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CITY OF CUPERTINO MECHANICAL
ISiRkI°'"". 2 6161
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
kS'Y85'A'@IkkgB NO PROJECT IP7 A ION t:ts'+ratY lu';'
BUIL/DING ADDRESS: /� SANITARY NO. APPLICATION SUBMITTAL DATA
O� I , Sr-n44. 4L ci 1... /Lp'I UNIT# LOTH 1/1
OWNSeAeF.. DptZ: CONTR C.R'$NA1 _ LIC
,NO:
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19
OIs PKC JL ZV „ I♦ Lww %C5” NC
CONIROIN
tC51TFCr/ENGIN[IRLIC NOAUOO :' frtY4co sVT `3,
CONTACT: PHONE.
J4,4 I"itµ.'i;ti°ti: y18U11:U1NO l'RR.F11T WPO
' T. "Y}, A• '.. � . ' BLDG ELECt' ,�dB MECII
PERMIT ISSUANCE TVI ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL T09 DFSCRII710N
KZ I hereby affirm ro
that l am licensed under pvi,ionsof C'hapler9(commencing with
Ron Section 10N1)of Division 3 older alre nd Profewians Cade.and my license Ps in PANES �� L•%Q� �.
o�kuF full facamdeffect.i
License Clrse_(��Lic.N oft VPT0200AMP5 C{4 Q er
m7y Date Convector 201-IOW AMPS SQ.frl'.PLOON ARCA E/SQ.IT.
ZFNy ARCHITECTS DECLARE O OVER 1000 AMPS
OO Z— I understand my plans shall be used u Public reccut
FH� Lieenud rrorea,lmn.l SIGNS ELECTRICAL
K OWNER-BUILDER DECLARATION SPECIAL CIRCUTUMISC.
Oyu I hereby affirm that I em exempt from the Connector's License Taw for the
3 W in following reason.iSeaion 7011.5.Business and Pmfeesiau Code:Any city or only TAMP.METER OR POLE MST.
t Esyg which requirt,a permit to construct,alter.improve,demolish.or repair my structure POWER DEVICES
N� prior to in ismame.Msorequireaddeapplicard formch pemmiva file odgmdatatement
.O that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter SWIMMING POOL CLECIItIC
�jn9(cammeocing with Section TSD)or Division 3 of the Business and Profession.Code) VALUATION
on mthnhei,ramp therefrom and the baai,far thedleged e.cnpion.Any violation of
i• Sectio 7011.5 by any applicant for a permitmbjecm the epplicanuoe civil penalty of OVILCI'S-SWITCIICS-FlXTIINBS
6 not more than five hundred dollars(1500).
NEW RESIDENTIAL ELECIR
❑ I,uawrteroDhcproPeny,mmyemployec,with wegnudheirwlecompenssOm, ..� S"I'( I TYPIi ONSMUCHON
—, will Bothe work,mwre
d thesrtmeNrot intended offered for 40 Wa(Sac.10Business \/ •T
end Pmlessi:me Gdm'rhe Cnm.1m s License Lew does not apply so an owner of YY
proludy weobulld,orimproveathereon,and whad.mch work hienselfe,througehis --'
cmpltebuildnvided Natrace yen
theownIL -..�0 1• LS. NIT.
however,thebuildingthe burden
ofpmengtt is he,ld edidnot build m mproeeifr theownes- .�� E
builder will have the burden of proving Octad he did not build or improve for purpose of
sale). i' ' t seas•a,w+ ,Y o-y` ytc�1., gr✓I't.
❑ I,ax ownerafthe praprrty.amexclusivelycantracting with licensed contractors to `,e:'e�x'�,-Gr s�UJ WG PeaMITN Yt`e. 9vrie r3St?s WOZON. APN
construct the pmjecd(Sec.70,14,Business and Profes,iems Cede:)The Contractor's
Liceme awdoesnod opplymenownmofpmpnywhobulldsmimprovesthemm.md PERMIT ISSUANCE
weocmvmuforsuch projects with acanux'mrD)licensed puraumdmthecmdenclms ALTER (PA) w' '•'!' 7i Wr+•+,v rrf.
