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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO n H.)INr-ELECTRICAL
APPLICATION/PERMIT PLUMBING,-MECHANICAL
BUILDING DIVISION BUILDING PROJECT HUNI
N
PERMIT NO.
1 p 5 L 5 r /� r
- 24525
L 4
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
0' 1 UNIT# - IAT#
-
O /
OW NB iS NAME: - PHONG
rS
N'i'RACTOR'S NAME: LIC NO:
N/C
❑
CON'IROLp
C
I
P r nee. Se ";Cef �f�
ARCHI I HCUINGINEEEU LIC NO:
ADDRESS:
CONTACT: - PHONE:
_ n¢�
XfCN
QTY. ELECTRIC PERMIT PEE
ISUILDING PERMIT INFO
BLDG ELF.C' PLUMB MIiCH
PERMITISSUANCE l
J
M A
...y /
E E El
LICENSED CONTRACTOR'S DECLARATION
hereby affirm that I am licensed underprovistonsnf Chepter9 (commencing with
APPLIANCES - RESIDENTIAL
1011 DESCRIPTION
Sermon 7") of Division 3 ofthe Business and Professions Cade, and my license is in
roll form and cp$(1. I^
Llcema Class ate" �Lic.#
n
PANELS �Vd
/ UP T02t111AMPS
Do, Conmano
201 - 1000 AMPS
ARCHITECTS TION
OVER IIXMIAMPS
"
SQ. Irl'. BOOR AREA
S/SQ, FT.
I understand my plans shall be used us ublic nrds.
SIGNS ELECTRICAL.
1.icemseJ Professional '
OWNIiR-BURDER DECLARATION
SPECIAL CIRCUIT/MISC.
I hereby affirm that I am exempt from the Contractors License Law for the
TEMP. MTUEER OR POLE INST.
fohovvingrdwan.(Serino 703L5, Business and Pmfeasiona Colo: Anycity or mnmy
which requires o permit to construct, alter, Improve, demolish, or repulr my 9mclme
prior to its issuance, also requires he applicant forsuch Tamar in filen signed atonement
POWER DEVICES
_
the, he is licensed pursuant m the provisions of the Connector, Laramie law (Chapter
9(commencing with Section70PE, of Division 3 of 0e Business and Professions Code)
SWIMMING POOL ELECTRIC
VALUATION
nr Fouhe is cnempuherefrn Torrthe basis for Fri Red Tramption: Anyvl.bmhm of
Semon 7031.5 by any applicant for a Permitsubjects the applicant to a civil penally of
not more than Five hundred dollars ($500).
❑ I,asownerofnhepmn rty.ormycmployeeswithwugesastheirsolecompensation,
STORMS TYPE CONSTRUCTION
OUM M, -SWITCI117S-FIXTURES
NEW RPSIDENTIALELECfR _SQ. FT.
will do the work, and the soucmre is not i mmided or offered for sale (Sec.'1044, Business
.,Td Professions Code: The C'nuni License Law Joe, ant apply m an mearo of
-
pmpeny wM10 buildsorimpmves Nercon, anA whndoes loch work himself.rNmughhis
ownemployees,providedtbatsuchimprovemenmarenotimendedorofferedforsale. If,
OCC GROUP RES. UNITS
TOTAL: 3 3
however, the building or improvement is sold within one year of completion, dm.wner-
hander will have The burden of proving that be did an build or improve for purpose of
QIY' PLUNKING PERMIT 111, 17
a).
❑i. es own<ror me propmy,ameadualvdycomrvctingwithlicenxed commcmrm
FLOOD ZONE AI'N
construct the project (Sec. 701Q Business and Professions Code) The Commemrs
License Law docs not apply mein owneroflim,any wholaildsor impmvesthereon,und
PERMIT ISSUANCE
whomnu.cts forsuch Imports ,iIh.TawI hflm(a)Ilawcad p ... coal 1. The CGmtrmmrls
License law.
