26489 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOPLUMBING�"Dn PERMITNO.
APPLICATION/PERMIT ROJFC7P 1WXTICAL 26489
BUILDING DIVISION .A \ BUILDING PROJF.LT IDP:NTIPICATION
BUILDING ADDRESS: r I / (- / SANITARY NO. APFlJCATLJN SUBMITTAL DATE
33- 6 \ UNITY LOT# (0��^q.
O 'NF]S AME PHONE NTRACTO 'S NA LIC NO N COVMItO1,N
RCIIITECT,I NGINEFI R: LIC NO: I ADDRESS: M w ❑
CONI'ACI': PHONE: QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
PERMITISSUANCE 7� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
pyy I Meby affrvi Nal lw h="a Mviaima ofaaPer 9(commwcing with
+100 Sxtim]0ndi,fUiviaionJ o(Nc Beircea erd Profedwu Cdc,and my licrnuisu ppNP,lS
of I[Accc cc adcffcm. UPTOMAMM
F�u1 I.ianu CWu 1JcN I
In?y Dete w
Cha,tor MI-1000AM1'S
i FONZ ARCHTH;CTS DECLARATION OVER 1000 AMPS SQ.FT.F10pR ARBA SISQ.FT.
O7_ IunJcnund my pl:vu shall«uml as pubis rosodx
SIGNS FJECRICAL v
...4I ueenYd Imrndmm
�yG OWNER-BUILDER DECLARATION SPECIAL C'BtCUIT/MISC.
JD
X ,F 1 M1veby efnrm that 1 ern caemP from Ne Cmva.'tm's Licrnu law(a Ne r IY ■ 1
W 3 u,N¢ following rcnaan.(S«tinn 70316.Buri.and Pmfccocos Cods:Any city«cowry ]TIME.METER OR POLE[NST. I' B 1• - I\Vp
F 4 O J which requirtn a pmnit m csmnun,elty,irrynove,demolish,orr any structure -
Y7 pnormiu iuuuee,Bsorequitn Ne epplisent far tach pemtit to Rkrte ngadstvctrcnl POWER DEVICES
MO Nu he is lianaed pursuant to Nc provlsiom of the Cmtnmor'e Licrnx law lChaptu t 11
dKo�' 9(cmunercingwith 5scnon]000)af Oivisim Jof the Baines.end Pmfevionx Cadc) �POOL ELECTRIC - i I ! ' 1 IV LUATION
Nt W
u1 or at he is cm cfmd Na basis abasis for Nc ucmp
Mf,d iw.Any vioWiw of 1^- j �
ZY Stttim]OILS by wY opplicvttfa.pvnut subj¢uthe applicant toaevil penalty of OIf11EIS-SWITCHES-FI E
r_
a oat mmeDw Ove M1urdrM Jolun(5500)_ NEW RESIDENTIAL EIE —SQ.
C � ❑ I,usowneroflhe lNWertyamYemOleYedwilh wa{cau Nrirwkcompava4on, STORIES TYPE CONSTRUCTION
a3� win a Ncwork.ardi, w,Conusmtinwddw awcost vcnl apply oOS4.Bniri of —�
and Professions Cole:Th,,Cautzt«a license law doe mt apply to an awriv M
progeny wMhuilNor impmvn Neran.ardwtwdonsmh wvkhiwelfo-Nmughhis
employees,pn�viJdthvt each lmprovcrcnuamrwiacrdedaraHad ferule.I(. GC R UP RFS.UNITS
tmvcv,Ne buildingmimpmvementuwld wiWin meyar ofcampletim,ticowar- T
builds will hevc the buten of proving Nat he did rot build o-improve fa purpou of
yk)' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I.uowmrnfNcpm y.amexclusivcfycwme ilg wiN liccmcdcmuacwsto
c.t Ne Projm(See.7094,Basins.and Prof.ims Code)TTu Cmuam«s
IJcenrclawcRaca.apgymsaowncrofpmpcny wM1u builds arimpvve U•cmn,erd PERMIT ISSUANCE
who mmxa To-amh Pojocu wiN a mnoacmr(s)iatucd puruant m Nc Cmuen«s
Lia.law. ALTER-DRAIN&VENT-WATER(PA) FEE SUMMARY
❑ 1 am exanpt uMer Sec. ,B&P C for Nu memo BACK FLOW PROTECT.DEVICECUTS,IDE FEES
SANITARY
UwartkyaI l:rrtCnbmy vpfeOnWrsmuOiNRonvKMl lAaNveCaOreMrtPiF(LIcer'SreAoTIfmnum to uiOf-vinessve,err a aniRete of
