30055 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO • BUMi NO-F.LFCHANICA ?ERh1ITN0 30055
BUILDING DIVISION APPLICA'T'ION/PERMIT I'INGP PROJECT.-MECHANICAL 114
I BUILDING I'ROJECI'IDENTIFICATION !!!
(BUILDING
'//\\A�L'S5: � � ^� `^ �Y Q / SANITARY NO APPLICATION 5UBh11TTAL DATE
' NAME: �/•'C/\ PHONE TNIRAACC'ITI/S�NI _ / LIICC/No
' ��I�-syI N/C CONTROL# ,
RCIIITE tNGIN L NO ADI R v S �� / ❑ - I r
coN'ncT PHONE BUILDING PERMIT INFO
i El Consultant Fees Paid by Applicant(Initial), BLDG ELECT PLU R MECH
,a
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC FERMI'P FEE•
1 hereby affnn that I nth licensed under provision,of Chapter 9(rmnmenang I I rJOB DESCRIPTION
CC
11yy Z with 1 fame ide ec Uisuum Jof the Business trod PndesrvmsCNe,and mylicenu is
f-0p cen,.ice send effect
PERMIT ISSUANCE RESIDENTIAL: •
�FU�U Lteeuu Class Con ❑SFDWL ❑PLUMBINGREPIE1.
NG� Uetc Contrvnor AP1'LIANCIiS-RESIDENTIAL ❑ADDITION ❑PLDn1BING RI:PIPIi
ARCHTFECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCUM. `
,O on I uaderHand ni 1 pu r
7•pv2'� ypanv shAl nc rased ni hhc m.ords MODIFICATION
OZ-O UP'1'0200AMP$ El INTERIOR ❑CHIMNEY RIiPA1R
Licensed Pro fessional 201-INX)AMPS IMPROVEMENT
PPPQGGG OWNER-BUILDER DECLARATION AMPS Q 1 hereby affirm that 1 am exempt from the Contractors License Law for Lou OVIiR 1000 E' BATH REM HUREPAIR J DEMOLITION.
follo , Se<uan]Bl LS,Business send Rrfcssmm Cnde.An t tin y SIGNS ELECTRICAL ❑OTHER s �L
yd mgreasm 1 ya ynr cis t
F�Oa prior.,,a s,irowc.1, requires thetauhlicam fnrwehemrmilm flee signed stmemem
.] poor qu pp pc gn SPECIAL CIRCUIT/MISC.
p. that he s Incensed par...A,1.theproviemmol the Contractors Luuru Law(Chapter 1)
00 (conunencmg arm SeefimnT)XIIr1 Div,arn 3„rthe iunnms and PoAcasums Code)nr TEMP ME9 HR OR POLE INST COMMERCIAL:
that he G1p�o�� Sectmni]oil exempt
yany appfcam basis for the
alleged tAcrophoo.Any v
appl cammacorlipcnahyof POWER DEVICES ', - ❑NEWRLDG/ADDITION DIJEMOLITION
t man fou lontred dollms($5(x)) ., OTFNANT ❑FOOD SERVICE;
1-=n6 ❑1,as owner of the progeny,or my employees wnh%ages as their vde compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F will do the work,and the stracture is not intended oruffered Erode(Sec.70TI'Business ❑OTHEN
and Professions Code:The Contractor's License Law does not apply to an owner of OUT LETS-S f ITCHES-FIXTURES -
�'3 progeny who builds or improves thereon,and who does such work himself or through q
has sewn employees,pros Wed that such nmpn,emeal,one not mu nJed or offered far NEW RESIDPNrl .ELECTR SQ IT
sale.ILhnwever,the bunldmgonmpmvemnnssoldwitbnonc Yem of tt,mpinnm,the ( SQ.FP FLOOR AREA' $/SQ FT,
pneer-budder will have the harden of provmgihat he Jnd nut hwld nnmpnrve for
nfnalc.l.
