27733 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOenj PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING 27733
BUILDING PROJECT IDENTIFICATION
BUILDING ADDDRESS: �y SANITARY NO. APPLICATION SUBMHTAL DATE
(/ Y Dt. UNIT# LOT♦
OWN NAME_ ONE: CfOR' NAME 1, O: l
F NIC C NTR L�
�4 CIIITF.CT/I]JOINF.I]U WC NO JDDRESS: ❑
Ill to. gv4tif Ave, Nm
CONTACT: PHONE BUILDING PERMIT INFO
QTY. CIRIC PERMIT FEE
BLDG ELECTR.UNIB MUCH
PERMIT ISSUANCE � IR � 1i�'
OB
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JP�
py2, Ihcrtby affirm lh.11emli<rnnd undcrprovi.inn•nfnalef9(commrncingwiN OB DESCRIPTION
EOF Scion7full irons,rad)ofMvuwion 3 of the B ,ed Pmfcmi.Code,and my licc,lsc u in PANELS
1<F..:z,UU nx LiccClea UP T0300AMP5
Lic.g
y<y rho. ronvutm LII-1000 AMPS
G O,z ARCHEFECT'S DECLARATION OVER 1080 ANff5 SQ.FT.FLOOR ARES $1SQ.FT.
OZ—w 'slm'd mY Pl+m shJlhumdupablic record,. ^ _
SIGNS EIECIRICAL
Y 7C' Lkemcd Pnfe,sionsl
�I+IU OWNER-BUILDER DECLARATION SPECLILCIRCU UMISC.
Oatt-- I hereby eHi dor I un eaemq fano the Cmosetoes Licaue taw for the
4ptn fallowing lcnsan.(Seclinn7031.5,Bu,i.sd l'tof.imu Code:An,city arnrntY TEMP.METER OR POLE INST.
which rtquires•Permit to m,, s Jae,,a move,dentnlish,or repair any munch,
�} Prior m its i.ssu.nc,also rtquncs,the applicant for such permil to rile eugned ns..t POWER DEVICES
,<C) th a he Is Ilttrued mem nt as the provisionsOf the Cmtrs .Lina law(Chum
9(c«nmcocingwith Scmion0000)of Dwi•itm 3 ofthc Bunrra.rld Hof¢•iun Code) SWIMMING POOL ELECTRIC �-VALUATION
m mhat he n escotpr tMefmm said the basin l«the alleged comelion.A,violeuan of
tZa Smion'/031S by any applicam f«apcomi subje ii thcapplicnnt w acivil petullyof OUTLETS-SWITCHES-M(TVRES
tgn mate llW Bve hsudrW dd art(5300). NF.WRESIDENTIALELECTR SQ.FT. STORIES TYPE NSTR ION
K p ❑ Luown6.thcpnPmoft,s( mPlnym with wngeaes the'vnakc«npmwion,
y $ walldotbcwmk,CJe Tht,Cartistlot intendd«new dre,snor Rply to 4,w,nmof
ud Prafmsiom Code 01rt Ctntrecals Li«nsc law ach nm apWY to an awrrr of
owmemtywWddM•afimpmvea Ihemn,sN who dan,uchwort cooffi ar tfo wc.hu
wneyer, ca.pmviddthnmeuchimismid mu nmol interkMmdfttal fmmle.lf, C. R f!P R NITS
however,tM W ilding«impvvemrnt is.aldwithin omr yr„ofmwpledan,tlrowou- TO
builder will havoc the buNent oZ�k id Rol build ve for purymeof
,ek.).
❑ I.uownvufOcpeopern mgwilhlic lmctona QTY. PLUMBING PERMIT FEE FLOODZONE APN
comtrcl Ilk project(Sec.9( Icahn,Code:)'Dte «utnctor.
