28169 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CI'PY OF CUPERTINO BUILDING I I ECI RICA], PERMff No.
APPLICATION/PERMIT TING PROJ MECHANICAL 2 O e� 6 9
BUILDING DIVISION BUILDING PRodLCI mEN'ITNYCnTTON G o 1 U J
BUILDINGAD11iUDR7S/I_ //,�� ���� ��, ,.gSANITARY NO. APPLICATION SURMfITAL DATE
2 2 I� \L/ UNIT» 1_0'1'a � -
OW ME: PHONE: CONCTOR'SNAME LIC NO:
N/C COMROLN
_ "111GI BBR: LIC NO: ADDRESS: l ❑: PIIONG � �• Ur N
QTY. ELECTRIC 6ldrr FEE BUILDING PERMIT INFO
iTaccocA _ PLUMB MEC
eeVVFF -726,11,80PERMIT ISSUANCB Ti(,
LICIiNSED N'IRACI'OR'S DECLARATION APPLIANCES-RESIDENTIAL. s�
C=Z I hcrehyaer
ffiren that l an+IicesedunderForvisimnofammr 9 mmumencingwirM1 IOII DESCI 1'TION
{=00 Sectionncandef DtvisinnJe(Ne Business and Professions Code,end my license is in PANELS .fig
C� full Secion7roti effect,
QZW License Clasa Liak UP 0200 AMPS
oos6y Date Contractor 201-I"AMPS
o� ARCHITECTS DECLARATION SQ.FT.FLOOR AREA S/SQ,FT.
ZZ-0 OVER I(X10 AMPS L
OZ-0 - I understand my plans shall be used as public recnMs.
r 4�W SIGNS 17LEMICAL
Q '� Licensed Polle,dimell b
KK yv d'� OWNliR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC. '
KOaF 1 hereby n.Se Nm I am exempt from the le,,mr,Co Li Arly Law for the /1�/n 1
,4LL0m following(came(Section 7031.5.Bun+ness and Pnd'cssiorrs CnJe:Any city or cnunry 'fEMI'.MllfliR(IR POhf:INS'1'.
f'�va; which rcquirexa pe(miuo c.nxwaalcor.improve,demolish,or repair any swcture
W>r:� Britain its issuance,also requires the applicant for such Permit o file a signed statement POWER DEVICES
41Kap that he is licensed Panamint to the proviWars of the Cameroo 's License Law(Chapter SWIMMING p001.ELECTRIC VA UATION
aa�do� 9(commmcixemwith Sttlion Xl00)oe basis
Softlle Business exesption,AnyvmB Code) �� �a
W� orthmhei31.5 by any oeficull apalicund the perentnathect%theJexemprt to A civil puminn of QlIf1.E3'$-SWITGIIES-FIX'1'URF.S
oEa Sen ion tha5veanydreddan,for ulienor,subjects the applicant mtcivil penalty of
WS not more then five hundred dollars(SSW). NEW RESIDENTIACELECfR —SQ.FT.
� $ ❑ oonvork,adepmpeny,ormyempindedswhhwngwr sals(sole cont*Blearen, S'fORIFS TYPE CONSTRUCf10N
L will Profession,
structureCaeroonsent'sLiense offiread Law
rdoes at apply
to se Business
and property
wh ens Calc:The improves
ttheeon,License Law tines or apply m an owner rf
pmpenywyecs.pdserimpatsuthereon,and
ents=smchworkhimself for,ugM1hie
employees,pfird,mdmatostanc vprovemenrsarenm imenJNnri+ffcretlfrrxalc.If. OCC.GROUP RES.UNIT'S
however,thebuildingor, surof,emcntissoldwithin me
m omprols.(,it purpose
of
. builder will have the burden nfPmving that build not mild er Improve for purpose of
ale.).
❑ I,asownero(rhe property.son exclusively contracting with licensed contractors to QTY PLUMBING PI712MIT FEE FLOOD ZONE AI'N
construct the project(See.0044,Business and Professions Code:)The Contractor's LicenscLawifices not apply to an onvocrinpoSperry wholbuildsorimprovestramor,and It PERMIT ISSUANCE
who contracts forsuch projects with u conwmnrm)licensed pursuant mhe Commctor's ALTER-DRAIN VHN�f A'IER EA
Llano Lew. ( ) FEE SUMMARY
❑ 1 con neap,unJcrSm. ,R&P C for this reason BACK FLOW PRO EVICE OU TSIDI. EG
SANITARY Y N
OwnerOna DRAINS-F1.00 ,RO .A,COND. RHCHIPfN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
TI
❑ Ihereby affirm that l have acenificate ofeortsent roself-insum,ora certificate ofEIX'1'URES-PER TRAP RECTI I'g -
Warkers'Compensation Immune.oro certified copytboroof(Set,38Xh Lot,C.)which PARK PEE Y N
rovers dl employee's nucleators permit GAS-HA.SYSTEM-11 O S al
C/
Policy# HUI G ISIONITES
Company GAS-IiA.SYS,EM.OVI:R I: PLANCHIiCKFEE
❑ Certified copy is hereby famished.
