28116 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-KLIAN RICA• PERMITNO. ^ a.a �I
APPLICATION/PERMIT PLUM NG-MECHANICAL L l8 "1'.
BUILDING DIVISION {6
BUILDING PRO]ECTIHEN'IHICATION
BUIIAINGADDRfSS: SANITARY NO. APPLICATION SUBMITI'AI.DATE
11 NffN OTM -2qS
OWNERS NAME: PHONE: C( T rj`�(OR'S ' , N/C CONUl
Ir Fili'll!)
RCH1TECT/f7NGINEER: - LIC NO: A IiSS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT' FCIi BUILDING PERM19'INFO
@LDO KLE❑'Cf PLUMB MP❑Cfl
PERMIT ISSUANCE. �LL/�S-
LICENSEDCONTRACTOR'SDECe(Chap ON APPLIANCES-RESIDENTIAL 1
ION
OCC Thereby of car Division
amlicenxmins,ind od.ofCCoele ad my Neese with �.I .I
4100 Semian]II(I(B of Division3 of the easiness and Professions Code,and my license is in PANELS
Ctj full material effect. /� p /g
<Z 41 License Class_n-�� Lie. a D- UP T02g1AMPS
vFi<a'We -Z? ��Conlmaor T 6 iol-10(111AMPS
F _ ARCHITECTS DECLARATION / OVER Iqp AMPS SQ.Fr.F100R AREA E/SQ,FT.
Oz'-p IundersuutA my plans shall be used us publlcrecant...
Py Ij SIGNS ELECTRICAL
6yY Licensed Professional
CyC< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
4 V I hereby affirm met 1 am exempt from the Contractor's License law for the
413 u,y¢ following reason (Swtinn]031.5,Businexi and Professions Cale:Any city or county TEMP.METER OR POLE INST,
Cpm.] which reyoircs a pennon conatmer.aIle,,improve,demobs,,or repair any structure
&2}7 prim to its issumlx.also requires theapplicant for such parna'a fiv.signedstmemcnt POWER DEVICES
Pew<p that he is licensed Pursuant to the poevisiormofthe Cmumemex License law ItMcd,er
°'P�e 9lcommeneing with Section 70M)of Division 3o17the Business and Professions Code)rn SWIMMINGPOOLELE VALUATION
W_ or 111.1 he is exempt thereao
frmnd the basis for the alleged exemption.Any violation of OUTI F,TS-SWITCI Iii'-FIXTURES
f,yQmom
Seen..7031.5 byanyappiicantfar.permit sobjectstheapplicannna civil penally of
nmthan five hundxAdollars, S5o(q, NKW kLS1UfN AL ELECITt S Q.
Q<
❑ Lusownendlhepmpeny,ormyempinyres with wugeaaztheirsolecompensulion, Q STORIES 'TYPE CONSTRUCTION
a willdu Imwmk,mathesv..mr.isnotimendedorofferedforsale(SecJ0W.Buciacss /
and Professions Code:The Commerce.License Law does not apply to an owner of
pmpertywhobuildsorimpmvesthemon,andwhodoesvachworkhimxlforthroughhis OCC GROUP RES.UNITS
on employees,providedthat such improvementsare not intended oro ffeadfooale.If.
however,the building or improvement Is sort within one ye:uofcomplmlon,the owner,
builder will have the burden of proving llist he did not build or improve for posa`�of
sole.).
