26241 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO .-H "'MIR PERMITNO.
APPLICATION/PERMIT MUMBfNc-MECHANICAL
BUILDING DIVISION BUILDING PROJECT IDENTIFICAI'IOry 26241
BUILDING ADDRESS SANITARY NO. APPWH
CATIONSUBMTALDATE
-\S'5 3 UNIT* LOTH
O NAME: . TONE: CONTRACTOR'S NAME: LIC NO: NA `��COMRJOLN`•
RCIIfIECT/FNGINIA:
LIC N(I: AD S: ❑
PHONE QTY ELECTRIC PERMIT FEE BUILDING PERMIT INTO
�' •1"�/ l 3Z1 a8 BLDG r PLUMB MECH
PERMIT ISSUANCE
IJCENSEDCe)NTRAlerpmG mudfCbamr9 APPLIANCES-RESIDEMTAL
pyL hereliy vnlicensed!uMm pod PmfmionsCov9nd!my I eirg whin JOB DFSCRIPf10N
+100 full force l)��visim3uf the Bunnanmd Rofwians Cade,erttl mylicenuuiv / PANBI9
5y88y1
? ti
` u Crown« I I-IOOOAMIPS.' \ 1
GOyZ ARCHf1ECIS DECLARATION 0YERh000 AMPS SQ.FT.FLUOR AREA S/SQ.FT.
Oz_ lutdmtard my pfernsM1Wbeucd v pudicrcwrd.
Pgl5� s -s e�PGTRIcuI h lj�
yEw IieeruN Profmimtol
z6V OWNFR-BUILDER DECLARATION SPE IT/MISC
qx Oa 1 hereby affirm shot 1 em cram from Ne Caowetor'a Lic,tu,Law for the
W3� fohlowingrcu«L(Sadmto031S,Rustiness;and Pmfenipn Code:MY city m cvumY .METER OR POIJ BJST.
Cu'ONS whi,h,,um a. —i,,n.,ether,improv,denuliah,or repair troy atrunur,
i }S prior to its ivuuce,alwteyum,,iheepplieenr f«uehpmmit to Bk eaigved ell 1 POWER DEVICES
aC<0 tht he is IiamN Fossil to dat pvviu«uoftle Contractor's liceme lsw(Couper
�cc 9oc',o ml wit Section 7M)3)of Pviixxi 3aflte Business grid Pmfissims Code) SWIMMING POOL ELECTRIC VALUATION �•
_y «that Mia exempt thmefrom and rte bass for de dkgcd c.acmpim.MyrkLtianm U`T,ff S-SWIT' CUES-FIXTURES
Smn...re ito ,cauma llufl f (SSmnit wbjanthe epplirentw•evil pemltyM J J
rt«more than feet Imrdml�kllars(5.500). NEW gP51DINIlAL ELECTR
_SQ.FT.
L'C$ ❑ I,uownmo(de pmpeny.mmymploymwltM1 wtogesu Jwirwkcampewtion, STORIES I TYPE CONSTRUCII)N
4e3— will da Network,nndthc stnrtwcisnlo,I ie l Low los weer of
total 1`mfcvions Codc:the Cmvutor's Liamc Low dos rt«apply w an owner Of
PWcrtY who duWa«itrtlmrves thermn,W wMdmwch work himclf«throughhf,
If, OCC.GRP RES. IIS
owncmPloyca provided tM1et such improvcrannercmnLimcNcd«Mfmd fmaetic.
huildcr ,Ncbve she, aims mvinusoldwithinot Y®roreamPkdm,duownm-
WiWerwillNvcN,burhn MpmvinB Jut he alk rd build«improve f«Inupwe of 1' r�
sale).
❑ I,esown,rd'thc polerty.tome.acluvivclycmtr`^'9WNlicrnudwnnecwra to QTY. PLUMBING PERMTT FEE FLM5 E APN
.,«alma the projm(sm.'/fwt,Bosiness.rM Pfofeauwo Codc:)The Comissior's
I.icen.c lawde,rodaWly iaunawnerofprnpctywMlwilds«impmvu Nvmn,erd PERMIT ISSUANCE
whocmu.cu fms hpojecnwi acamior(s)Imud pvsu.etwde Conhsta'• ALTER-DRAINh VENT Lkmnc Lew. ME SUMMARY
❑ 1 em e.aempt umlm Sa. ,B&P C f«Nis rtuon ,I E
BACKFLOW PROTECT.DEVICE SANITARY Y N
Owner Dote RECEIPT M
DRAINS-FLOOR.ROOF.ARG,COND, SCHOOL TAX
WORKMAN COMPENSATION UI:CI.ARATION
❑ IMeby toffum that((ave.ccrt.ciwtcedcc,y wrclf-louue,m.mC.)which F:CEIPI'N
W«kcrs Cant tion under
nrmilL cdc PlXTl1RCs-PER'IRAP
pcnw opy Ncwf(Sa.3S(MI,Lab CJ which PARK FIE N
covers all employs i uMm Nu pemJL GAS-EA.SYSTEM-I INC.S OUTLE-1'S R CFJ x
Policy .DI JAYMON FE
C«npary GAS-EA.SYSTEM-0VER 4(EA) RAN
❑ Cmtifed capY u hereby fmolsMd.
