S 1126 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PIT"NG. 112 6
BUILDING DIVISION APPIACATION/PF,RMIT PLUMBIlo MECHANICAL
IIUILDING PROJECT IDENIIFICSI'lON
SANITARY NU. AYI'LICAI'ION SUIiA11'1'IAL DAPI
BI�INIF•14Xn
O .R'SNAMF: PH O RA AMT::aujol29i CONTROLp
C[H /ENGIN[ER: LIC NO: DkFSS: W \ krc ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC P177RMIT FEE JOB DESCRIPTION
1 hemby affull aha I tun berate l under pmvi.iona of Choper 9(commencing
O0Z with Senion]1Xglofoivi ion loflhe Businessland Probexion.Qdc.and my licensis RESIDENTIAL
y)DO n PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
F m full force rad L
aUU Limn: Lic.X APPLIANCES-RESIDENIAl. ❑AUDITION ❑PLUAIBING RIiI'll'li
IFZW Dae Commit El MULTI-UNIT ❑STRUCURAI,
ARCHITECT$DIiCLARA PANELS MOOIPICATION
OZ�" lundeexend my plans wbal he used us puhlic rccuNs UP'T02W AMPS
❑INTERIOR ❑CIHMNI:Y REPAIR
Cj Licensed Pnrlcesionit2(11-1(NXIAMPS IMPROVEMENT EjSWIMMING POOLS
Qy ; OWNER-BUILDER DECLARATION OVER IOXIAMPS ❑BATA EVRI?PAIR ❑ EMOLITION
CC CY Q 1 hereby affirm that I tun exempt Gam the Coronalor'x License Law for the ,R
Xfollowing remon.ISeaton]IU1.5.Bu.ainens and l'rnfessin I,Cole:Any city or county SIGNS TiLECI'RICAL
W 3 tr0 y which reclaims a rcr,na tu consuuM almr.hnprove,demolish,or repair any structure FuO� psis I I pli II 1, tl g J,aemcnt SPECIAL CIRCUI'IIMISC
� y thvtl 1 Ip II II p It C t t L I' (Chaptcr9 COMMF��'
LLal 00 (e°tensa ngwth Sul na]fNX)rl U'v'sim9of lLJfud nuxxuW Pn le.:'lnx GdeN'r ]EMPMCI'ERORPOLF S'E.
dy e that he is exempt Ihua{'rona and the basis for INe allcecd exemption.Any violation of ❑NEW BLDGIADDITION ❑DIiM01.1'TION
Xm� oat morethanfbd
Section five uns filra I'llalxnnil subjects the applicant It, penday of POWER DEVICES []TENANT ❑FOOD SERVICE,($51X0). IMPROVEMENT
FZD 01.as owner or the prnpeny,onny, employees with wages as their sole compensation. SWIMMINGP H. .." RI OTHER
P., will do the work.onlfle,lriclure i,not imendcd ondtctiol All late(Sec.70aP.Baoinc,x CATTLE -SWI ILS-P '1'
W m and Professions Codr.'ITc Conwmor'x License laaw does not apply m an owner,of
pm,dy who hadd,nr impn..a,thereon,and who Jae,such work himxdf or through NL RESIDIiNTIAI. '.:CT
his own employees,provided that Inch impmvemcros arc not intended or offered for SQ.FT.FLOOR ARTA $/SQFI'.
,ale.If,however.the NailJing nr impmvenmm is>nIJ within one yea of completion,the
waerbuilder will have the burden of proving that he did, build or improve far pur-
pn¢aLale.l. 1 I
1,as owner,of the propeny,am euclasively contractual,with licen¢d comrucmrs ao PAID
con%lmct the project(Sec.'(WL Business and Purfe.ssions Code)The Cuntmcmrs Li-
amcLawJtesnotj,dym.nowaerol mparty who build,.,improves thereon.and QTY. PLUMBING PERMIT FEE
whrcontmns for such pmjects with a contmot licensed pursuant to the Contractor's FEBOO RIIL
License Lax'. PERMIT ISSUANCE F L9 fir/ /'UC{7
I am exempt under Sec. .R k P C for this maw. �'5/
ALTER-DRAIN Fr VENT-WATER IFA) CITY/YL rNWL11Sx(�NI��
Owner Data V V' VVI 1.
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby off n under penalty of Perjury one of the following declarations:
I have and will maintain a Cenifcam of Consent to self-inure for Workers Compat DRAINS—FLOOR,ROOK.AREA.GOND. STORIES TYPE CONSTRUCflO
anion,as Provided for by Seninn 9101 of the Labor Crdc,for the peefomunce of the FIXTURES—PF.R TRAP
k for which this permit is issued,
1 have and will maintain Worker',Compenmtion Insurance,as required by Section GAS—[iA.SYSTEM 1 INC.q Ul1TLP. OCC.GROUP AI'N
.]1111 oft c Lahr Crile,for the performancc of the work fur which phis permit is issued.
