28305 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO f'-ELECT CA' PEiRMITNo.
APPLICATION/PERMIT PLUMBING-MECHANICAL 28305
BUILDING DIVISION BUILDING PROJKCI'IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APLICAlIWSORMOTALOATE
UNITX LOTX ��
T NERgN HONE:S �C CON OR'g<NAA11i: 7ry� 1.1'NO: WC CONTROLX
I\
RCI IIIECl/ENOIN�IIea: LIC NO: ADDRESS: L�O -JY?ec& .� ❑
CON'EACT: PHONE: " ' n"-pfr•an r � r)� .+ — .r7 - 'i�r BUILDINO PERMIT INFO
QTY. !'�'.,;4 .;.'BLL'CPIUC PERxb�ITr4 ;
•o'nr ✓� RCI '� PERMITISSUANCE - BLDG
LICENSED CONTRACTOR'S DECLARATION PLUMB MECII
APPLIANCES-RE.SIDEbIGAI'
owz IharhydnmiMlimmlicmeedunderpmvisimsofC epter9(commencingwith ROB UESCRIi'IION
Sect
WOO❑ flit ]000)of Division 3 n the Busimssand PrnfeuionsCale,and my license ie in ppNE15 Kilt
�'�I
FhdVU " .areaandcRcn. K Z
QQF ZN License Claa Lic.X UP TO 200 AMPS
Comn<tor O'a'XC 201-IB(III AMPS
s�ZV ARCIIITECTS DCCLA A'HON OVER IIXXIAMPS SQ.FT.FLUOR AREA $/SQ,FI'.
OZ-0 1 onderemnd my plana shall heaved As public records.
K Ht W SIGNS ELECTRICAL
Q � Lmensed Rvhssinnel
g OWNIiR-BUIIAIiR DECLARATION UCIAI.CIRCIII GMISC.
xu006 Oa V 1 herehy affirm that I em exempt froth rhe Contractor's License law for the
W3Oy following ressim.(gmtim7UJ1S,Baeinanand PeofessimaCMe:Any city one.may TEMP.MEILR OR POLE INST.
I:A0 which ne,inese permit to cnnevua,almr,Improve,demch,tr.m....Irany structure
f!!1Q� Prior to iuisenance,eh ,t .n fo
o,egalrehe app0crueeh permto gnaanter
rem,file a Pill aemem POWER DEVICES
d—y_�p mat he is licensed Is n
ursuanothe provisinsoof the CmtmrorPartnerea License Lew( pmr
m� 9(csomeming with Sectim]00)of Division J of1he Innis itnd Prokmime Curb) SWIMMING POOR.ELECTRIC
_y un hat he la Assistslhcrefrmn..it the Norsk for theilleged eaempi inn.Any violninn of
tZ< Sema.7051.5 by anyeppliam for epnmi.subject,the eppllam 1.a civil penalty of UTLIGS-SWITCHES-I'IXTURES
fF Iwt momlhan ave hundred dnlhra(S50). NEW RPSIDT:NIIALELFCIit _SQ.IT. r.
�C$ ❑ I.aanwnerofthepr rty,ormyemployas with wagesasshelrmleconpensnion, 'TYPE CONSTRUCTION
3 will da thewmk,end doxwcmm isnot immrided maffercd fmmIA(Sec.7W.Business
and professions Cnle:The Conuacmrs License Law do..,nm apply in on owner of
Property wla)builds m improves thereon,and whodms such work himself or,hmugh his oF
n employcee.pmvidalrhat earn impmvemenuare not imm�dnbndfcreA fmsole.If, 0( - Our RES.UNITS
however.the buildingor improvement is sold within me year ofcomplerm,the owner-
builder will have the burdened proving then,he did mI build m improve Ins fuBaore of T
21
sale.).
