26937APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPENO - PERMIT NU
BUILDING DIVISION APPLICATION/PERMIT PLUMBINBUILUNG-b1ECHANICAL
BUI W TNG PROJECT IDENTIFICATION„
BUILDING ADDRESS. SANITARY NO.
APPLICATIO
T# O'TN
OWNERS NAME : PHO
ej e+1S
CONTRACTOR'S NAME: LIC NO:
-
AOL P-0s 1 � 60,.l 6 K # N/C CONT
\RCHITEC� GINEER: LIC NO:
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ADDRESS: ❑
ygo SAu /2µMe u u� ItrBl.d. #i99 Arno
CONT,ACT: PHONE:
z a y m , rV o, vPr xUa st 7 4+y s ,y. x s'n * •• .x 4BUII:DING PERMIT I
•.
QT•Y:a a v¢ ELECTRIC PERMIT*'-
/ t
#+s4' &'w#afS`£vN 6+»•'+4 BLDG PLUME
PERMIT ISSUANCE
El❑
LICENSED CONTRACTORS DECLARATION -
pppLIANCES-RESIDENTIAL
nzz
Ihrrebyaffirrn 'lot' lam licenced underprovisionsofChepter9(commencingwith
JOB DE RIPTION
FACO
F-
y
Section 7000) of Division 3 ofthe Business and Professions Code, and my license is in
effort,
Emmentanse
PANELS -
U
Licfailense 6o YZ6 e-�i
License Class
Clas
UP TO200AMPS
Fzµl
Lic#
Date p3L
rel h
_92ii Contrar
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201 - 1000 AMPS
I"',o
py4p
ARCHITECTS DECLARATION
I understand my plans shall be used as Pahl is records.
OVER 1000 AMPS SQ. FT. FLOOR AREA
64
�
SIGNS ELECTRICAL-
LmrnsW profesemnal
C
fqYC1yU
0 A.
OWNER-BUILDER DECLARATION
I hereby
SPECIAL CIRCUIT/MISC, -
X
W3U-rn
affirm Thal I am exempt from the Contractor's License Lew for the
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following reason.(Ireland 1031.5, Business and Professions Code: Any city orcounty
which
TEMP. METER OR POL INS
coniPrior
requires a Permit w construct, alter,improve, demolish, or repair any structure
I p N7
its issuance, al so requires theupplicant for such permit to file aneredstatement
POWERDEVICES
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that he is licensed Pursuant m the provisions of the Contractor's License I.aw(Chapter
W yo�1
X�❑m
9(commencing with Section TIDO) of Division 3 class Business and Professions Code)
SWIMMING POOL BLE
or that be is exempnherefrom and the basis for the alleged exemption An
& p Any violation of
VALUATION
B.za
for a subjects the applicant ma<ivil penalty of
OUTLETS- SWITCHES FIXTURES
O
no,. m,h.a veanydreddamrs($50rmit
not more than five hundred dollars ($500).
y^9
❑ ,ormyemended
wrk,
NEW RESIDENTIAL e al
_S ES
y y
will dothewons add the
othe adbepstruch orofwed forstheireo 70,1,L Business
T144,Business
TYP:
h. Comment,
end Professions Code: Tha Contmemr's License Low does not apply to an owner of
apply
own enywhobuildsarimprovesthereonandwhodoessuch work himselforthrough his
employees,ldidgmJ shave improvememsarene
OCC.GROUP
however, ear oedimplel n, then nscr,
buildingorden
within oneyam ofimproe
wthe
b odpmrntis un fatheowner-
will have the burJen of proving @at he did not buil) or improve for of
TOTAL:
purpose
le.).
e77
0 t
❑ I ns'be
TY1 d e i �-1 PLUMBIN(3'PGRMIT3 BEy u FLOOD ZONE
Q r$§ $ 9
the project (Sec
elect (See 70, 4, Business add Potractingwithllc:) The Champion's
emess and Professions Code) The Canton,
gYg y o
License
Licensetrawdeeshot PPly o an, owner add
thereContractor's
PERMIT ISSUANCE
such jects withslu berous)whnsedPsoocol toles the
for such Projects with aeonvaewr(e) licensed pdraumuo the Convector's
whocontractsLave.
License Lew. -
ALTGR- DRAIN&VENT -WATER (EA) x FE4 SUMMARY
1
❑ 1 ata exempt antler Sec. , B & P C for this reason
11
BACK FLAW PROTECT. DEVICE ITTSIDE FEF,S
Owner Date
SANITARY Y I
WORKMAN COMPENSATION DECLARATION
DRAINS- FLOOR, ROOF, AREA, COND. RECEIPT #_
I hereby affirm that l have a ceniftcaw ofcoment to self-insure, orncettifate of
SCHOOLTAX y_I
FIXTURES TRAP RECEIVE If
et"Compensation Insurance or acenifed copy thereof(See. 3800, Lab C.) which
-PER
PARK FEF.
covers all employee's under this permit.
Y_I
Policy#
GAS - EA. SYSTEM- RECEIPT # _
IINC.4 OUTLETS
Company
BUILDING DIVISION IT
GAS -EA. SYSTEM -OVER 4 (EA) PLANCIIECK FEE
❑ Cenifed copy is hereby famished.
,Certified copy is fled with the city inspection division.
GREASWINDUSTRL WASTE INTERCEPTOR
GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE'f12AP
COMPENSATION INSURANCE
TOILS FEE.
(This section need not heeompleted ifthe permit is for one hundred dollars($100)
SEWER-SANITARY-STORM EA. 200FT.
orless.)
ENERGY FEE
I cenify that in the performance of the work for which this permit is issued, l shall
WATER HEATER W/VENT/ELECfR
not employ any person in any manner all as to become subject to the Workers'
Z
Compensation Laws of California. Dow
WATER SYSTEM/I'RFATING PAID
Q
APPlicant
Date Receipt#
NOTICE TO APPLICANT: If, after making this Certificate offixemptied, you should
NEW RESIDENTIAL PLMB. SQ.E-n
tr+ Vj
become subjecna@eWorker's Compensation provisions of the Labor Code, you must
TOTAL.
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forthwith comply with such Provisions or His permit shall be deemed revoked.
BUILDING FEE
�Lki Q
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
,Z
I berehy art,. that there is a consvuction leading agency for the performance of
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the work for which this prima\i�Issual 3099, CIv. CJ
Lenders N.._/1 F+
TOTAL: ELECTRIC FEE
LI.
V
Lenders Address
µ
Qpg1,}is#aMRCHANICALP8R1v11T'm4reREEsA PLUMBING Pee
3
1 can fy that 1 have read this application and state that the above information e
'' °' r # t ' s - e'a z fi ;b,s 04 Y `
PERMIT ISSUANCE �� MECHANICAL FEE
r' a
correct l agree to comply with all city cod county ordinances and state laws timing to
building consvucmn, and hereby authorize repmeentativei of this city to enter upon the
U
above-mentioned property for inspection purposes.
ALTER OR ADD TO MECH. CONSTRUCTION TAX
(We) agree to save, indemnify and keep harmless Ne City of Cupertino against
lislet ities,judgm ts,cnets end expenses whichma in any way accrue ngainstsntJ City
AIRHANDLING UNIT(TOIU,000CFM)
que ed of fie gmntingofthi permit.
AIR HANDLING UNIT (OVER IO,OIX CFM)
t�°
.-O " 81r-9�f
9rgnntnre of Applicant/Contractor Date
EXHAUST HOOD (W/DUCT)
PAID
HEATING UNIT (TO 100,000 BTU) Date Receipt#
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
-
asdefinedbytheCupenlno Municipal Code, Chapter 9.12, rad the Health dad Safety
HEATING UNIT (OVER 100,000 BTU) TOTAL.
Code, Scalia. 25532(a)R
VENTILATION FAN (SINGLE RESID)
❑ Yes a a No
AIIIIIIIII
boliding
Willthe uexam'snrrants
cesanagement
BOILER - COMP (3HP OR 100,000 BTU) ISSUANCE DATE
hazardous
s,
air contaminants as defined by the Bay Area Air Quality Management
bythentuse Area Quality
BOILER -COMP OVER 100,0(X1 BTII
( )
1pDlsvictP
❑Yes Lq.No
A
NEW RESIDENTIAL MECt1. Rn TT '
I have read the hazardous materials requirements under Chapter 6.95 of the
California
if
Health & Safety Code, Sections 25505,25533 and 25534, (understand that
the building does hot currently have a tennnq War it is my responsibility to
AUG 2 5 19
Occupanty/
nmlfythe
cupea Oe mqui�t9�encs which musyhe m nor, to lesuance of. CCeeediifush, sof
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UJ- 1
Owner
ITV
or authorized agent Date
TOTAL: ISSUED BY:
269371