S 2264L
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPFICI'INO BOILDING-ELECIIRICAL -
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
III111,DING I'RfId IS(."1' IDN.NTIFICA'1'IOA ',
PFg1TNO, 2264
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BUIDINGADDRPSS,_
°�o Io SLS; su>J
SANITARY NO.APPLICAT
ION SUBMITTAL DAI'li
OWNER'SNAME: PHONE: -
Ells Vee�\ a-
COIFKACTOR'S NAME: LIC NO:
jtJST A U
-
NIC
❑
CONI'ROLp
'
1
AItCHITECTIENGINEER: 1 NO:
ADDRESS:
n.p
CONfACI: PHONE: s\O
I EIJILDING PERMIT INFO
-
❑ Consultant Fees Paid by Applicant(initial)
BLDG EhleCf PLUME MECx
Aeo0c").3 12-
❑ ❑ ❑
7aZ
O
XO
I—t
_Z'
_ D m
m Z
L4-
LICENSED CONTRACT OR S DECLARATION
IM1 by If that l'ml J J p : of Chapter 9( cng
inns f 700f11 fFast ".' 3 rmfl1 dProf .. ,C I d ryIi. n.v
'n I'll l' end ,. �] q
Ic a Ess � LIC« 5g�3a 1
Data %�Contrac ll Willi s1=
ARCHITECTS DECLARATION S'�
unJeramn:l mY plan' nv 1112111 he used m public rconnlc
QTY 4 ELECTRIC PERMIT I'EG,
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN It1.MODF.I.
❑ADDITION ❑PLUMBING RE PII'I:
❑ MI11,T1-UNIT ❑ S OD[I7[UCI AI IO
MODIPICA'1'ION
❑IN'I ERIOR ❑ CHIMNEY REPAIR
IMPROVEMENT lSWIMMING TOOLS
❑NATE ItEMDDEI./1t1i1'NR DEMOLITION
�/
W o-FHER 1lPAx2P S
I'EIt MI ISSUANCE.
APPLIANCF_S- HESIDENTIAI.
PANELS
UP TO 21111 AMPS
nFW
{yah
7 W V
3 LL vFi
A
y yy
�N
FF.O
Licensed Pmftslinnet
OWNER -BUILDER DECLARATION
1 hemhy affirm than Inn] cxempl hour the Conlnmmh License Law Gtr the
g ria Y cl y or rna0 Y
0ill0win xan. (Section ]11.11.5, Huxlneex and Professions Code: An t 7
which rs a... a Rnnil to construct, cher, improve, Aunranit fi repair any [Immure
cons ismance.vknre thea licnm for zuch no Rlexsi tlstamanem
poor 90 die pp Rani Rne
rsunt 7000)pmviem... nfthe Qm'snd '111elaw(Chnptrr9
that hc..r,un will, Section
I, War wt daere nvanad of basisun 3ort the hc ArReitBillion" uplioo. Any st hnion or
that M is exempt Iherefrnm uOW Lou basis Iia the 111.,211 uenption. Any violminn or
that
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Rwlry of
not more than five hundred dollars (55011).
01, as owner of the property, urmymnpl...... ith wage' as lbciraole eemlxetxminn,
wittlo theas k'aadmes¢nnure is nm inwnJed orof l'creA lhrvalc (Sm."I(M4, Burincxr
andl Ic .Cd Tb C t t .1 r La I I pplyl a ter or
20I-100DAMPS
OVER ❑NM]AMPS
SIGNS 1!LP.CfRICA1,
$1'ECIAI. GIRGDfI'/AjISC.
yAG
TEMP MI!'I'I!k OR l'OLH INS'I'.
COMMERCIAL'
EW HLDC/ADDITION ❑ DEh40LIT10N
ENAIST ❑ FOOD SERVICE
ROVE?MENT
fHl!k
POWER DEVICES
SWIMMING POOL I!LI!C'TRIC
OUII.I:TS-SWITCI1Ll 11XfDkES
NEW RLSIDENTIAI. FLECHR SQ 14.s:de.It,a,,,vendc
T.'FEE"
proper, li b 'IJ p : th d h i s M1 k 1 If IM1rnugh
bis ply : p 'J Iflat hp t: t'I 11 firnf for
huld't,trnpmvcnLtesold wnntne yu-:fen OpWm.IheSIJ.
FC FLOORAItEA
AISQ. FI'.owner-builder
will have the burden of transit, that he did not build or improve I".se
nr sailed.❑ I, as ownerofthe prupcnY• nm exclu ively tunneling with IiacnseJ emurvcmr, loTOI'AI;:
m.t tt I I(S .7(94 N..v1 II le,oi o Code)'I he C..moon, 1,
I d : lapplyt rtoltr ptr n hdd. or improves thereon.nd
'minse
QTY' ' PLUMBING PERMIT .
who contracts for such projects with a contractor(s) lamed pursuant the Contractor's
FERMI r ISSUANCIi
-
License law.
I am e,e np0 mulct Sec. . R k P C far drs rroxon
Owner Date
ALTER -DRAIN ffi VI?NT-WATER (EAJ
VALUATION
WORKER'S COMPENSATION DECLARATION
HACK FLOW PROTECT. DEVICE
I herehy tf ion under Iwnahy of perjuryone of the following declaration
❑IhuvwmAWill ndharmSe,lit.fcnl)nf he LnuoC le. for therabarensent lie
).turn, ar pmvidhi fur by 37ql til' the InM1Or Cndq for the RA'n:muncc 1(111.
