S 2107 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.LLECI'R ICAL PlittI'No 2107
BUILDING DIVISION APPLICATION/PERMIT PLOVIRING-MECHANICAL `\1
BUILDING PRO I:CT IDCN'I IFIGA'I'ION
RUIIDINGADDRE.SSS:I y� SANITARY NO. APPLICATION SUI3MII I•I'AL DTAE
2 /�T7 �Q1''i 160 k/ AA ,
OWNP.R'S N/q�'4E: Ii'IIO�Nli Q L ON'I'FACTTOR:S NAMIi: LIC NO'
imp/IB /ir ' N/C C(lN'1'Nlll.p
�I ARCHITECI'AHI GINEE : LIC NO: ;DDRFSS/ / /1 ,a A ❑
'' 73 aU <AJ'/d Xl� �/C•
CONTACT: PHONH: BUILDING PERMIT INFO
Consultant Fees Paid by Applicant(Initial) BLDG ELECT Pr MECH
Sa 3 J' EJ ❑ ❑
I.ICENSED CONTRACT'OR'S UFCLAltATION QTY III.IsUFRIC PERMIT FF17
1 hereby affirm mal 1 am licensed under provision,of Chapter 9(eommcaeing JOB DESCRIPTION
O IyO with Statical 7000)of Division 3ofthe llusincusand Pridn"iom Code,andmy license is RESIDENTIAL:
{rl O I'IiRMIT ISSUANCE
Fa�F. nmll fume anile cy, /J 39' /rl 3 ❑SFUWL ❑KIUMPING RF PHIL
QVV Liccnsc Civs ` O/-`4�L:,flh APPLIANCI?S-RESIDI?N'I'IAL ❑AUDYf10N ❑PLUMBING RE-PITC
NQ6 Date Colli LCL
FOy ARCHITECTS DECLARATION PANEIS ❑MULTI-0NI'1' El STRUCTURAL
Z O-Z l understand my Plans shall be used as public reu,Nx MODIFICATION
O Z.'-, UP'102axfAMl'$ FHF
RIOR ❑CIIIMN17Y REPAIR
hiacnsed PrtF„,sinnul 2f11-IlIll11AMP5 IMI'ROVI3MhNT SWIMMING POOLS
yF
�+1fJ OWNIiR-RUILDIiR DECLARATION DYER IINNIAMPS ❑BATH REMODFUREPAIR ❑DFMOUTION
Q y wi inn that 1 an exempt from the Conlmcmr's License Law for the
ig5O0.V following reason.(Section]031.5,Rosiness and Professions Code:Any city or cloudy SIGNS RI.ECfRICAL 001'HER
Ira'3 t whieh umpires.permn to cmmnuhar,
tst , imprnva,de.....k ,m repvIm
it y sm.0ine
prior runslssuanro,also requirus the applicant lnrsucli,,ndua filensigael shoo ct SPECIAL CIRCUIT/MNC.
f, }'a Thin he is licensed Pa....,-the povisioroof he Contractor.Liven-lvw(Chhptar9
W y'QD (commencing with Section 7000)of Of vision 3 of the 11 uxineas and Professions Cole)ur TEMP.MFG:R OR DOLE:INST COMMERCIAL:
a c m
that he is comma Iheafmm and the basis f r me vllegM cxempdion.Any violminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
-,h Seetian70315 by any.ppllcum For.penut Subject, he atpllcaal ma civil ponal,of POWER DIiVICP.S 01HNANT ❑FOOD SERVICE
nal more that live hundred dollars($500).
f50 FlI.us ownerof me prNamy,or any cmployceswidh wages as their sole mmpen,alion, SWIMMING POOL RLECIRIC IMI'ROVIeMIiNT
aaF will do the work.and the stronure is not intended cropland fir,,le(See.7W.Business ❑OTHER
halt Prohessinas Cade:The Connector's License Law does not apply ,,un owner of OUTLI3I'S-SWITCHI7S-PIXTURPS
a'a property who hdlds or improves thereon,n al wit.line,such work himself or(I I,
his own employees,prmided TIO,such improvements are nm intended or altered far NCW RESIMiNT1A1,Ii1.F:C`R SQ FI'.
sale.If,however,the bhildirger improvement ill wolinane year afrompledion,the SQ.IT.I7LOOR ARBA ESQ.I.-F.
puer-bolder will have the burden of moving Thal he did not build ar impmva fm pur-
aur sale).