ElI,azownerofthepropeny,amexclusivelycontmetingwithiieenw contracmnto Qr' PLQMHIN MIT �/' I1.00D ZANE AVN
construct the project(Sec,9044,Business and Professions Carol Th Contractor's /
License Law Anes rut apply mnnownuref property who huikhor improve Iheroogand PERMIT ISS± E
whommaraca,for such projects with a coomelogs)liceirad pumuanno Ih Cemram°te
License ALTER-DRA IiNT- eR(EA) FEE SUMMARY
❑ 1 am exempt under Sec. ,B&P C for his reason i CK (W OT[CI'.9 ESIDE FEF
\ SANITARY Y N
Owner Date -PLO K' � AREA,COND. RIiCGIP1'p
WORKMAN COMPHNSA'1'ION DECLARATION SCHOOLTAX Y N
I hereby affirm that 1 have a cenificam of comern m self-inure,nr n ceniBcme ofRECFIT'T g
FIXTU S-PER TRAP
Workers Compens.1ionInsurance
rnart.OeJ wpythcreaf(Sec.3g00,Lab Cis hieh PARK FEE Y N
roorc,salt cmployec's unAm this pennih GAS-FA.SYSTEM-I INC.4 OUT.;TS RECEIPT
Policy k BUILDING DIVISION IgiF.S
Company t GAS-EA.SYSTEM-OVERO A) PIANCHECK IFP.
C1Cenifiede.pyisherchyfbmished.
❑ Cenifial copy is fled with the city inspection division. GRFASIgINDUSTRI.WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EX13MMON FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE.
(This w,aion need not he completed ifthe p emit is terrorist hundred do][.S100) \ SEWER-SANITARY-STORM F.A.200FT. ENERGY ME
or less.)
Icenify he,in the perfmmunceofihe work for which this permit is issued,l shall WATER HEATER W/VI?NTAH.ECTR
nm employ any permn in any manner so as to become subject to the Worker' PAID
Compematiou Lawsef Califomia. Dam SYSTEM/1'RIiATING Ume Rec ptk
C) z Applicant
z (2) NO`HCHTO APPLICANT:If,after making this Ceriricamof Exemptiomyou should NEW RESIDENTIAL PLMB. SQ.IT. TOTAL:
become subject o the Worker's Compensation provisinmofthe Labor Code,you must
? forthwith comply with such provisions or this permir shall be deemed invoked. BUILDING E
OCONSTRUCTION 1.13NDING AGENCY SIi15M Eli
I hereby uffirm but(here is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: 7R ..Landers NameQLcndcr's Addrees QTY. MECHANICAL PERMIT FEEV I certify that 1 have read Ibis application and stun,hal the above infomwlion is>" Lt1 correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE0 building canshua ialsod herebyremhorixa xnutives of thisciryto emereponthe AX
U Z shave-me soured formerly for inspection purposes. ALTER OR ADD TO MECH.
(We)agrcc to save,indemnify sort keep hamtless the City if Cupenino against
liabilities,judgments,costs and expenses which may l n any way accrue against said City AIR I IANDLING U N I'P(To l o,em CEM)
In cnnu nre of the granlln of this penult.
AIR HANDLING UNIT(OVER I0d.CFM)
IF
04, Signamreo AppfamVCnmrammDam EXHAUST HOOD(W/DUCT)
PAID
HAZARDOUS MAT:VIALS DISCLOSURE HEATING UNIT p'O IIIO,IXq DTH) Dam Receipp
Will the applicant or future building occupant store or handle hazardous material
ax refined by the Cupertino Municipal Cale,Chapter 9,12,end rho IIcahn mal Safety HEATING UNIT(OVER 100,000 BTU) T
Calc,Section 25532(a)P
0Yes ❑No VENTILATION FAN(SINGLE RESID) t
Will the applicant or future building occupaxnt saeyvipmorem devices which emBOILER-COMP(311P OR I(Iq(1(XI BTU) IU DATE
it '
.aridardoo?s air contaminants as defined by the Bay Arca Air Quality Manugconcur BOILER-COMP(OVI:R 10fjXX)BTU) AMY 231995
❑Yes ❑No NEW RESIDENTIAL MECH. Fr
SQ. .
I have read the low nlous maleriuls rcquiremcros under Chapter 6.95 of the �17Y Ut (;UNEklINO
California Health&Safely Code,Sections 25505.25533 and 25534, I understand that
if the building does nm m currently w have u mnarll,that it is my ssupnce oility ernotify the
occupant of Ibo requirements which must m met prim m issuance o(a Certificate he
Ottupancy.
Owner or authorized agent Date TOTAL: ISSUED BY: �+ V
OFFICE