27738 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CIPY OF C UPERTINO R ILUI. -t.LL 'RICAL PERMIT NO.
APPLICATION/PERMIT PING PROJECTB NG IDEM—MECHANICAL 27738 7 7 3 8
ISUILDINI:DIVISION IIUII,ULU PR OJECT'ICHANIFICATION G v
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
UNIT# LOT
OWNERS NAME: PHONE: CONTRA I R'S NAME: LIC N'
2I o NIC CONTROL#
RCHI'F,Cf ENGINEER: LIC NO: ADDRESS: •J El
N mo q
CONTACT: PHONE BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT PEE.
BLDG ELECT' PLUMB MECII
PERMIT ISSUANCE ® I�.I 0 El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL �-P
OKZ I1enby:dfrntwtl:un licensed undcrprovisionsof Chaptcr9(commencingwith ('�� ��,,�� JO.�Utt' CRIPI'ION
�00 Seadon]0(0)of Division3 of Ne Businessand Professions Coae,and my license is in PANELS S"CR/yeR_!sl
f+l C full force and df
"i<cL Licenx,CJass, l,ic.p la UPT02fN1AMPS L^�Jwe
yQy Data.Lust L'TjL_Cmuni do 0 " 201-I"AMPS
D SQ.Pf.FLOOR AREA $/SQ�FT.
Z~O"� ARCfII'1'F;CTS DECLARA]'ION OVER IOW AMPS
m 1 understand my plam,hall be used as public records.
OZ-0
F.,yFtu SIGNS ELECfRICAI, 41
Q J
Licensed Professional
yfJ
KseQ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
X06U 1 hcrchy uffmt that 1 nm exempt Imre the Cnnw nor',Li 'e Law for tM1c
W�Oy followingreovr.fSxaImn]031.5,Business and Yrofesaiom e:An city or county TEMP.MEEER OR YULE INST.
r— Q
which requires a permit to consumer slur,improve,d wh,or rcpai any sweure
$�}$ prior rnitalasumce,also requires Ne applicant fo permiltu Neaxig ed smtement POWIiR DEVICES
,s<0 that he is lacroad pursuant the provii the Contractors License w(Chapter SWIM O .ELECTRIC
1aa<a�' 9(cammencing with Sarni vision 3nfthe Business and Prof sons Code) VALUATION
W—rn or that he is exempt in and me basis for the alleged exemption.An Auditioned O EES-SWITCI{ -FIXTURES
f—Z Q Seniors]031,5 by any app ant for u permit zubjeas the epplicom m e civ penalty of
� G mtmuve thin Hive hundred ollars(SSW). v 1 oro 'W RFSIUFMIAL.ELE SQ.IT. 1`--�
W e ❑ Lmosocroflepfope rmyernployesswirhwag<a ma.on, STORIES TYPE CONSTRUCTION
d,3 e_ wilt duthework,and the stow mismaintendednro r 1 Sec.7044, aTinesa I
and Professions Code:The ntractors Lic se pply to an o er of
propenywbobuildsorimprov thereon. J , workhimulfor 61da
cmployec,,pr.vidal than,chimpro n timmhadoroff Jfar'. e.Lf. OCC CROUP RES.UNITS
however.th<building.,impm amen ismid i n<y..fc ction,the owner
builder will have the burden of roving that he di n build orprove for puEso. f
.talc.)' QTY. MBING P MIT FEE
❑ I.asow.n.ifbepropeny, mcxcluslvelycontim' with licensed con Ionto FLOOD ZONE ANN
onsnan the pncpe l(Sea]W4,Business and Pr „ions Ctale:)The mater,
License Lawdsnanot apply tom o at fpsm whobuildsorm, athetmn.and PER ANCE
who<tmlrectsforsuchproject,wim. am r(sHicensdpcoman otbe Commumn'a
Llcunso I.... -DRA BNL'-WA'fh (IiA) FEE SUMMARY
❑ 1 am exempt under Sac. B& for this reason BACK FLO P ECE.DEV E OUTSIDI;FEES
SANI'1'ANY Y N
Owner Dae DRA S-FLOpR,ROOF. REA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y f N
❑ LM1ercbymffrmthmlh:wcacenifcancidonsent l,,suit nv a,.rac ifcateof FIXTURES-PER T'RA RECLINI
111—
Wmk<tiC.mpensation lnsurmu nrn eenifid copy lhertof(Sae.J#W.Lob )which PARK ME Y I N
rs.Hma l.yclunder is 'r. GAS-EA.SYSTIi IINC.40UTL S RECIiIY #
Policy# L — BUILDING DMS r ES
Company GAS-EA.SYS M-OVER 4(G PLANCHECK FEE
C] Certified copy is hereby fumishcd. L
[RbCmiti<st copy is fled with the city inspection division. GRF]SERN STRL WA IN RCEPTOR GRADING ME
CERT RICA]F OF EXEMPTION FROM WORKERS' GREAS RAP [PAID
S FEE
COMPENSATION INSURANCE
('"is section need not be completed ifthe permit is forone hundred dollars(SIGN SEW -SANITA -STORMEA.200PT, RGY FEE
or less.)
