26625 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HMBIN-G-MECH MICAICAI' I'ER"4D'"o. ^ ^
APPLICATION/PERMIT PING PRN'G-MECHANIFICA Lb L
BUILDING DIVISION uN1.mNc PRUdEfl'u)EN rrvTcp'noN'
BUILDING ADDRESS: - SANITARY NO, APPLICATION SUBMITTAL DATIi
W� �U]'I'# LO'1'M
OW R AME: RI ° R CI'OR'S NAME: LIC NO: �9^f/
U - DLJ t-r 5 SNrc CONTROL#
AElRCI IIIECT/ENG INFER: LIC NO: D S ,, LL
3rt w MrN.J16.V kpj
-CONTACT: PHONE: y --1 BUILDING PERMIT INFO
y ELECTRIC+PERMIT. 'FLiE
..Sr/TC It+ati4orL 4's- 9'6$-56¢(, - I PE�RISpANCER Cos,. - B XPLUJIB SUCH`
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL LOB D[SC IPTION
affordKZ Ihereby afford that l am licensed underpmvisionzof Chepter9(commencingwiN
uCqF: Scdion 7000).f Division Softhe Business and Professions Code,and my license is in PANELS
ecWU full forte and cffec I
FGm Llarnse ClaI Lie# O� UP TO 2W AMPS
m<a P Commit, 201-IOW AMPS
%FO ARCHITECTS DE ARATION \ SQ.IT.FI RARER S/SQ.IT.
l undcommul my plans sh ill be used as public onords. OVER 1000 AMPS
FyI=w SIGNS ELECTRICAL f„ �,.31 `I) i� �
4 J Licensed Professional \ ✓ /�1TJ
"'y a'6 OWNERHUILDIiR DECLARATION SPECIAL CIRCUIT/MlS�i
KOiF I hereby affirm that 1 am exempt from the Contractors License law for the
Y13LLrn following reason.Section 7031.5,Business and Professions Cash:Any city or county TEMP.M ISR POLE IN
ST.\
F�-�; which requires a pertnil to constnet.etre,,improve.demolish,m rcptir any structure f,
Comas prior to its issuance.also,equims theapplicanl fo...ch permit.file asignedamtenumt POWER EVIC'E$ /'
W,p0 that he is licensed pucmant 1.the provisions of the Communes License Law(Chapter SWIMMING POOL ELECTRIC
aXo f' 9(commencing with Section 7000)of Division 3 of the Business and Professions Code) VALUA'ITON���
LL_y or that he n exempttherefrom and the basis for the alleged comnum Anyviolatl...o! CC..���✓
F'ZQ Section 7031.56yanyupplicant fare permitsuiffe.theapplicum to.civil penalty ofL'y 11TLETS-SWITCHEIg,AFIk URES l� (I{Ir It'Lyf/�
_
O t more than five hundred dollars(S5W).
C o n❑ Lasnwneroftheprolerty.ormyemployeeswilhwagesasthcirsulecompcnsation, NEW RESIDENTIAL ELECTIT SQ.FT. STORIFS TYPF,CONSTRUCTION
a3o0 willdmhe work.andbhe structure is not imendcdoroffered frrvale(Sec,7044,Business V
and Professions Code:The Contractor's License Law does not apply to an owner Of
,.sexy wImmilda.,improves lhema..and who dons such .,it himself erdam,hhie on
employees,pvidedthal such improvementnae not intendedoroffend forrale.If. OCC GROUP RT:S.UNI'I'ti
horowever,the buildneg or improvement is sold within one yearofcompletion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
.ale')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ I,as owne,oflhe property,am exclusively Contracting withlic sed contractors,,
cunswn the project(Sea.7044.Business and Professions coda)The Corpownes
License Lawdoes nm.pply teen ownecul property who builds.,improvesthem
rn,and PERMIT ISSUANCE
whoemonets forsuch projects with a coulactons)licensed pursuanuothe Comuchrs A ALTER-DRAIN&VENT-WWA E
License law. Ego FEE SUMMARY
❑ 1 am exempt under Sec ,H&P C for'his reason OUTSIDE FEE,
BACK FLOW 1'HOIECT.DEVICE
SANITARY Y N
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
❑ IM1ertby alfa.shell hav<ecenifwte of canum.self-into.,orecsnifi<ate of lgXTUR[S-PER TRAP' RECIiIVI'p
IWrnken Cominmmsmi.n Insurance or a certified copy thertof(Sec.3800,Lab C.)which PARK FIiIi Y N
covers all employee's under this permit GASA.SYSTEM-1INC.4 OUTLE IS RECHI
Poly# BU I.