❑ Certified copy Is fled wit the city irsp ticn division. GREASFANDUSTRLWASTEINTF,RCEPTOR GRA hl:
CERTIFICATE OF EXEMPTION PROM WORKERSGREASETRAP SO ,. FEE`0
COMPENSATION INSURANCE
(This section recd oast be cmtpletM iflhe pvmit is for are huMredddWs(SIM) SEWER-SANITARY-STORM FA.2X)FT. ENERGY FEE ILA-0
or I..)
I«nify that inthe perfomuna a dte work for which Nis Permit ivuM,(shall WATER IIHATER W/VENT/ELECTR
rt«employ any pe.in any.m u to become,subject to Jet Wmkcri PAID
Comprnvnon lsys of Gli!«nito. Due WATER SYSTEMVIREATING the eiptx
O z Awllum
z 0 NOTICETO APPI,ICAbtT:If.dust,makivg Nu CmIl.of Esemprion,you to.W NEW RFSIDFNTIAL PLMEL SQ.FT. TOTAL:
(~ .C-. beam,subject to the Worke s CamPmatodan pmovidorn of the luta.Cade,you must
foMwlth comply with such mvisimu«ids pmmil shod)k deterred revokes BUILDING FEE
ra
W F CONSTRUCTION LENDING AGENCY SEISMICFF};
5 I hereby toff Jw Jxre,is.cmnaunbn lending agency for Jet pcf.M
U 0
the,work!«which this permit is issued Pica.3(i9/,Civ.C.) TOTAL: ELECTRIC FTP
L.crdcrs Nunc
W" U Lmdm's AAdondi QTY. MECHANICAL PERMIT FEE PLUMBING FTP
U I cmify tbt I hate teed Nu it'licuien W nate dal Nc abavc infmmatim Is MECIIANICAL FEE
correct. Ing We mplywiNWidyvdcnunty Winua; "sM lewareloirtgw PERMIT ISSUANCB
E-' building c«uuucnu,srdhmbywNvi pue ,iuriva of tluscitYnmum upon Ne CONSTRUCTION TAX
V ebweWemio«,d to Ni,Yrinsp,n ion Puryoba. 'ALTER OR ADD TO MECII. ��
(We),gra tn.coast
itdcmnify and keep M1umlas Ne way accrue
r Cupertino ill Cit t
Iitodlitia,jWgma'hemu udeapevnavldcM1 may inany wya¢rue.6ainn vial City AIR HANDLING UNIT(TO 10,(pp CFM)
N<nn yuenee Mthe gr.nun$ minis pemmi.
0 , -/ rty y � a� /!/'y AIR HANDLING UNIT(OVER E J)M CFM)
nammofnppliunii/CCodmLiLior S (/I 1 EXHAUSTHOOD(W/DUCD
PAID
I IAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Due Receipt N
Will the appliauttorfuture building occupant nate or handle M1arnrdow materiel HEATING UNR(OVFR M."BTU) TO
u deli l pel by the Cupenion MumciCade,ChWa 9.12,and the Hea1N total Safety
Cob,Secd«t 25532(eYf
❑Yu ❑No VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
Will li nmrfummhuildingoccu B01LER-COMP LIHP OR IW,OM BTU) n
MP at Bay Area rot«rdity Mwhichcmit k" Y
hvuNous trim rnmuninanv n defiled by Ne Bay Am Air Qwliry Menyment DOILEIt-COW(OVER IOo,000BTU)
Dinrini
❑Ya ❑No NEW RESIDENTIAL MECII. SQ,FT. JUW 1,S 1p�
I hive end the huud«u maetisIs rryubcnenv under Chet /J94
pter 6.95 of Ne
Calif.i.Health&Safcy C«Ie.Senlw 25505,25533 and 25534. 1 uoderueod Jur Cil Y W,
ifaleWildingdoattaatrtmlyluve.teovu.thu it is my a
rpmtdbiliy to roily de 1-urr,
icV
cupant of Nc rey uirrnm
erL,which on he met prior In iawence or.Cenir e of
o,caparey.
0wvar or t umnriud ascri Doc ISSUED BY:
OFFICE