❑ I,ere ownerarlic property,am exclusively emnuaning with licensed mnrracos In QTY.-x.,' PLUMBINOPERMITIN_ :L. 'MSS FEE,-- FLOC AI'N
construct the pmjm(Sec.704,L Business and Professions Code:)The Comrec,ore
IJcerec Lowdues notapPlyma-1owmrofpopcnywhobuildsmiruMvatherem,amt PERMIT ISSUANCE
whocnnuacn for such projecu with a conhachmad licensed pumuanslo the Cmtradoe, :FEE SUMMARY
License law. ALTER.DRAIN&VENT-WATER ODO
❑ I em exemlx uMer Sa. ,B&P C for Ihie neasm BACK FLOW PROTECT.DEVICE DO'I, DI:
SANITARY YN
41
Owner Dem pRAINSPLOORROOP R ,CONU.. RECEIITX
- .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ 1hemhyaRrm Nor I have ecenificne a accuse..selbimore,macenincate of FIXTTIRPS-PE:R TRAP/Ng.., RF.CF.IPTX
11 Workers Cnmpensetianlie,...cemaceal0edeapylherenf(Sec.1800,Rah C.)whichPARK RE Y N
van all anploY-ee'ya i RECEIPTX
CaliryM lX'i5 Y "' �SL GAS-GA.SYSTiiM l C.40 EI'S �� BUILDING DIVISION FEES
Cumpany ' OAS-FA.SYSTEM-OVERd
J�'CeniBM copy s hmehy famished. G A DING FK Flili
❑ Crnified copy:,Bled with the city Inspection division. GREASEANDUSTRL WASTE I R GRADING FF.Ii
CERI IFICAI'E OF EXEMPTION FROM WORKERSGREASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thio section meA not he mmplemdif the permit la fornnehrusheddallan($10) SEWER-SANIIARY S'I'ORMEA.20(l ENIHRGY ME
or less.)
I certify that in he perfnm.nce of the wok fm which this permit is issued,l shall WA117R IIEA"I'F.R W/VENTAO,ECB of
-1111 rmploy any pent.in any manner sen es It,became sobject to the Workers PAID
z Cusn"imtionlawanf Cnlibnnia. Dam WATER SYSIENtTRFATINU [)aree¢i X
0 O Applicant
•/7��=.1 NOTICE?'IOAPI'LICANT:ILaftur. aAing,his Cenificamnf Eixen,ptinn.ynu should NEW RESIDENTIAL PLM. SQ.FT. TAL
l-' > fiamwi i,on ly it Worker's Csmpenssmi.pmvisinall be etales Cs.ked, must
, La,hwithcnnWly with such prnvisiommlbi.prm,ilsMll hr�kemnl revoked. fl1111.UING FEE
21 CONSTRUCTION LENDING AGENCYSEISMIC pill
tttVVV��"' owir
z I hereby affimnhat these is a construction leMing agency for the perinmmna of
O the work hen which this permit is issued(Sec..W97,Cin C.) UINi< Fi.rMRICI '
U.
s.. Lender's Nnme
Lender,Aldrea, QTY. MBCIIANICAL PERMIT pgg.;l' rLUMnING nsE
{tl 1 certify Rha 1 neve read thio ii'diraim aml'tutu that the edove inhemation is
nein.l agree to cmAPly with all city AM county anlinances andatate laws mining in PERMIT ISSUANCEiMECHANICAL) s
1 y building construction,and herehy aurhodm repiesenmllves of this city menter upon the
C.17 -P mentioned prnwrry for inspection performs. ALTER OR ADD TO MECII. CONSTRUCTION TAIN
G (We)Igoe to save.indemnify aM kap harmlAm be City of Cupertino against
Iiabiliriei,judgmenb,eissend expenses which my in any way accrue against mid City AIR HANDLING UNIT C O I(J"CFM)
In consequence of the granting of,his permit.
AIR DANDLING UNIT(OVER 10,0110 CFM)
Signature of Applicant/Contractor Dom MHAUST 11001) WA)UCH
PAID
HAZARDOUS MATERIALS DISCLOSURE MEANING UNIT(TO 1MMIl BTU) Dote Loa iN X
Will fl a applieenl or future building maupmt none or handle hazardous mnmrml
m defined by the Cupertino Municipal CMe,Chnp,er 9,12,snit[be Ilcnl,h and Safety HEA'1'INC,UNIT'(OVER 1000M BTU) TOTAL:
(:Me,Section 25512(.)7
VENTILATIONON PAN SINGLE
❑Yes ANn
ISS ANGE QA'I'E
Will the airapplicant nrfumre building by the Bay A Ali unlit c Management BOILER-COMI'pI1P OR 101,(X0 NIU) ',11 t7 gA
moardma air cmmminems as donned by the Bay Area Air Quality Management BOILER-COMP(OVER 101,000 BTU) w� C s
DisvicG pI aw
❑Yes IV NEW RESIDENTIAL MECII. SQ.IT. 6 0
1 have read the hamdmes mareriah requimmems under Chapter 6.95 of the C// 1995
Cali(omio O'elm&Safety CMc.Sectim. 5505.25531 and 25534. 1 understand that
inhehuadi-1gdm nmanrtcn0ylrav m a,lhat" a ponsibilbym-1atif the
woupom of I oi, d.a wis rre n m m i.a ante of a C it. e oI U
Oce
)wanh
,u.mirnl agent um L. ISSUED BY:
OFFICE