25247 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINORIJfLD1Nf:-P.CHCIRICA. PERMIT NO. ,.a
APPLICATION/PERMIT PLUMBING-MECBANICAL 2547
'LJ
BUILDING DIVISION xUILDINI;PROJECT IDEYDPICSTIUN
BUILDINGADURESS: \ SANITARY NO. AFPLMATIIXN SIIBMrITAL DATE
3 V UNITY LOT#
OWNF SN ,,t511 PDONE1 CO CTORS NAME: LIC NO:
IC
- NCONTROL#
;•ARCHI'HiCT/F;NGINFIItr IC NO: ADDRESS: ❑
2 0 PI-
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB DESCRIPTION
K 2 I hereby aRtm Nu I am llremM sailer pr0.iuoroofOupler9(rotrvrrncing WN
00[ n](p0)of Divi" the Busiro.WPmfetiolu Code, In PANELS
falln
TUU full arasmalcHect. C UP T03g1AMPS �+
FZ Vly
U.Clnsa tic.M
D
y<y ue Cmtaaam 201-DOW AMPS
Z O,Z ARCHITECTS DECLARATION OVER 1000 SQ.FT.FLOOR AREA $rQ.FT.
OZ—fq IUMnuertl my Plans Cull be du public oaomx
SIGNS ELECTRICAL It
I.ianscJ Potrislatd OWNER-BUR.DER DECLARATION SPECIAL CItNIT/MISC. - �r ® I
xC�x'Oc_ 1 hereby grim,that I am exempt Dan the Ctamnnr:•Neese Law for Ne
a1LLpm following lcwm.(Section]031J,Buunw and Pmfaeimu Code:My city ma»unty TEMP.METER OR POLE INST. e uuuu {{��
_y which rtyvim a pmnit m mwwet,alta,impove,denld'ah,m repair my smunure _ - J y E R,
y:; Prior to its isistasi also reyu cs the elylicmt fa such permit to fdeaalgrlm aWrnnnl POWER DEVICES P'
ul �O that he is lion.cd puroorm In Ne poo,mom.ftbe Cmanacnr'n License law(Chap¢r
ag 9(mmrcttcin8 with Scction]Ot10)of Division lartheBuirimseM Pmlavov Code) SWIMMING POOL ELECTRIC ZATE ATION
y�'4_sy
to than he is exempt therefrom and Nethum,fm thcalRgcd m
e`cption.My vidnon
eof OUTLET$-SWITCFIFS-PX'NRES
SZa Scmion?0315 by any applicmr fa a Penor subjrcls the applicant to a civil penalty
rot mesa Nan five hoa4ed dallaa($5Ml_ NEW RFSIDFNIlAL F1ECTR PT.
,�,�,, ❑ and
dthe sauartis not
empercm iNwnecaatM1ewk 1M4,Business
u �' RIGS TYPE CONSTRUCTION
L3$ wdldothe wmk.Ccru: awnweiatotimwdnle, offeLaw ed for cloasnalc(0ysoan,Bw of
end Pmfessiana Cale:TM1c Conlnaclar'a License,,ho loew doe.not apply w m scorer a(
own cnYwMes.roaimProveth mo in,andwho doorwchxvkhirmclfa thmugh M1ia
cmpinycea,prnvidedtMrwcM1impovld ovidinn,intrndWmoffc+N for msmx.IL (TC,GROUP PFS.UNITS
M1ailderwtheavRidingorlen ovemviniscold ilici oreyea of cornpktion,theowar- TO'A
bdlder will have dtc burden ofpm'inH thatkdd rot build ainpmve for purpmc of
ale).