DRAINS-I1,001t, ItOOP,AItHh GOND.
- 5'I'ORlli$
'fYPECONS'1'kUCT1UN
is is..
work lirr which thi.v permit is i+.wed.
FIXTIIHIS - PER 'i'RAE'
have and will maintain Worker's Compcmmion Insurance, as required by Section
)Ilof he "be, Codyye. for the perfannuncc of the work for which Oils permit is i.sued.
)B
GAS-13A.SYSTEM-I INC40UHATI'SMy
I ROUP
APN
Cron Work 1, cmricPOlicY Nn, �.����
/^
_1
GAS -IiA.SYSTEM-OVER 4(EAj
CHIFFIFiCAST 0P EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASHiINDUSTRI, WASTE INI'EItCF.POR
`
a"1V, INGD 'ION FE,.
frhh... Ior.-it trot It, contpleledl f the penni7'wfron, It dreddohhis (%10X1)
or lean-.)
GREASE'I'RAP
Z
C) O
h
W
pp, a
J Z
VO
F
O
I certify that in the perinrmance or the work for nbich lhisRmtil is issucglxhall
not emtriny any person in any anannerso;u nbecgmeyyh ".NC Wndccv' Contpen-
.motion Lnw,v Calilorna. Duro
Applicant r
SEWER - SANITARY - STORM HA. 200 Fr',
n
ENERGY ITE 9
WA'G!H III!Afl!R W/VI!N'I'll!hEGI'Ii
nowt HIT
SOILS
M-�(,.R
NCOICHIOAI LICANC If.:J¢r making this Cenifmam or Exentpticn, you should
become subject m the Workds Comper alion provisions of the LuMa Code, you must
forthwith comply with such provision, or Ili is permit shut l be deemed us liked
CONSfRUCi'ION LENDING AGENCY
Inorworr that lsaconsteed30TC, Cis. agency for theRrfnmmnce of
the der'sNrwM1iclt this permit i. iaucJ (Sec. 31Yd7, Civ. CJ
Lender's Nameill
WATER SYSTEMORHATING
WATER SERVICE
PAID
Da R.ceiptM
NEW RESIUENTIAi. 1'LMR. SQ. IT.
'T(1f�l.:
TDI' Ft
WV
Ltndm'I Address
BUILDINGAT
y
rn
U Z.,
is
1 cenify that 1 have nod 1Mv application ant sesta that Ili)11-1x) las astral,
cnmet.lagre)menmpnY x4111 all cup and county ordinance.and kyllawn remtin,m
building a:rowc7inn, and M1creby unnnorim rtpreeenlulivux of anis ei7y wumer spun the
Q'IY. MECHANICAL, PERMIT IeF;E
Iia
SI315MI
PHRMH ISSUANCE
IiLI!CTR ';F.
ahove.n... award prupcny Ibr Inspslion troopole''
1 We) agree to save, indemnify aJ Accp hnnnlesl the City of Cup)ttmn ugninx0
I'IDh1R1 x'iiiAPPLI
O
liahili&n,o"h may in any way accrue against said City
near
in
LV WITH AL1. NON-I'UINT
ACITiR OR ADD TO AIF.CH.
AIR HANDLING UNI'I'(TO 10,111111 CPM)MIiCHANICA,I'EE
AIR IIANULING UNIT (OV6R IILgNI CF.N)
CONSTRUCIlO'TAXto
. re ofApId,,a / t r Umc
17XHALJSI' HOLD(W/DUCT)
HOUSING MI' I'IGA'I'ION FEE
HAZARDOUS MAA 17RIALS DISCLOSURE
HEATING UNIT CFO 100,000 ETU)
-
Will the applicant or future building occupant gore or handle harandoos material
m d)6ncd by the Cupertino Menicipai Caie. Chapter 4.12, and the Health and Safety
Code. Section 25592(0)?
HEATING UNIT (OVI!It I00'0n) It put
•
❑Ycs [I No
Ng11 thea applicant or future building 1 use equipment or devices which
ptr gby he
emit hveardous all cnnlamin:mix as JeRneJ by the Hay Area Air Quality hlanagemem
VENTILATION CAN (SINGLBRET By
PAID
-
Date Receipt «
BOILER- COMP (31411 OR IW,003 R'IU),
DIAL:
BOILER - COMP(OVER 100,000 E'NI
�Yn, 7] No District?
AIR CONIAHONER
1M1ave Imad FStM hmanbSe mnleriaH 5.2553 ununder 41a hrvE of the Cali-
mai255119, t�mifIlio
ISSUANCE. DATEformal _
/l a?
NEW RI!SIOBNTIAI. h1I!CI{, gQ. I*f.
is mytad2.5514.1 it) upland
huddi,dons&S.....Codaea LLnamJhwo isuaceoft ihEftymnmffymepancy.til
huddfn,dlimmea
I�j --c-1
0
whicyhuvun
n[ the uryimmenu which maul les tne0 Prior m isuanc)nf u Caifrme til Oc.uPaney.
(/l
ISSUED BY. ::rO
TOTAL:
Owneror amhomed agent ()ate
OFFICE