Cr W'o It,
' @ t'ti I ane r Policy
y No.: �'4�rt�
Gariel, Policy Nu.: Y."i"3.Y55�4Sn IF' GAS—EA.SYS'I'P.M OVER J(li
CERT IT ATIi OF 17XMKH(1N FROM WORKERS' GREASF%INIID$'fRL WAS .INI'IiRC1iI'1 OR
COMPENSATION INSURANC17 BUILDING DIVISION FEES
(lbix,rel oreed not hecomplaed iflhe penin is foroac hundreddollars($I(N) CREASE'I'RAP PLANCHECK FEE
lost.)
Iva,ytha in lh,,annomncent the wok lorwhichthislxnnit is i...call,[,hall SEWER—SANT"T —STORM I!A.2a)17K ENERGY FEE
not employ ally Person in any mannerrotn toheemne amca w the Worker,Cameo
Z xa,in I Lows MCalilornia.Date WAIFFRIEA' .RW/VENT',FIJC'IR GRADING I'EE
z APPllcanl t
h NOTICETO APPLICANT:IL altermaking this Certificate of Exemption,you should WA'T'ER: SIENIGREATING SOILS FEB
become whject India Worker,Con,wredion pravhinn,ar Bat I..Nar Coda,you orma
W forthwith enntply withwch Provisions(itmi
r this pert shall he decmadrevokcd, WAT SERVICE
[� PAID
0. CONS'I'RUCI'[ON LENDING AGENCY ;W RESIDENTIAL PLMB, SQ.KE a Rcceiptr
U O I bcreNy uflinn Jmnhere i.w um.amcainn lending agency limbs perfononee of
L. f" the work for which this punnit in issued(Svc.NMA,Civ.C.) 'IOIAL:
O U Landeex Name 'I(yl'AL:
>" D.I lender's Address BUILDING FEE.
6 I certify that I have real this application and state that the above information is
It: rn come.l agree to comply withal]city and county ordinances and rare laws relating to QTY. MECHANICALPERMIT FEE SEISMIC FEE
U Z huildin6 mmametion,and hereby amhotiw rcprcxmaaives of chis city mercer upon lbe
Move-mentioned property for inspection purposes pERMITISSUANCF O FLECTRIC FEF.
(We)agate a,ave,indmnnify and keep harmless the City of Cupertino against
liabi]iaics,judgmenrw,casts and expenses which may in any soy accrue againot said City ALTER OR ADD TO MECII. PLUMBING FEE
'nconx uenttnftheg tingafflu padn't.
APPLICANT UN STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Irl,(XXICFM) MECHANICAL FEE
SOURCE CATIONS.
AIR HANDLING UNIT(OVER 11).000 CFM) CONSTRUCTION TAX
"greare of ApplicaMContracnnr Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEF.
HAZWilljacupplcard Tut rre�Idin,ocDUS MATALanr,toDISC..OSURE handle hazardous material HEATINGUNI'T00101,1X0B'I'U /Z• �O
to deMcJ by the Caperino Municipal Cade.Chapter 932,and the liealth and Safety HEATING UNIT'(OVER I(1B,1XX1 H'TU)
Crile,Section 25512(.)? �e
�Ya ❑No VENTILATION FAN I SINGLERESID) PAI?
Data kecoipap
Will the applicant or future Nailding occupant ase equipment or devices which NOILER—CO....11P OR Ilp,050 BTU(
sit h riallous air coneminants m defined by the Buy Arca Air Quality Management 'TOTAL:
Wildcat? BOH-ER—COMP OVER IIXL(XXI It'I'U)
❑Ya, ❑No
AIR CONDITIONER ISSUAN DA'T'E
I have ,S ahs Imeardou,Scotian,
25.5 15.255 3 al,under Chuper understand
of the CdI-
lomiu Ilculth ffi Snfcty Crile,Smtinre 255n5.25519 and 25514.I mdcrntunJ alma if the NHW RI!SIUEN'I'[AI.MRC?I, SQ.PI',
' building Jae nm cumnllye hvca¢'n nl,Ih:n 11 is my ruPmaihilifyu nollfy the oc upum
or the n,,,irenrenu which oma he incl prior to is.role'If u CriicaetT lkeulrouly
Owner or robot/•d.'al Dole
'I CIA.. ISSUED BY:
OFFICE
LIC. NO. 445162
condition ¢cJ aif
ASSOCi
FEBRUARY 20, 1998
CHARUb
22191 AGRAWAL �i^��(�
22191 MCCLELLAND L �u(
CUPERTINO, CA. 95014
HM: 446-1741
Q � CONDITIONED AIR ASSOCIATES PROPOSES TO FURNISH AND INSTALL THE
lJ` FOLLOWING:
1 - LENNOX G20Q2-3X75 FURNACE
1 - 4" FLUE HOOK UP
1 - GAS HOOK UP WITH COCK AND FLEX
1 - ELECTRONIC AIR CLEANER, LENNOX EAC 12-14
1 - ELECTROSTATIC FILTER ON- DOWNSTAIRS UNIT
FURNACE $1 , 475 .00 + PERMIT FEE
EAC $ 650.00
STATIC FILTER $ 100. 00
• TOTAL: $2 , 225 . 00 + PERMIT FEE
TERMS : PAYMENT DUE UPON COMPLETION
ACCEPTED BY:
DATE:
r CE E ,
BIL N�
PRESIDENT/OWNER
164 GILMAN AVENUE
SUITE B
CAMPBELL, CA 95008 408-374=6311
17 _.. --