1]1,as owner of the papacy,am exclusnely commetm6 with licensed crmracton m \ TOTAL:
c omme,the pro3en(See ]MJ,Bacra,saal Profnsions Cale.I The Contracmrs L-
Genie Law ores not apply it)his ownend pugwny who M1UilJe nr improves Omrenn.and QTY, U RING l' 1'EE I
whocontrems foreseen projects with a emanations)bttawd purmanno the Contmchrs
License Law, FERMI SUAN -
]f am exempt under Sec. BAY C for this reason �
Owner O„• ALTER-DRAT VENT�F.R(EA) ' r . I VALUATEfi6i��,:
WORKER'S COMPENSATION DECLARATION BACK FLOW 1'ROTIi ii
1 hereby affirm under penalty of pmqury one of the following declarations. \
❑I have and will am main a Ceraficate of Consent to self insure for Workers Compen- ) DRAINS-FLOOR.ROOF,ANAEACOND. i STORIES TYPE CONS'IRUCTIt1N
satinn,m provided tar by Section Tom of the Labor Cnde,tar the pert ntmunce of the ` N
wod.forwhichthupenm ,ousued I FIXTURES-PERTBAP
❑1 have and xdi nnamm n Worker's Cnmpcnsa0on Insurance;as re'and by Sent nn i
3]00of the Lnhur Cnde.Tnrtlie performance ofchework fee h! dr, .it is issued, IGAS-EA SYSTEM-I INC.J OUTI.lq S _ I DEC GROU, APN
My Wokera Comp cremoon Insurance carrier and Policy number are: - Ls
Carrier:'_ Iblmy No IGAS-F.A.SYSTEM OVER d(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS” I �' 96
COMPENSATION INSURANCE I I GREASMNDUSTRI.WASTE:INTERCEPTOR t
(TL....her need not hcmmdetWd l hap nor nc for at hundred dollars i$1 Q)I t ^r Bp VIRg DIVISION FEES,
GRfiASETRAP (b
or less.) - PLANCHIiCK •,,� \\1,�
Icelnfy that in performance ofthe work for which it perm;t ns issued,lshall ILSEW1iR-SANITARY-STORMEA NX) T, v�
not employ any pennn many munnersoas to M1eromc sublecunihe Worken'Cnmpen
z w+ VI
O z so,nn Laws of Chlt6rmm.Dam IV U O Appliant WATER HEATER WNFN /ELEC GvNRAERDGINY G P FI?Ef:E
NOTIcCE A'
l C y
Vr
TO APPLICANT If,after makmg this Cemriume of Esempmn,you should WATER SY59 Eh1/TRIiATING /0 (�
F become subject to the Workers Compensation provisions of the labor Castle.you must SOILS PER
C Q
forthwith comply with such prc,oums or this permit shall Fermented revoked. WATER SERVICE
az CONSTRUCTIONLENDLNGAGEN, i NEW RESIDENTIAL PLMH SQ,FE (PAID
V p l hereby affirm that there na construction lend;ngagency for the pvrfonnunce ul Date Recmpl»
(~' me work for which this permit is issued(Sec.3097,Co,C) r
Lenders Nair. TOTAL:
{U Lender's Adore^ - -__ �'I'OTAU� \�•�
I cenrfy thm 1 have mad ork apphcmmn end slate that the clause nommmtlon is - I BUILDING FEE �`Sa
A. eo,rem.l agree to comply with all mty and.onnty roommates nndstmc laws ri ,, I QTY. MECHANICAL PERMIT FEE
"V Z building ennamchon,and hereby awhim,,n,o,senwnvm nl'Ihncity hence,apnnthe ISEISMIC FEE r
alsoc-memionest p napery far inspauon purpous. PERMIT ISSUANCE
I We)agree m save,indemnity and keep hamder's the City of Cupenmo against (ELECTRIC FEE
` habihtms,ludgments,costs and expenses which may in any why accrue ngannst said City + ALTER OR ADD TO MECI L PLUMBING PEE
of the granting rf thrc pcmiiI
c CANT NDERSTANDS ANDWILL COMPLY WITH ALL NON-POINT ( AIR HANDLING UNIT 10,000 CFM) MECHANICAL PL'E
SOLIS
AIR HANDLING UNIT(OVER 10.000 CFA) ICONSTRUCI'IONTAX "
Signature of ApplithanNmntanA( Date/ •' EXHAUST HOOD(W/DUCf) HOUSING MITIGATION FEE
HAZARDOUS M IALS DISCLOSURE '
Will theap eamnr lnmm bud.bngncea,m,hmnr handle ha r..hmmatenal HEA'T'ING UNIT(TO 100,000 BTU)
as defnul by the Cupertino Municipal Code.Chapter 9.12,end the Health and Safety ,
Code.Section 25532(x)" HEATING UNIT(OVER I00,IpO BTU)
E]Ye' i]NO o PAID
VEN9'ILATIUN FAN(SINGLE RFS113) Date ftecc,po»
Will the applicant or furore but by the ti use equipment or devices which BOILER-COMP(3HP OR 1110,0(X)BTU)
.snit huraNum am cnn.ammunts as defined by me BuY Area Art Qunlnty hlnmagemen( I i 'Ib'1'AI,
Duane,' I I BOILER-COME(OVER 100.000 BTU)
❑Yes E_]No
I have load the havidnus notsrim,rtgmtemenu under Chapter 6 95 of me Call. AIR CONDITIONER
ISSUANCE DATE
fnmm Health
6Es,,n Safety Cade,Sectinm 25505,25531 nmJ n,C 21534 1, I send, Offi maid the NEW RESIDENTIAL MECH SQ FT
hml nu urtcntly hhh�����,ea tenant.tool weyrespons,b'anyy' ,tify thciKCypant
�uws the f aCc�� ulie
t9mhovcJ agev,i 11�'11j Dam�YP "I TOTAL: (ISSUED BY:
OFFICE