❑ I, 1 gracoswr ject Uirs,.7 .Bexclusivelytri
cononessi nst C re)The amectaato QTY. PLUMBING PERMIT FEE E OOU LONE APN
casnbuct w project My omo Busies ab ProMu ld Corte)The Contractors,and
Licensel.aw6xa such
of tomownaofaapmy lkcn"demimpmvw Canm,aM PERMIT ISSUANCE
wMe Law.forsuch ptojeca with acontractures)licenced PunumttotheConuectals
ALTER-DRAIN @VENT-WATER(EA)
0 l lbw. FEE SUMMARY
❑ I non enanp coder Sec. ,fl&P C fm Nie reasao BACK FLOW PRO TECT.DEVICE OUTSIDE
SANITARY Y N
• 6OwnerDataWORKMAN COMPENSA E LAAATION DRAPES-FLOOR.ROOF,AREA,GOND. SCHOOLTAX YECEIPTY N
❑
Workers,
C yaffirm lM1atl M1avcaanifwr s lisself-imurt,mncerYficare of RECEIITY
PXTfIRGS-PER TRAP
Wohrn'Cvmpmandm lramulzor• thrtaf(Sec.3800.Lab C.)which PARR FEE Y N
fish, is�tmi GAS-EA.SYSTEM-1INC.4 OU , BUILDINGRFiLFST#FEGS
C`m y GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
ifiedc is hereby
Ceni Retic yis film wi city inspection division. GREASELINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFlCATE OF EXEMPTION FROM WORKERS GREASETRAP
COMPENISATION INSURANCE SOILS FLP,
(Thi.section nem ml 4 complexed i(the permit is fame himNerl dolma(SIM) SEWER-SANITARY-STORM EA.#)OFT. ENERGY FEE
arlea)
Imrifyuhat in the perfixmuec of the wmk fawhkh Niapermitie ivum,lshall WATER 11HATER W(VETOCELECR
tett employ my Peron in my mm as to become subject m the Worker? PAID
Canpumtim lawn a(CaBfania. Due au WATER SYSITI.1a`MEATNG Date Rereip0
O Z A,li.
Z Q NOTICE TO APPLICANT:If,after making this Cmifkue of Gempdon,you etrould NEW RESI DETIAL Pil SQ.FT. TOTAL
Iccmc wbjat to Ne Worker's Cwnperatian Taovisiaa tithe Labor Carl you mars,
forthwith comply with such prrviamsa or this Permit shall be,lmr<d nvokm. BUILDING FEE
d (] CONSTRUCTION LElxDWG AGENCY SEISMIC FEE
Z 1 hereby aft Nn Nero is a caabuaion lading agrnry for the perf0mnance of
U O the work fm which this Permlt is issued(Sra.3097,6v.C.) TOTAL: ELECTRIC FEG
Tender's Name
0 U U Leader's Addnv QTY. MECHANICAL PERMIT FEE PLUMBING FEE
CI certify Nat I have rem thio applicot aM....e that the above rfmrerino is
erect.lli t 10 comply with all city and rnumy adlnaucea aM sone laws relating to PERMIT ISSUANCE MECHANICAL ITE
bbrowe-gsonmed firm std hctcbyw nepreaalY{Iva ofthisaryto cederupon the CONSTRUCTIONTAX
(� above-mentiarcd per puryne¢. ALTER OR ADD 3O MECIi.
e aerze to eav kc<p hanmlev Ne City of Culaedim egad.,
limbiuse which mayin my way.rcrvc against said City AIR HANDLING UNIT(M I(L"CFM)
no soy the ofthispermil.
AIR HANDLING UNIT(OVER IO."CFM)
knot of Tro0tormacto, Dere MHAUSTEIODD(W/DUCT) PAID
T)VARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO IM,000 BTU) Tate Receipt �
Will the epplicanr or future building acuptnt store or hmsNe hatandou material IIHAIING UNIT IOVEIi 100,000 BTU) L:
an hfircd by ds Cupenim Municiyl Cade,Chapter 9,12,and the Hu1N std Safny
Cudc.Section 255331.)? VENTILATION FAN(SINGLE RES1D)
❑Yea ❑No
Will dcappticentafuturt WilNngacupantuacqulpmerllatkvimwhichermt BOILER-COMP(311P OR IW.000 BTU)
ISSUANCE DATE
• hasamot'air com,rn;nr,ia m dcfiad by Ne Bay Area Au Quality Muagerrcnr BOILER-COMP(OVER IO0.0f10 BTU) PAID
District?
❑Ye ❑NO NEW RESIDFMIAL MECH. SQ.FT.
1 have read IhC haxurdous material,r,nint under Chapter 6.95 of the "JUN
2 3 tiJ93
CWifomia lit&Safxey Code,Sxliara 25505,25533 aril 35534. I unJ mud that /s
if the banding dono
cs t.1y hatoned,
,Nat t ,Nm
at it is y raspaaiGldy to notify the .
capant err Ne reyahm mw
emcm,whiIN,non 1+in,m issuance ora Cr ifirate of yl'T Vt uuetM I I V
ana(„rlcy.
Owes a aulM1orircd egrnt Tate TO'T'AL: ISSUED BY: