28176 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUH,"ING-EI.EC I RICAL PERMIT NO.
APPLICATION/PERMIT PI.IIMBEVF-MECHANICAL. 28176
BUILDING DIVISION BUILD117C PRW.C'1'IDEN'I IIICATION
BUILDING ADDRESS: / SANITARY NO. APPPLLICATION SUUMITTAI.DATE
.VO/�! a(j(� 10 'UNIT# LOT# 6 S'
NER Rio"
PHONE: CO RA� yAME:��� �N �� NIC CONI ROL.0
ARCHITECA..0140.11:, -I LIC NO: A S_/7tl�Y� ,/�AW
z ❑
CONTACP://ff// CJ PHONE: QTY. ELECTRIC PERMIT EEE? BUILDING PERMIT INFO
BLDG ELECT 1'i MECII
PERMIT ISSUANCE o o
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-It LSIDEM'IAL LfU' t
mCz I hereby affirm that sm licensed under provisions of Chapler9(commencing with ION FIZ
F00F Section 7")of Division 3 of Ne Businessland Professions Cade,and my license is in PANELS
,J ,i
y� full force and effect.
6V� Uccme Chte.v I'ie'# UPT02MAMPS
ot, Date Continuum— 201-11100 AMPS
zO�z ARCHITECTS DECLARATmN OVER 1000 AMPS SQ.NI'.DOOR AREA WQ,FT.
0 z I unJcrstund my plans shall be used as public records.
SIGNS ELEMRICAL
Q � Licensed lyofessi...I
K 9w< OWNER.BUH.DER DF,CLARA'I'ION SPECIAL CIRCUIT/MISC.
�O i V m 1 hereby about that 1 aexcmpt from the Contractor's License Law for the
r+13Wm folowingfeuwn.(Secdan 9031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE INST.
�¢•O; which issuance,
eeralso reconstruct.alter,improve,demolish,or repair anyhwcture
Y0 pat heir licensed
dpursunt to the
the
proisionsufthe CoPermit torile a LimmigLa smhapterteravent POWER DEVICES
uK p0 9(I heislicenxdpursmion700pmvisiision the CommonsLicense Law(Chapter
L D�L 9commencin with Section V0001or Division 3nlale Business end.Any iota Cade SWIMMING POOL P.LF.CINIC
f b ) VALI3A'I'ION
_y action hot 7031.5 by tyapplimanf the bermitss far bjets theeexemptt to civil
of
F=zQno,
Section LS by dollrs($50smit subjects the applicant ecivil penahy of ODTLITS-SWITCHES-Fl%TURES
mol more Than Ove hundred dollars ,amp. NEW RPSIDENTIAt,EIEC R _SQ.FI'.
K m ❑ othe wrk,ad thespeey.onnycmpinded orthwagesahtheirsolecom.1lasmess S'fORlliS 'I'YPIi(:ONSTRl1Cr10N
will do@esions andthestm nture Cmdisnnts Lieederoffmad.does net apply
9044. wner of
and Professions C,m Trope Commcmr s License Law Joss nor apply m an owner of
pmpeny whahuilds urimpmves thereon,ane who does mimema oinficonhmugh his OCC.GROUP RES.UNIT'S
awneer,hocs,provide)thatseemimisseld nlsurcnot larroldmnlYcred for swan;
however,thebuildingnrimprovementishathwithinoneyear ofc paroveion,theowner '1'O'1'AL:
builder will have the harden of pnrving that he did not buil)or improve for purynse of
sml
E] 1
❑ ,mownerof the property,am exclusively contracting with licensed comractomm QTY. PLUMBING PERMIT FF.F. II,OQD ZONI% APN
comment the propel(Sm.7014,Business and Professions Cade)the Contractor's PERMIT ISSUANCE
License Law dossot napply loan owner of property who b u i I ds or i mpraves thereon,and
whomarmms for such projects with a contrunor(s)licensed pursuant o the Connors AI TEN-DRAIN&VENT WATEN
License I,ow. FEE SUMMARY
ClI can excmpt under Sec. ,B&P C for this reason BACK FLOW P .DEVICE SANITARY VDI;FF. S N
Uwner Date
WORKMAN COMPENSATIONDECLAR9TIDN DRAT -Fl.OUR.BOOK AREA,CON 1). SCHOOL FAX Y N_RECEIPT#
❑ Ihercby affimr Natlhave acenificate nfensentmxlf-Insure,ora reoperate of XTURFS.PER TRAP RECEIPT#
Workers'Compensaion Insurance or a emitted copy thereof(Sm.39M,Lab C.)which PARK FEE Y_N
covers all employee's under this permit. GAS-EA.SYSTEM-I INC.40UTLE RECEIP #
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTHM-OVER4(EA) PLANCHECK FEE
❑ Cuddled copy is hereby famished.
❑ Cemioed copy is fled with the city inspection division. GREASE/INDUSTRC WASTE R OR RAVING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' REASETRAP SOILS FEE
COMPENSATION INSURANCE
(Thls,mism need nut be completed fdepenult is forme hundred delta.($100) S WHR-SANT"I ARY-STO A.2WFT. ENERGY Il112
m rev.)
