28167 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO .) G F,
- ,EE RICAN PERMTNO.
APPLICATION/PERMIT -PI,UMB NG-MECHANICAL
BUILDING DIVISION BUILDING PROJECI'IDENTIFICATIOV 28167
BUILDING ADDRESS: 1. SANITARY NO. AITL]CATIIO}N SUUBBMITTALDATE
UNIT# >- LOTM C yf iA s
OWNERS NAME PHONE CONTRACTOR'S NAME LIC NO: 1- l
'17 Tit MO erg �D�`` ) - C /Ll NV �1/T CONTROLLIIt
UCH c�INDGI S: _ I SIC N , CADDR4SL.Y�I Lt,.JfLry+E--� f�V polio G 4 � J✓
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CONTACT: PIONS BUILDING PERMIT INFO
QTY. ELECTRIC PERMIT FEE
CWP 1/��� J)` JCw ,// 'I -XYJ B�%y T PLU MEcI
Y e-V Efz¢i✓�(� �TI� �_® PERMIT ISSUANCE YLDJ(�
LICENSED CONTRACTOR S DECLARATION APPLIANCES-RFSIDGTAI.
pKZ Thereby affirm dnllam li¢nacd utdapnwisianof Cheta9(mmlrcncine with JOB DESCRIPTION
4100_
full fioornceransf of Divlsion3ofthe Bunncv eM Pmfavom Cak.aN my limier is in PANELS
cBm.
IF¢.ZW I.iceluc Clnrs Lic.Y UP T0200 AMPS
In?y ).(a Conutsctar ]111-I""PS
ZOyz ARCHITECTS DECIARATION OVER 100( PS SQ.FT.FLOOR AREA S/gQ.FT.
OZ—c lundcnwd my plane shell be usedupublicrm�ndv
r,i1 ) SIGNS ELECTRICAL
IJcemed Pretfcaionel
W,m< OWNER-BUILDER DECIARATION SPECIAL CIRCUff/MISC.
Ax'Oa0 1 hereby affirm that 1 om exact flan the,Contractor's Liceoae 1,w for the
W 3 tL following rtnwm.(Section 70313.Bu inear and Prof sooca Cade:Any city or county TEMP.MET1R OR POLE INST. \
which requites a Parmil to conalruct,alter,iminove,denolish,or repair any structure
E;!(}� Ria tofu ivuure,Wu.rtyuirts Ne ggliaan fu wchpentdt to fikeugrN swemmt POWER DEVICES
_<O than he is licensWputauant to the pmvisiau M the Cmvarfr's Liccme 1Aw(ChWar
". �m FL 9(cmtmcncing with Smti.7 llof Division 3 of do Buslnass and Pndaesiona Coda) SWIMMING POOL.ELECTRIC ALUATION
ca
Iy_y m dwr W Is enanpt therefrun and the bait for the alleged exaction.Any viduion of ^,a
1-Z)' Smion7031.5 by any applicant for a protract subjects the at,, ttoanril pemlty of EIS-SWITCIHS-FIXTURES �a aiO/L—r
S•r.< rwt m«e than f.c hmmcd dol W. `JY(5500). c
CRO NEW RESIDENTIALELECTR _SQ.FT.
ad ❑ Ids,ao erof d'hetpeny,mnryemployeeswilhwagdrtlhnr.okcmtpuuarion. STORIES NTRUCIION
3� shad dothcwak,andc:The nami,an,imacease stw dmf sok(Sea. Bc,owner of
ird Pmfe..:.....Code:The Conlraclor a License law das Trot apply m N owner
prgmywhohuildsaimprnethcmtnmdwhodocs his stchwakhirmelfa WwYM1OCC.GROUP RES. NITS
own ccplcym,provided that such Impmveetents ere not intnakd cohered far ina.IL
btweva,the buildings imtovemen is akl within one year ofcompleim,theowmr-
Wilda will have the burden of proving that be did not build or imtove for pupae of
d.).
El 1,as owacr.fflba mY.unexclusivelycunvactinY with liceluedc tnc .to QTY. PLUMBING PERMIT FEE FlOODL APN
<nnstrux the mojecl(.Seer TUW.Nusinca and Pofeuimu Cadc:)'1 Cont oars
lis lAwd not RTlytomiowmoftopmywMdrildmina nthcrta and PERMT ISSUANCE
whocmtrvns fusuch projects wiIt•mato,, t(e)licmud pts wtlrC
IJcctua Law. ALTER-DRAIN&VETT-WATER(EA) FEE SUMMARY
❑ I em cacmt uukr Sa. B&P C tet Ihk rat BACK FLOW PROTECT.DEVICE )
SANITARY Y N
Owner Due RECEUP1711
DRAINS-MOOR.ROOF.ARBA,C
W ION DECLARATION SCHOOL TAX Y N
❑ Ihrrchy offir that l hoveaanifceraofci mitoulf-insure,a ane Ecu of RECEIPT.
