25009 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOELEU1 RICA M"I' ND 25009 L 5 O O 9
APPLICATION/PERMIT PLUMBING-MECHANICAL J
BUILDING DIVISION NUILUINC PROJECT IDF.NTD'ICATION
HUIILkDING ADDRESS: SANITARY NO. APPIJCATIONSUBMI'DALDATE
OL/I J D UNIT♦ LOT Y -
OWNP NAME.: PIIONE CONfRAC1pR:S NAME LIC NO: ALJ
0 N/C COM IOL Y
O_ARCIII'IECDENGE&Ii LIC NO: ADDRESS:
CONTACT: PHONE ElQTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
RMIT
PEISSUANCE ❑ ❑ T&
LICENSED CONTRACT'OR'S DECLARATION APPLJANCES RESIDFNITAL JOB DESCRIPTION
hmchy effort that I un liccnrnl mdttgaviaina ofChngananl
9(concfcbig with�00 S,tim77")ofDivision 3 aft Business and Pmfn�iauQC-ofde,W mu
my lie is in PANpS sSy— RT
Nil fi�sod c
<'o, Idcnar.l.ic.N .5" -5- UPTO2o0 AMPS - , I�
,Q=y )mc Co rseamtib---� � � 201-IBOOAMPS
LQyZ ARCHITECTS DECLARATION OVER Ba))AMPS
SQ,Ff.FLOOR AREA 550.FT.
O'G`3 I undcalud my plat shall he itt as W bfc rtcmds.
F set SIGNS ELECTRICAL
sYS'� Licen.ad Nofcaionsl
OWNFR-BUILDER DECLARATION SPECIAL.CIRCUIT/MISC.
06U 1 hereby of no that I urn exempt from do Cmuecons License I-aw for me
%4 vFi following sensation.(Scum 70313,Basirwv and Professions Code:My city or wwly TEMP.METER OR POLE INS(.
� O; which rt,hres n permit in conamul,d er.imgnve,demulkh,m o"ir any nrvcmro
6� prkrminiuuureclaims faysohpeamottoBkasigtcEuavtent POWER DEVICES
hO mat k is licenem psxuanl m the rovisions oftM Cn
mmor's Liun-c law(Ch'ter
o.n��c 9(cotunuKing with Seat 7")aDivuim Joffe Buirrss ad PmfmSWIMMING POOL F�CIIUC ions Code) VALUATION
as tnet he is excmpi mcrtfmn and the bags for me alleged exemgiml.Any violation of
>-
Section 70313b I tfcra OIrfM-SWITCHES-FIXTURES D- pv
(_ZQ rayapp icl pcmit subjcco the applicant m•civ11 pemltY of
m mac tha Tues M1undmd dellen(51110).
yKK�Co ❑ Lasowner andth inoto,armyemploywwlmwellfor vsokewnpenvyon, — Q'ff' STORIES TYPIi CONSTRUCTION
3°p will do dcwmt,and thcswnortisaatntcrdedmoffmedfm who(Soo 7006,Business
and Pmfeuiea+Codc:The Carurztei s Lismae Lew does rat apply to an owls of
plopenywMWuilds«improver mneon,and whtdoa such work himself or Waugh his If 11 ) 91
un cmploYaes.providm llutwchinlfaovcnrnuane oa intrnhdaroRemlfmsak.IL OCC.GROUP R '.UNITS
howevn,the buildings imgtvemrnl is sold within me ymr of cwnpininn,me—ric, TOTAL
builder will have the Widen ofpsoving thatk did res Will or imgovc for p rpone of
snk.).
ClLuowlierofthe goperty,emuduvvdycmtrryng wimuammn.m.a«.to QTY. PLUMBING PERMIT FEE D'[oNE APN
corwnxt the pmjen(S ,7006,Buaime and Profcasimu Cmc:)no Cmvulor'x
Liccmclaw does res apply man owrcrofpropcny whodyldacr Lnproves mertm,ud PERMIT ISSUANCE a1
wlnconwcu(crouch pmjec'with•cono-onsm.)heonotand ,to llc Conmctor's
Licoroe Lew ALTER-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ Tun exemp unda5a. ,B&PC(cr fie rtaxanSI
BACK FLOW PROTECT.DEVICE SANITARY Y N
Owner Due DRAINS-FLOOR.ROOF.AREA,COND. R'CFIVI'M
• WORKMAN COMPENSATION DECLARATION G, SCHOOL TAX Y N
❑. IMeby alarm lhatlhnvca¢nif to Mcmaenl to uJriesurt.are cuyfiwte o! RECEIPI'Y
Wcrkmv'Cmtpenseyonlmzm
uxceani0ed a'oPY OertoflSec.1800,laPLCIURES-PFR TRAPb C.)which PARK FEE YN
covet.ell 1 'a cr this mm RIiCEIPTM
GAS-G.SYSTEM.I INC.6 0UILBIS
PulicyM m u — 3 BURRING DIVISION FEES
61
CoroPaY 3GY -� GAS-FA.SYSTIM-OVER 4(EA) PLANCIIECK FFJi
❑ coed nam r ramw�e.