whohuiWs«impmvea mud PERMIT ISSUANCE
whocanrtasrorwch Pmjttv ,)hemeod pursusnuomheC vrwr's ALTS-DRAIN&VENT-WA'IFR FAU.L.w ( ) FEE SUMMARY
B&P C f«t OvrSI
BACK ROW PROTECT,DEVICE SANITARY Y N
Owner
W AN COMPENSATION DECLARATION DRAINS-BOOR,ROOF.AREA.GOND. SCHOOLTAK RECEIPT" N
I hencbyef Ortlhave.ccni0cane.fmn.ent lnm f-iruurc,uremmiBt'Nc of F1XTlIRCS FfR.DiAP RECEIPT
atm'C Iwumm«amti0adc m.3g00ZC.)which PARK FEE Y N
mJ11 'ce',uNm Ni,Pemtil. l GAS-LA.SYSTEM-I INC.4 OUTLETS RDIVIS N
Polcy♦ BUILDING OMS
0 Cormnary ted c"uhertby GAS-EA.SYSTEM OVER 4(EA) PI.ANCTIECK FEE
❑ Cerci copy is Bl int,seeichl�division. GRFASFONDU.STRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE EMPHON FlIOhTVO S' GREASEIRAP SOILS ITE
COM SATION INSU CE
(this tianrcd,mtbc dW iIthe pmmI u for ane htpdfed dollen(5 SEWER-SANITARY-STORM EA.MET. FNFRGYFEF,
m Ica)
Icmify in the perfmmanee ofthe wart fm which Wn penmat is i ,I,hJ1 WATER HEATER W/VENT/LLECIR
rut employ person in any muurr m a n be«rc sub' dr Workei PAID
R
Cortryrnadan wsof California. Date WATER SYSTEM/IREATING IttciPt0
O Z Applicant
ZO NOTICETOA ICA2,tT: .afro
a > rmdrwim emaply rnC t..•,Irof Exmpwryou ehwld
TOTAL
U,) bm«nesubjzlt theWorkeNabafCode,ywmoal
im .hpria;m,.«m :
dmnrd mooted. eul r �a
Q NSTRU NLINDING AGENCY SEISMIC FEE
OIMrcby JErm .constnntim imine,,. cy for the perfs menceof TOTAL, ELECTRIC HE
the work for which thu permit u iced(Sec 3090,Civ.C.)
Lcndcr'a Ntmr
de
i' lenr',Adam, QTY. MECHANICAL PERMIT FEE PLUMBING HE
LU7 I certify 1hn I Dave Rend this epplication ad nate tha,tan above informuimt it, MECHANICAL HE
CmccL Isg,,cW.,I,with Jl city".,,mdwncv sand mus,4.reach,,to PERMIT ISSUANCE
bulldingcmutrucdon,and bench,autharve eepmesendMvo of thio city loenim upon the
Z above-mentiond popeny For imupecvim purpura. ALTER OR ADD TO MECIL CONSTRUCTION TAX
(We)sgrm to uve,irdmnify end keep hvmlea rhe City of Coprnima agairul
liabllitio.judgmmm.,cmuamespensawNchmayinanywayaa ogcn. .mid Ciry AIR HANDLING UNIT(TT)10,"CFM)
in athe teg of - 't. / .
AIR HANDLING UNIT(OVER 10.OW CPM)
Signeturt of Appliwt/Cmtrectm a EXHAUSTHOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO IM"BTU) Detc R«ii
Will the Ine Cuant oo Ma andel CRd, pvtome«handle luaudous mtmJ I ILATI NO UNIT(OVER I W,M)BTU!) TOTAL:
a,de.Sm by the Culrnila Municipal Cde,CTepter 9.11,ed the I IcJth and!Safety
Code.Seetiae 1301(gT
CI Y. CI Na VFNTILATION PAN(SINGLE RFSID)
ISSUANCE DAIS
Will the app=t m forme building cm,WR use equipmrntartkvicci which emit BOILER-COW L3HP OR 100,000 BN) /� p
-amdotn au contmumme,v derimrd by the Bay Aro Air Qwlky MsnageNPry
rnma BOILER-COW(OVER IM."B
) /,D
CT 10
❑Yn N' FM
❑No NERESIDIAL MEC11. SQ.Fri. L�
I havoc mod the harudau,matcnela im,aitemenn order Cham 6.95 of the c�14
CJifomis H-Ith&Safay Cde.S«riom 25505.25533 ud 15534. I uderstod dtu Il•
! if the Wilding docs not rummy hive a terant,that it is my m,,poombility to Ratify the
emulam of 0r rtgaimmmla which most be,nrl prior to isnunce M•Ctttificue of
tkcupmr .
OwneroramhmiSdsgcot Date TOTAL ISSUED BY:
OFFICE