Fl%TIJRI'S-PER TRAP
Wades Gnycns ion lnnmmrcaacmifietl cropy Womflsec-3gIX1.1AbC)w ch PARK Fl?E YN
mean ellempbya uMer Nu permit / l�� GAS-EA.SYSTEM-I INC.SOUT.EIS RECCIPTY
Paltry. BUI DIN IVIS FEES
Company / y CAS-U.SYSIW- -OVER 4(EA) P1_ANCH11CK IPC
❑ CeniRed copy is erebyfun ted /-� >
W 11
❑ CmiT lcogtls NwiNthecirylrupecti di A" / GREASF0NDUSIRL WASTE INTERCEPTOR GRADING FEE 1
GERIIFI ATE OPT.' I. F O KERS' GRFASIi'IRAP SOILS EEC
�1 ('o PEN - cc t
mlrn�s•sotion Jd be jtufa art doIMsIS100) SEWER-SANTARY-STORM EA.3(IOFT. ENERGY
Icenifythati nthepc rmonccofd wA forwhiispmnil ix i—eal.I"I WATER HEATER WNENT/FJ.ECIR
out "Iny any Person an uly'ioaflfle so to subject to the Waken' PAID
Canpctlswim U.,of Gla anis DuIR
Due WATER SYSTEM/ EATWDuna R i
C) z Applicant
z C:) NOTICE TO APPLICANT: L.. mILtsatin nCmif am of Ehrnttion,You sMuW NEWRRSIDEMIAI.PLMB. SQ.FT. 'AL:
Metre sult)Cel to the WmV: '.Cunpc tet povi.siom of the lAlrt Coda.You must
PG 7 furhwith eatrply will such this pmnit shall h cleaned rerakaL BUILDING FEB
W Q CONSTR t ION LENDING AGENCY SEISMIC \
^� I hereby affirm that alae u a mnstrunan lending agency for the perfomwtcc of
V O dte wet fu which wi.pact,h iss cad(Sec.309].Cis.C.) T FR 55
✓
Isnder's Nano
OF Lca&r's AtNress QTY. MECHANICAL PERMIT FEE PLU
LLJ J 1 certify Thu 1 have read thi.t,l.a.and vara Nat the alae infotmetion a, it
caner leete<tocmtply with all city ad county adi,w,eaa and.Hws reWingm PERMIT ISSUANCE MSCI IEE
� building cons uucuon,Whereby,...ho^,•retesrnarise,of ddsdry m ental. athe
U 7 obmc-muni p,=.y fm itupn:licn Purgoes. ALILR OR ADD TO MECfI. CONSTRUCTION AX
to aver,itdermtify and keep humlw Na City of Capcnirlo agoitu'I
liabilid ,j gmrnts.mw"expansew ' mayinanywyacrueegw
alsaiciCty AIR HANDLING UNIT OU) 1100 1), Mkk
AIR HANDLING UNIT(OVER I0,000 CPM)
ppT nuaxa /or loath, EXHAUST HOOD(w/DUCT) -
PAID
I IA%ARDOUS MATERIALS t mme as SURE
HEATING UNIT(TO 100.000 BTU) Due aceiWY
Will theby the,Cumlafuamicipcd Car,Cha latmeu M1.Mehvudomt!Weld HEATING UNIT(OVER 100,000)BTU) 'OI'
n Aefined by the,Cupeniro Mlmicipil Coda,Gluten 9.1;ud the I health ud surety
Code,Section 25532(a)P
❑Yes El No VENTILATION FAN(SINGLE RESID)
BOILER-COMP(3HPOR 100.000BTU) sa$$UANCE ATC
WiB do applicuda(wurtbuildingompmn uucquipmcm adcvim which unit
baaSRllaa air mtunminan.u defined by the Bey Arm An Quality Manaieroau BOILER-COMP(OVER 100,000 BMDqII
istrix! {/
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.FT. I )> 1 s 19$S V
1 have toad the ho vdae metcriah reauirtmrnu Cl
under nte of 6.95 ttte
California Icalth&Saary Codc.Sectiau ISMS,25533 atel 25534. Lund thud that t.y
if the building du7 aot cutrendy Imve a Ian.nt that it is my nspomihillly to cosily the rey��N
sccupaa of the re9uiremams which rrv„Ix ret prim an is of a Ccnifime M
Qau nry.
Ownef or auhori>N agent Dec ISSUED BY:
OFFICE