIsIP.METER OR POLE INST.
C�'o which re,eires a permit to ctnmttcL.Itn,morpmve,demolish,in repair my mrttcsme
5'ttvVV'>� prim to its i.sla..aBn rtyuiru the applicant for such permit m flee aigrdmmcmem POWIX DEVICES
W<0 man he is licensed pursuant to tine pmvieions of ilc Conmaor's Liccmc law(Chapter
dXo� 9(cmmc«ing with Sectien]000)or Division 3uftlte Business and Prefeaaimu Cale) SWIMMING POOL ELECTRIC VALUATION
orIhm Mie exmapt therefmm mrd the bola for tra idle desempxlo Any vioWlm of
�Za Saetitm]031.5 by anY ti lirent for. mareil subjem.rhe applkaet to ii civil penalty d OUTLETS-SWITCHES-IINTURfS
nmmmcihen fvc hudrd ddlars(551%0. _ v
❑ huvnwmm�ftM1e propeny,ormy employers with wegnaatheirsdc mmpcmutian,
NEWRFSIDENTIALELECR SQ.PT. .TORIES TYWCONSTRUCTION
e _ wJl Jo lhewM.monde,T nctum is mtintendede,Latw ed raraak(Sse.] in Buslmsf
and Profevaom C.r,The C«urxsola ulama law dart m apply to m owriu of
propmy whobuidsm improves thncott ad wMtdm.uchwork Nmselfor Wrwgh hu
wn employees,pmvndd liners«lsimpmvmrcntxmeanaintmdnl«nRemdfmsale.IL .GROUP RFS. N
hawcvepthe WilAingor impmvenein iamldwilhinmeycntrnfcwnplodm,ihcownm- TOTAL:
Wilder will have the bmdm of povinS ilw he did not buiMl or improve for purµrse of
a ).
❑ Las ownmof tineleopeny,amexcluuvelycanirsstingwith licensed rorumctm to Qom' PLUMBING PERMIT FEE ROOD ZONE APry
omtrvct the rc*,(Sec.7W,Busine.s end I'mfwions Cods:)Thin Cmuna la
Iitt.lawdui apply tomuwnmofprapcnywM builds ur impmvn thrmm.and PERMIT ISSUANCE
whotmtrucu(«auchpmjccuwiihecmmcmr(a)I'taaaWpunuamorhe Ccn mrx
ursine Lew. ALMIZ T &
-DRAVENT-WATER ) FEE SUMMARY
❑ 1 am eammt under Sec. B A P C f«Nu tmson BACK Fl. PROTECT.DEVICE
SANITARY Y N
(hvncr D:nc RECFIPI'M
c U S-I1,OOR,RUOF.AREA,CUND
WORKMAN COMPIicna, fcNDECLARATION SCHOOL TAX T N
❑ Ihncby fires lhave.
.an.orale edl copenteself-insure,«acmlDcucM RECEIPT'#
WMm'Contpemmian lnur.mcmeeenifid ropy thenal(Sec.3800,lab C.)white Fl%"IlTRFS-PIiR TRAP PARK FFP. YN
n all amployce'n urnkr this pmanit. GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'N
Policy N _ TLBUILDING DIVISION Il?
Company IC- GAS-EA.SYSTENUOVER 4(EA) PLANCHECK FTE
❑ CrniEd copy u busby fusdslc+L
❑ Crnifd copy uEkd with the city insymMn divisial GREASPANDU SMI GRADING IlE
❑R'I'H'ICAM Oil EXENIP'NON#BOM WORKERS' GREASHIRA�%V v SOILS 194.1H
COMPENSATION INSURANCE
('#his section need not be comped ifile permit is for arc hundmd dollan(S ) SE ARY- EA.MIFT, FNFRGY FEE
or Inv)
Icenifythan intheperf«menceofiMev kfawhichthisl itisiraud,l 1 W IIP ryPM/ELECIR
not mnploy any pervm in any i av iU Wcome aMjns to the Wnrk PAID
Z
Canpcnarrionlawaof Celifomia.n�UNr w EATING Date ccxipt0
AOT#int
NOTICE.TO APRICaWT:IL alta making This Cenifioie or EsanWd^.yw slnauM NEW RISIDI2If1AL PIl+1B. SQ.FT. TOTAL:
I-- y became subject to the Workn's Canpcnaetion ponsfacm ofthe labra Coda,you mum
forthwith comply w Ills such povrsinm or this permit shall W d axd mvokd. BUILD
CL Q CONSTRUCTION LENDING AGENCY six SEISM '
Z I Wreby err lino chert it.tmmrnction leadmi,agmncy for the pMmtbrx of
L) O the work r«which this piamh is ivmcd(Sec.YyU.Cis,C) TOTAL ELECTRIC FEE
U. r !Leader's N. PLUMBING IE
F-' L<wn's Amtcu QTY. MECHANICAL PERMI1 FEE
U I cmrify That 1 have mid this"lication.d swc that the above womna oa is MECIIANICAL FEE
ormccs. Iegtccto campy with Al city and wunty mdm.rncn amlame l.wv ralwing to PERSUT ISSUANCE
U z building coeavumim,and hmcbymfnorim reptarnuuvaaf mini.citym mtcupm tEe CONSTRUCTIONTA
ehmcmcntionN pntpcny for ins ection pur oaca. ALTER OR ADD TO MECI 1.
(We)agta to ease,irdemnify end keep Manias the City of Ct, rnirc ageiam
Ikbiliti u is uses which may in my way acsry agaust sad City AIR HANDLING UNIT(TO 10,000 CFM)
B HpvwL
•c n AIR HANDLING UNIT(OVER f."CIN)
mm opplicR1ALS DISCLOSURE m % AUSIIOOD(WMUCI) PAID orUT
HEATING UNIT(TO IOO,IX)p BTU) Dais ReeeilnN
Will 1W applicant to futmc Wilding occupant non,m handle haaeNtxss amminl IIPATING UNIT OVER 100,000 01V) I O
as delired by the Cule+tiao Munieipd Code,ChaNer 9.12,and iM Ikahh and S`afay -
Cmk.SmrIyea ❑No
(ep
0VENTILATION FAN(SINGLE RESID)
Yn
BORER-COMP IMP OR ft,"BTU) IISr A4�Dt
Will the applicmt«future WilJing«cupmtuucquipmem mdcvicm which mar -�
. famolou.v air mnumtiamia as Jeri«d by tin Buy Arent Air Omlhy Management BOILER-COW(OVER IIN)INp BTU)
Demic1' AUG 31 1995
❑Yca ❑No NEW RESIDEIJHAL MECII. SQ.Ff.
1 have road the M1vadou.mammals myuiremrnu urndm Chapter 6,95 of the
California Henlih&SafelyGxlc,See0um 25505,25513 nand 25534. 1 mndmamad dost yI' 1I Ur UU!t
if IEc Wilding docs int cum,mly have a taunt,than it iz my rnpnmibility to notify the
necufvnt of the"moments which most he met prior to asoma of a Ceriif to of
Olocapi.
Owner to authonacd agent One TOTAL ISSUED
OFFICE
i