DIVP60N IBES
Company GAS-EA.SYS'1'CM-OVER 4(IA) PLANCHECK FI
❑ Certified copy is hereby famished. as
❑ Ccnlfied Copy is filed with thechy inspection division. GREASEpNDUSTRL WASTE INTERCEPTOR GRADING
CERTIFICATE OF EXEMPTION FROM WORKERS' ORT- SETRAP SOI (
-
COMPENSATIONINSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM EA.200FT. ENF,RG ' 2
Crisis.)
I certify that in the performance of the work for which this permit is issued,laugh WATER HEATER WNENT?:LECTR
not employ any person in any ma.rer x as to become subject to the Workers PAID
Compensation Laws of Culifnmia. Dam WATER SYSTEMTRFATING Dme ecciptp
O Z Applicenl
C) NOTICE TO APPLICANT:IL after..king this Certificate of Exemption,youshould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
becmna.bject to the Workers Compensation previsions of the Tabor Code,you most
� > forthwith Comply with previsionsthi
such or s permit shall bat dad mrevoked. BUILDING FEE
dQ CONSTRUCTION LENDING AGENCY - SIi15MIC FEEqL
I hereby affirm that is a construction lending agsnry for m
the performance of
UQ the work for which this permit is issued(Set.300],Civ.CJ - L: ` ELF ETHIC
lender's Name
u' F Leder',Address QTY. MECHANICAL PERMIT FEE PLUMBI aE
U I csnify that 1 have read this appliwdon and Can that the above infmrommo is - MECHANIC
correct l agree to comply with all city ad county ordinances aralume lawsrtladngto PERMIT ISSUANCEIL
I" budding construction,and hereby authorize representatives of lhiscity to emetupon the COIfqTIONX
m
U mince- emionW property for inspection purpaxs. ALTER OR ADD TO MECH. Tf
(We)agree to save,indemnify and keep harmless Ne City of Cupcnino against
Iia 'udgments.costsandespens whichmayinanyway accrmca,mm,aald City, AIR HANDLING UNIT(TO Willi CFM))
e rifthe, thi emit.
' S./014
AIR HANDLING UNIT(OVER 10.000 CFM)
Si ppibe
Contractor Dale EXHAUST HOOD(W/DUCT)
PAID
1 L1RD0 MATERIALS DISCLOSURE I MATING UNIT(TO I Io,WU BTU) Un. Rccci Iltl
Will the applicant future uildingoccupantsmmorhandleha dousmatchal HEATING UNIT(OVER IW.IOH BI'of TOTAL:
as defined by the C.Ion o cipal Code,Chap.,9.12,and me Uedth wed Safety
O
Code,Section 25532(a)'1 VENTILATION FAN(SINGLE RFSID)
❑Yes ❑ NoISSUAN D TE
pp
Will thea Iicanmrfumre buildingmention tordevices whichemit
aaBOIL[R-COMP(JHPOR IIq,IKK1HTU)
ncpan S
rardnus air Communard,as defined by the Bay Area ca Air Air Quality Munngemcnl BOILER-COMP(OVER 100,000 BTU)
islnmT
/ ❑Yes ❑No NEW RESIDENTIAL.MECH.-SQ,FT. g
1 have mad the hazardous materials mquirements under Chapter 6.95 of the P W ' ^a
California Health&Safety Code.Sections 25505,255]3 and 25534. 1 understand the
ifthe buil dingdoesunturcregyharmatenantthatitit myresponsibilityenotify t of - �1
sopa.of the requirements which must be met prior.issuance of a Cenificme of /mI�(�
Occupancy.
�1 .
Ownerorauthorieedagenl DateA ISSUED BY:
OFFICE