❑I,vs owner of the property,am excloiecly tohmhatiu,saint Ilrcowd cro runnrx to 101AL'
instruct the pmjetl(See.](q4,Buslne,.,sad Pmfesslmn,Coact The Cnatracu,r'.I Li-
censeGave doesnot apply toanowner of property who builds or improves theram,and QTY. PLUMBING PERMIT FEF:
who umhnc.s for such projects with n connotations)licarvul pursumu IT mo Codnmcor's
License Law. PERMIT'ISSUANCIi
I am exempt under Sec. .B&1'C for this sector
ALTER-DRAIN&VI?NT-WAI Fit RA) / VALUATION
• Owner Date (\/P
WORK EICSCOM orfarj.TION DECLARATION HACK FLOW PROI'[C'I'.DGVICIi a O Clam
I hereby off rte under penalty al lwriury oma ul'mclitllowing Jedarnaintts; C/ �J
❑ Ihave andwillmainmina Cenificaaeof Consentmself insum for Worker's Conipen- DRAINS-FLOOR.ROOT.AREA,COND. S'rOH1ES TYPH CONSTR UC TION
cation,vs provided far by Section 37M of the Lahrman
Code.for me perforce of the
work f r Moo this permit is issued. FIXTURES-PER TRAP
�]
Elf
and will In.inalln Worker,Congmnsvtlan III eu.ance,a,required by Saellon
3]IN)nf me Luton Code,fnrlhe perfomrmce of the work fur which Ibis lwrmia is ,sued. CAS-13A.SYSTF.M I INC.40U'I'1.1 T5 OCC.GROUP APS
Aly Workers CnyyttRe m Imurn�1{� ;grierand Policy umbers
Entice C4/,ria ]=Me Policy No.: GAS-EA.SYSTEM OVER 4(HA)
CPSTipICArf OF EXi?MPI'[ON FROM WORKERS
COMPENSATION INSURANCI? GREASIJINDUSTRL WASTE PH IiRCFPTOR
(This-,tion need oat be eompleted Ifine Iwnmil is histone hundred dollen($111(1) HUI4DINC DIVISION PIiRS
GREASE'
or less.) 1 NAI' PLANCHECK IT?E
I certify lhm in[tic performance aDhe work for which this permit is issued,l Shull SEWER-SANITARY-S'PORM F.A.2W IT.
nal employ any laxwn in any manner yo ns IT bscaam al'i'th m the Workers'Cummer- ENIiRGY FGD
Z ,Z cationi-ocsof Califomia.Date WATHR 1111ATERWNEENIPLCCIR
0 Applicant GRADING FFF
rn NOTICE TO APPLCAN'1':If.after making this Cerificale of Exemption,you should WATER SYSTEMKRFAIING
(~ 5 become sobject In the Worker's Cmarpenmaion provisions of the labor Code,you must SOILS FEE
WI� fimbwith anmply with rich provision,in his permit shall he Jeonul mvnked WATFIt SIERVICE
U O CONST RUCTION LENDING AGENCY NEW RRSIDPNTIA1.1'LMH. SQ.IT. WTOIAL:
hte Hecci dX1 herahyaffirmIhatheir aacosaocdoo lending agency forthe perfomtanscofPme work lits which mix pennil is isu09],Clv.C.)
I.e.der's Name TOTAL:V Lenders AJdrcs, til0. 1 cartify that 1 have mad this application and state Thal the ab tie infommtion isli(A correct.l agree to comply with all city and county ordinances and.state laws relining to QTY. MECHANICAL PERMIT ITF,L) 7, buildus,onsnllninn,and bemhy Iothod,moncianaflve,ofonicitym enter npanthershove-mentioned popery Iia inspection purposes.(we)ag.to save,indemnify and keep hamdessthe Cityof Cupertino againt I'ERMII'ISSUANCEllliabilities,judgments,variation expenses which may in any way rearms,against said City ALTER OR ADD TO MECH. D
in ms :EAPPLICANT UNDERSTANDS AND WR �OMPLY WITH N.I.NON-POINT AIR HANDLING UNIT'110dpddCFM)SOUI`CE RF('ULAT NS I.IFE
-:L / g AIR HANDLING UNIT(OVER I0,000 CFM) CONS'TRUCION TAX
Sign care el'Applicant/Cont tar Fine HXHAUST HOOD(W/DUCT) HOUSING ME I GATION F1717.HALA Do us MAr1iR1ALS DISCLOSURR
Will the alrplicam or turn.building swchpanlnntuor handle hazarduusntaterial HEATING UNIT(ITT 100.000 Bi'U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cute,San a 25532(.)? HEATING UNIT(GVHR I100,000 II'YU)
0 Yes PAID
VCN'I'ILA'HON FAN(SINOLP.It13.SIU). Date Rcecipa#
Will me applicant future building hnl use aquipna+m or devices which cmM
idhamous air mminincovamsnsdehnW by by he Huy AovAir Quality Management BOILHR-COMP(SHPOR IW,(p(1 BTU)
Diprin'I TOT 1;
E]Yes BOILI?R-COMPIOVIiR IW.pfNI R'I'U7
I have mad the hichun s materials handuchrents under Chapter 6.95 of me Cali- AI R CONUI'1'IONER
ISSIJANCE DA'I'li
Forms Health AT Safety Code,Section,25505,25533 and 25534.1 mndersmnd that Hthe NP,W RFS1DF..NT1Al.MECH. SQ.IT. q �Q
hullJing doe,not-mmdlyha,aalan.nl,LWit i.nlym,pm,ihllily IT notify ma acahpanl
of the raparoments which must he mal prior to issuance Hit Carinthia,of Occupancy.
Owneror..thonmdtienl Doc TOTAL:
6 ISSUED I{Y:
OFFICE