❑ Ceriricicopyisfiled will 11i inspecliondivisinn GREASE/INDUSTRI.WASTECRPT GRADING FE
CERA'A'IFICATE OF EXEMPTION FROM WORKERS' GREASHIRAP SOILS IT 7 —�
COMPENSATION INSURANCE. ZZ
(This section need no,becomplmeJ iohepertnit is for otm hundred dollars(SIW) SEWER-SANITARY.STORM EA.200FT. ENERGY FTI? �f
or less.)
I cenlly that In the performance ofthe work for which this perm(is issued,l shall WATER HEATER WNEN'P/171AR71R
me employ any purse.in any rommer
so as to become subject u+the Workers' PAID
Compensationfawsof Califomia. DaleWATER SYSIF.MaRRA'DNG Date a Ig
Q Z Applicant
ZO NOT ICE TO APPLICANT:If,a@(makingthis Certificate of Exempvicn,you should NEW RESIDENTIAL PLMB.—SQ lel'. is r
TAL:
pJ uecnmc subjen vo the Worker's Compensation provisions of Ne Labor Cade,you mull
7 forthwith mnvply with sucu prtwmens or,his p mit stall m rimmed revoked. BUILDING ��
E that
thr RUCTION LENDING AGENCY
SEISMI O
It
Z Ihereby r which] isPermit is uned(Se.3097dingagency lin the performance of
U O the work for which this permit is issued(Sec.3097,Civ.CJ TOTAL: ELECT 1 :C Is
Lkn Lender's N. PLUMBING Pli
Lender's Address QTY. MRCHANICALPERMIT' FilE
V 1 certify Nat I have read this application and nam that,he above infomvmion is
cancer.Iagrcemn+mply lh all city'nd comayo(dinances and state laws mleting to PERMIT ISSUANCE MECHANICAL F.
buildingetndirco ,, rub n esenmtives of this city m enter upon Otc CONS'IkUCTION AS
V z aMve-memit dpm an ' slice tosex
u ALTERORADDTOMECH.
(We
m sa, it I( oily ea rel hurmkss the
City of Cupertino against
_
liuhfilie In p 'nate.is hi rayinanyway.ecrve a einstrid Cily AIR HANDLING UNIT(TO R1,000CFM)
incan a I.the
gr ex thi pe
AIR HANDLING UNIT'(OVER 10,000 CPM)
gnaI If
wrco ApplicmtiC comm( le EXHAUST HOOD(W/DUC) PAID
HAZARDOUS MA 6RIAL5 DISCLOSURE HEATING UNIT(TO I W,OOo JJTU) U;no
Will the applicant or future building receptor store or bundle hamrdous material HFAB'ING UNIT(OVIiR IOO,WO BTU) a TO 1'AL:
as earned by Nni
Elm Ca,edino Municipal Code,Chapter 9.12,u.d the Health and Safny _ J
Code,Section 25532m)P VENTILATION PAN(SINGLE RESIDE Qy A P
❑Yes ❑No
BOILER-COMP(31{P OR IIXI,IIW 03ll) NCE DATE
Will Neapplicenmrfomre builJingwcupantusecyuipmmlrrdevicee which emit /� 1
i'd1 us air conmmina,ns as defined by the Bay Area Air Quality Managemem BOILER-COMP(OVER 100.000 BTIB C//j(Jr • lgg
Cl Yes ❑No NEW RESIDENTIAL MECH.—SQ.IT.
I have read the baxamnns materials repti(emcros under Outlive,6.95 of,he ��fy/Yf rV
California I Health&Safety Code.Sections 25505,M533 and 25534.1 understand that
if the building does net.,cally have a mnam,Nm it is my resp:msibility to nmify rhe
reeupam 0 the requiremcms which man be inet prior In issuance of a Cenci Brute of
Occupancy.
Owner m sathnduJ ugen, Date TOTAL: ISSUED O
OFFICE