I cenify thm in the performance of the wmk(orwhich Nis pemtil is issued,Ishall WA ;RHEA' . W � TBII,ECIR
not employ,any person in any manner in m to become subject to the Workers' PAID
Z Compensalinnl.awsof Calibamio. Date WAT"R SYSTI: TING Date Recciplb
Applicant
O 0 NOTICE TO APPLICANT.If..for making this Ccrificam of Exemption,you should NEW SIDENTIAI. B. Q.ITTOTAL:
F4 become subject o the Welker,Compensation provisions of the Unn Code,you most
a ; I'orthwir cut 1,with such pfnv kions or this permitd.1 l he deemed revoked. BUILDING ITE
CONSTRUCTION LENDING AGENCY SEISMIC FEEL
S
✓✓✓ I hereby affvm that is a construction lending agency for the performance of
C) ,he work fnrwhich this permit is issued(Sea NEED.Civ.CJ T AL: ELECTRIC ME
Lk. Lender's Name PLUMBING FEE
Lenders Address QTY. ME NICAL PER EF,E
L) I cenify that l have read this ily and cora and sum That the strove information is MECHANICAL FEE
minding l agree m on.complyand with hereby authorize
and eepresourty nrdimm offlus sum lean r upon
PERMIT ISSUANCE
F'" Z advasenmentiofuctiooert orinsputhonzp purposes.
Ives of Nis city roamer upon the CONSTRUCTION TAX
V ,2 vMv(We)a goldpmperyformnify inspection peep law ALTER OR ADD TO MECII.
(We)agree m save,indemnify zed keep harmless Ne City Cupertino against
liuhililiea,judgments,costs and axpunxe which may in any way accrri ita vgeinsl said City AIR HANDLING UNIT(TO 10,000 CFM)
9211,001111 s Pen"
G /9` AIR HANDLING UNIT(OVER 10. 00 CIM)
• J
Signature of Applin n/Commcmr 7 Date EXI IA OST HOOD(W/DUC'1)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING ON]r(TO 100,000 BTU) Data Receipt#
Will lheapplicanlor future building recriminations or handle hamrders mated.] HEATING UNI'I'(OVCR 1110,000 BTU) 'TOTAL:
ns declared I the Capcmino Municipal Code,Chapter 9.12,and the I le.1th and Safety
Cade,Section 255321e)9
11 Yes 0N VENTILATION PAN(SINGLE RESID) SII
Will( BOILER-COMP(3HP OR 100,000 BTU) ISSUANA,DATE
he vpplicanl or lLwrcbuilding oscupt use eyuipmem
lmm�levicea whichemit './ p
be andouk dr connunini as defined by the Bay Arca Air Quality Management H
DisncR- BOILER-COMP(OVER I00,000 BTU)
❑Yes ❑No NEW RESIDENTIAL MECII. SQ.IT. JUAN 13 19
1 have mad Ne industrials materials requirements under Chapter 6.95 of the /+/�� xi g5
California Health&SaPo74
ly Code.Sections 25505,25533 and 255 . 1 understand that V
If th pard Ing a requirements
wy bromumnum,et prior
my resprce oft
to notify lM1e Ur Vl
Oc a ant of the reyuiremems which muss be and prior to issuance nfa Cemilicum of 6/—%'V
Occupancy. ,C`v//
Owner m wnhorized.gem Dam TOTAL: ISSUED BY
OFFICE
ADDITIONAL PERMIT FEES
w
BUILDING PROJECT IDENTIFICATION "� vALUATION
euuomo
oREu `
60 s
OWNER5
NAME
FEE SUMMARY
oNE
Co
NN crOR BUILDING
NA q�//
�Cc No .0,24,_
Y PLAN CHECK
carvmAcroRS FEE
SEISMIC FEE
Se
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES
—APPLIANCES RESIDENTIAL PLUMBING
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. - PERmir vnuonnoN
MOTORS SEE FEE SCH.
O SERVICE CHANGE
Z2
H 0ir V5 TOTAL
DAN E ATE
LU > CITY. PLUMBING PERMIT FEE BLDG, I ELECT. PLG. NEce.
CL 0
L =) Z ALTER-DRAIN&VENT-WATER(EA.) ❑ ❑ ❑
U O BACK FLOW PROTECT.DEVICE
O1 DRAINS-FLOOR,ROOF,AREA,COND.
} rn FIXTURES-PER TRAP
F z GAS-EA.SYSTEM-I INC.4 OUTLETS
(� GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-11NC 5 V.B.
LAWN SPRINKLERS-OVER 51EA.1
SEWER-SANITARY-STORM EA.200ft/
WATER HEATER W/VENT
WATER SYSTEM L
WATER TREATING EQUIP,
TOTAL
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MEC H.
_ APPLIANCE
AIR HANDLING UNIT ITO 10,000 C.F.M.1
AIR HANDLING UNIT(OVER
1()0"C.FM.1
EXHAUST HOOD(WITH DUCT)
HEATING UNIT ITO 100,000 B.T.U.1
HEATING UNIT(OVER 100,000 B.T.U.I
VENTILATION FAN(SINGLE)
BOILER-COMP(3 H.P.or 100,000 B.T.U.)
BOILER COMP I0-,ID0000 BTLII SEE FEE(rsfsM.
TOTAL