I ccnifythat Tribe perfamm<e of Ne work for which this permit is issued,1,hall WATER HEAT W/VF.NT/MEM
not employ any Person in any nr .r as.r become subject to the Workers'CompenaationlawsofCalifmia. Dae WATER SY BEATING Receipt#
Z Applicant
0NO I'ICF.TO APPLICANT:If.after making this Certificate of Exemption,you should NEWR IDENTIAL ELME. SQ.FT. TOTAL:
) hecomesubjecnothe Worker's Compensation provisions ofthe laborCrde,you must> forthwith comply with such provisions or this period shall be deemed revoked. DI IE7Ct them iUCTIONLENDING AGENCY MIC FII
Rz lhcrchy offrad Omt there isaamswmion lending agency fm @e performance of TOTAL: CTRIC PEE
U O the work for which this permit is issued(Sec.3W],
Lmdar',Name PLUMBING FE
Lender',Address QTY. MECHANICAL PERMIT FEE
V I certify that i hove tend this it,humm.and slate that the move information is MECHANICAL FEE
>. 14 cone,,. lagrec wcdnrply with all city anJ county oNinances andame lows relatingm PERMIT ISSUANCE
F" 14 building construction,and hereby auNoaAre representatives offl scity tomper upon lw CONSTRU NTAX
V z abova-memim,d propmy for inspcetion purismal ALT17R OR ADD TO MEC]I.
(We)agree to save,indemnify and keep harmless rhe City of Cupertino against
liabiliticsjudgments.costs and ca,saw<s which may in any way statue against and City AIR HANDLING UNIT(TO 10.000 CFM)
in nncyuenceof the gra ting of,hi,permit.
AIR HANDLING UNIT(OVER 10. CFM)
Signaurc.f piicun4Contrmmr I pitte I EXHAUST HOOD(W/DU PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 10 . BTU) Dae Receipt#
f Will the applicant or future building accuParrt norc or hurdle hassNous maerial
as defined by the C.Kr ino Municipal Code,Chapin 9.12,and the Health and Safety HEATING UNIT( F.R I W,000 BTU) TO
Code,Sonion 25532(.)" IlkIk�yyytg5{{{k #9 TT
❑Yes / No VENTILATIO AN(SINGLE RGSID) _ B ■�
/- BOILER-116MPQHP OR 100,1000 BTU) A CDATE
Will the applicant orfu umbuildingmeapanmsecquipment ordevices whichemit
• numbers air mina inmts as defined by the Bay Area Air Quality Management BOILF -COMP(OVER II#1.000 BTUJ J• 0
UinlvicR ,�/ `,
13 Yes 1,}N. N RGSIDPMIAI.MECH. SQ.IT. Ur
I have read rhe haunt/urs maerial,reyummuents trader Cwpter 5.95.f 0e Lu�C�IINU
California Ilcahh&Safety Code.Sections 25505.25533 and 25534. 1 understand that
if rhe building doe,not conn tly hove a I rant,Nat it is my rtsponsibility m nobly the ,
occupum of the rtyuirt cru hich must be con prim to issuance of a Certificate.f v✓#' N
OkS
,m �6)
/.
09.09.cr or mth .,in Draw I TOTAL: ISSUI:DHY: 1W
OFFICE