Cd'CerniBm copy is film with she city im mficn division. GRFISFANDUSIALWASIT:IN"Di PI'OR I GRADING FEE
CERTIFICATEOFFXF.MPIONFROMWORKERS GRFASETRAP S
COMPENSATION INSURANCE
(Hda secyed rmd opt b•camplwd ifdnpnmit la far.handled dolWs($Bp) SEWpt-SANITARY-STORM FA.2110FT. YFEI;
cr Im.) nJ
I citify lWinure perfirtatre ofthe work rcrwhich lhupnmit is lasood.I I WATER HEATER WNENT/ELECTR {ry
not employ any Pcoano to coy notorm,
ro as In become subject to me Work,' PAID
Comm, mnlaw.c(California DueWATER SYSTEMTREATING Dmc Rcuig0
O z Applicata
O NOTICE TO APPLIC,ANf:If.sfes Oda CutiBate of Ex TOTAL;
z fatty al,,m cm,You smnd NEW RESIDENTAL R.MB. SQ.FT.
� to bna,illscr A,theWmkma Ccrnpenrthis pmvs"I he dessmm Codeym roan
> fcrmwim cmtptY with wen pmvisionscr WapermitYWl b•dealyd sevokm. BUILDING FEE
1 (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.11hm that there is a construction lmiding agency for the grformure of
U p me work for which ata pcmtit u issued(Sec.3097.Civ.C.) TO ELECTRIC FEE.
LL Lender.Name I
O F I<sdan's AddvPLUMBING EEE
t QTY. MECHANICAL PERMIT FEE L
CJ 1 unify mat I have iced this eppli®Hm and sae mar be,al—c infmmeiitn is
2. omen. const toon,"wimall eiryand comuY ad4wreiud same
to en.rapongm PERMITISSUANCE
complyMECHANICAL FEE
_ Z buildingeeramretian,ud Mebypection Putman. delves of this city to mtcrupm mm
(� .Z abov tWcnticred p sao,ifor ndemnify
ke,p Im. ALTER OR ADD TO MECH. CONSTRUCTION TAX
lWc)ogresto.ave,e mal ex a and khcp hum lessthe City rt CupcnsasodRgumst
Citylublllyu,Judgmenl,cow all capenv which smymay way rmmagviw old Corry AM HANDLING UNIT(TO I0,000 CFM)
raequrnce of t1lcAlrenynp of pcmil.this
_�dAf/�/ J AIR HANDLING UNIT(OVER 10,000 CFM)
,natmmof AppltcanU(7momor Dote EXHAUST IIOOD(W/DUCD
PAID
HAZARDOUS MA'fERIA1S DISCLOSURE IIGTING UNIT TO 100,1000 BTU) Detc Rcccig Y -f
Will the applicnlcrfuturc building occultism wort m hmdk hermdoos ustmal
w IIGIINO UNIT(OVER IW,IX10 flIV) TOTAL 2
dcfmm by the Cu,omm,Municipal Code,(Tager 9.12,and the Ilemb sand Safety
Cede,Sear0O ye,
n30N VENTILATION FAN(SINGLE RFSID)
Will shoo licmlcrfuwrthuildin BOILER-COMP(3HPOR IIXLOOU PTU)
ISSUANCE DATE
Ip goccugw uutyulprtcnt ordevim which emit
lunnlaa air conlmnimma as,defies by tk Bay Arm An Quality Mamgemeam BOILER-COMP(OVER 100,000 HN)
.D Urin?
❑Yes ❑No NCW RESIDENTIAL MECH. SQ.II'. ^ p
1 have omd Ind heaarnrt
dooa mtri.lx goirelRlus under Citation 6,95 of the r N / D
California 1lcalih&Safety Cmc,Sec'I'misa 21Nn,255JJend 11534. 1ummmu iWt
Jure buildingdoesrotcorrm0yloveatc LWtitismyrups SliVioreifythe
occupat or the ngmrmrma which mutt We Ircr prim to issuaoce of a CenireNe of •w��
Occopary. 199
Owrarmeuthoriud aganu 0.tc TOTAL: ISSUED BY: ! y yr