Y
N
RECEIPTY
ON DECLARATION DRAINS-FLCKR,ROOF,ARE\.GOND. SCHOOL TAX YN
FlXTlRS PER TRAP RECEH`T#
Insurena J0 ,Lid, PARK FEE Y—N
—
cow,,oil
this permit GAS-E.A.SYSTEM-)INC.4 OUPF-EIS RECEIPT#
Policy N BUILDING DIVISION FlF
Company GAS-RA.SYSTEM OVER 4(EA) P NCHECK FEE
❑ Cc ifdcapyishcrthyfumishcd
❑ Cmifid copy is fill wiN Nc city inNccNm divium. GREASEINDUS'IRI.WASTE INTERCEPTOR GRADING FEL:
CERTIFICATE.OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(bui; ion reed lwt h complctd iflho perm,is for mchadml dollar(5100) SEWER-SANITARY-STORM EA.300FT. ENERGY ME
ocI )
I caDfYNat is Ncpsrfar r ofthcwork fawhich Ddsp it iaimd,l shell WATER HEATER W/VENT/ELECIR '
not miploy any pvsm in any marncr u m become ztbfect to the Wahm' PAID
Campwutian lawn of Glifmnu. Daum WATER SYSTEA1/IREATING Dau Receipt#
0 z Applicata
z NOTICE TO APPLICANT:If,afty nuking thla Cmlllca,of Eaentplao,yoo altould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
a > c,corc N comply
m W Ylo,'a Compv,uum pmviuu aof the labde
or Co .You
plyw p000kt o-this permit abed!Its, duvokd. BUILDINGFFE
CONSTRUCTION LMONO AGENCY SEISMIC TEE
Z
✓✓ I lemby affirm that Ncre is a conn ion lending agerry for De pvfmtuna of TOTAL: ELECTRIC FEE
V p lis,work for whichthis prom,l s iuud(Sa.-"7.Civ.C.)
Fk. l.eatara Name PLUMBING FEE
Q IcM+l Addrtv QTY. MECHANICAL PERMIT FEE
I certify NtaNu
at I have d applimim and soIhv D
u e above information Is
�" LT7 cauct.lagrtcu hall city and cowry adircnasad.wulaws mluingu PERMIT ISSUANCE. MECHANICAL FEE
I'^ builJing vucriart, l�q suRwrix represmntive aNla city uenuf upon the
U z vbwe- ai.4 bupeetbe purpose.. ALTER OR ADD TO MECH. CONSIRUCIION TAX
r k n,mDm roe city nr caprnim,eg.inm
livbil ti�dg do w hmay Many wayattme againnuid Gty AIR HANDLING UNIT(TO 10,000 CIM)
BN
J AIR HANDLING UNIT(OVER Iq(pfl CFM)
Sigrui eofA muvcmr Due EXHAUSTHOOD(W/DUC17 PAID
HA]ARDOUS MATMIAIS DISCLOSURE 11 F- TING UNIT CFO 100,000 BTU) Dau RcttiplN
Will the applicant or ralart building nuupam nim m herdic h000dous mnurial
u aft d by Du Cu I1EATING UNIT GVER IW."BTO)
Fmino Atwicilvl Cdc.C1eMv v.12.end Nc I lahh and Sakty
Cera.Sahni 25532feyf
❑Yce C1 No RESID)
ATION FAN(SING LE RID)
BOILER-COMP UHP OR IW.(p0 BTT) ISSUANCE DATE
Will Du algliantafutuc buildmgrcapmtuuvluiprncntaaviaswhich rmit mmm pp ,
hau aaardous ci ants v afreil by do, Ai
Bay Arta r Quality Shoots., BOILER-COMP(OVER 100.000 BTU) PAID
DDistrict!
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT.
I I hevc red fkS ft ty Cc u9 n ti,iala 5505, menu udn Chef un smo M Ns JUN -81994" 199
California IIcmad&Safety Code.Satimo 25505,255JJ andda Ch Ito 6.95 of
if the building doer not cumcaly have a Immo Dat It at my respm.iMlity to ndify Ns
rc ss 1 f�I
up ci of Ne mynru uirawhich must bmu prim mprim to isaaance of a Cmifcau la
M
(lccvpwuy. Ur �UYCH
Owwo-euNuried ngcm Dau TOTAL: ISSUED BY;
OFFICE