License law. '. ./:';° ,ni.!:FEB SUMMARY'• a, +-
❑ I am exempt under Sec. .B&P C for this tams BACK FLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS�FlSR)R,ROOF,AREA,COND. RECEIPTN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
I herthy a/firm that l have.ceni0eme orcceaerum tel-imun,ara canlneueof FlXTVRPS-PFR TRAP RECEII.1'N
Naders'CompemW
atinn urencemseeniRedcopy therenf(Sc 1800.LmCJ which PARK HE Y N
-Zi coven el empinyee'e under this prrtnll. g'1(� S-•'.- OAS-EA.SYITIiM-I INCA OVTLETg RECEIPIN
Polity
I' BUILDING DIVISION FEES
M
RmPN^Y GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK ITE
❑ Cenifiedcopy a hereby furnished.
J2 Certified copy 1.filed with theclty lmpec0ondivislon. GREASFINDUS'TRI,WASIAOJIF.RCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need and be completed ifthe Permit is foronehundred dollars(SIM) SEWER-SANITARY-STORM EA.20017. ENERGY FEE
or leu.)
I cenify that in Be performance of the work for which this Permit is issued,i shall WATER It EATER W/VENT?LECTR
not employ my person in my manner w as to become subject to the Workcn' PAID
Compensationlaw,of California. Data WATER SYSTEM/TREATING Date Receipt Is
O Z Applicant
z O NOTICE TO APPLICANT:If,after making thin Cmificam xempNn,of Eyou aWuI5 NEW RESIDENTIAL PLMR. SQ.FT. TOTAL:
V) mbecome subjectcit the Worker,Corepansman Provision,of the Labor Code,you must
forthwith comply with such Provision,or this pem,lt shell W deemed revoked. BUILDING THE
Q CONSTRUCTION LENDING AOFNCY SEISMIC FF.R
I herthy affimt Nad there is•conawcdm IeMing agetrcY fm the performance of
O the wmk for which this Pennh is issued(Sec.3O9I,Civ.Cd
z TOTAL ELECTRIC PER
Y{ vCr:,- NICErta IT ..s s. ' ," , PLUMBING FEE.
Lent
Name
I cenify Nad 1 have reed Nis application and sore IMI the above information b ":rc iS'iF�r,•u :�F,.rvl v,'Af '
GLlrtecl.infirm to comply with all city and county oNinen"S and slide 14we re14tlngm PERMIT ISSUANCE r MECIIANICAI.FEF.
(�r-t Lks building construction.and hereby authmim representatives of thlscity do enter upon the
CONSTRUCTION TAX
V r�O7 above-me)iaud to ave,indemnify
inspection ind kes,has. ALTER OR ADD TOMECII.
(Wejudgentwve,s and expi and keep may Inu the City ofe ag initoblCity
st
liabilitie,,judgmends,cosdsendexprnsee which mrylnmy wry accrue egsin,d(o�ld City AIR IIANDLINO UNIT(Ib IO,fXp CIM)
inQ� (�/e/e grmting of Ni,permit. a.3—
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicaunontmctor Date RXIIAUSIIIOOD(WMUCT) PAID
IIrt or
MATERIALS DISCLOSURE
HEATING UNIT(TO IWp(I(I BTU) Data RaeipsN
Wedll the dw C.ntm Tenurebupal ng Ca,Cb.patmar9.m handle huardommaterial BEATING UNIT(OVER IW,BBO BTU) TOTAL:
u defined by sM Cupcninn Municipal Code.CTapc 9.13,and Ne IIesIN and Safny
Code.Section 25512(mtNo VENT'ILA'TION PAN(SINOLC RPSID)
❑Yes
ISSUANCE DATE
Will theapplicanl or future huilAingoccupant uueyuipmem mJevice,which emit
BOILER-COMP(111P OR 101,00)B'N)
Vozardous air contaminants at defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU) P � ' Q
d1 ,,J/
❑Yet ',�II N. NEW RESIDENTIAL.MECII. SQ.FT.
I have reed the haxmdoa,material,"ttirtnums ands,Chapter 6.95 of the MAY 2 5 '1994
California I lealdh&Safety Code,Sections 25505,25533 end 25514. 1 undcmmnd that
if the building dart nee currently have a tenant,that it is my responsibility to notify the
occupant o!the requirements which must be met more,k%mance of a Cenifc m of CI I)f• V U �ry I I IVk)
sa3-g �
Owner or amhmined agent Dem TOTAL: ISSUED BY:
OFFICE