ALTER PA
FELSUMMA¢Y
❑ I am exempt under Sec. B & P C for this rtaann
BACK ROW PROIECp. DEVICE
FEf
SANITARY YIDE
N_
RECEIVE#
Owner Data
DRAINS- FLOOR, ROOF, AREA, COND.
WORKMAN COMPENSATION DECLARATION
SCI 1001.'TAX YN_
EIIherchyaff n that l have a certificate ofcomentto ulf-insure, or a cenificae of
Workers Ceap�mppeynsarion Insurance or a certified copy Prown(Sce, 3800, Lab C.) which
FIXTURES - PER TRAP
RECEIPT#
PARK I II Y N
OAS - HA. SYSTEM -I INC. OUTLETS
PaIICY # I P/L ac'sITT t tl O/
BUILDING DIVISION PERS
GAS - EA. SYSTEM -OV PR4 WA)
PLANCHECK PEE
Company �Q -a0 L
Q Certified copy is hereby furnished.
GREASIONDUSTRE WASTE INTERCEPTOR
GRADING FEE
6Tf Certified copy is filM with the city inspectiondivisioo.
CERTIFICATE OFEXEMPTION FROM WORKERS'
GREASETRAP
SOILS FER
'
COMPENSATION INSURANCE
SEWER - SANITARY - STORM HA. 200FT.
ENERGY PER
('DTisse, innneed notbepompleedifthepermit is fnronehunJrWdolleas($100)
.,-less.)
WATER HEATIERW/VphrDELFCCIR
I vanity Nat in The perlitmtance ache work for which this Permit is issued, l shell
not employ any person in any manner so is to become subject to the Workers'
PAID
Compemsatlonl.awsof Califnmia. Date
Applicant
WATER SYSTEM/IREAUNG
Data Receipt
NOTICE TO APPLICANT': If after making Ibis Certificate of F,xensptinn, you. should
NEW RESIDENTIAL ELME. SQ. Up.
TOTAL:
become subject o the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions..Ihis perrnil shall be deemed revoked.
BUILDING Iql:
SHISMIC TEE
CONSTRUCTION LENDING AGENCY
I hereby ulfimt thin there is a careum, ion lending agency for the performance of
the work for which this permit is issued (Ser. 3097, Civ. CJ
'1'O'1'AL:
ELECTRIC FEE
Leri Name
Lender, Address
QTY. MECHANICAL PERMIT FEE
PLUMBING PEE
1 certify The, 1 have .it this nppliunion and x,a,. Th., Ib. ubnve Infonnmlon Is
correct lagrtc 1. cnmplywith all city und county nnllnunces und stem lows rclmingm
PERMIT' ISSUANCE
MSCI IANICAI. FF.E
_
building con,.actim. and hereby amhnris reprtserad ves.Dhis city to enter upm IM1e
mimed psny for inspection purposes.
alxmc-mepe
AI: TER OR ADD TO MECIi.
CONSTRUCTION TAX
(We) agmen. save, Indemnify und keep harmless the Cil, of Cupertino ugr;nst
-
Iiuhilitim,judgmcnD. costsund.xpeow, which may if umy way o'com.gaust said City
AIR I IAN FILING IN] 'r(TO 10.(w(I CPM)
in consequence of the graining of this permit.
AIR HANDLING UNIT (OVER 10,000 CFM)
Slgnameol Applicem/Comrum.r Dole
EXHAUST HOOD OV/DU CT)
PAID
HEATING UNIT (TO Ila," Ell U)
HAZARDOUS MAI HRIA1S DISCLOSURE
Date Receipt #
HEATING UNIT(OVER I M,000 BT HE
TOTAL:
Will the applicant or future building occupant store or handle harardous material
us defined by the Cd,cmua Municipal Code, Chapter 9.12, and the IElam uad Safety
VENTILATION PAN (SINGLE RESID)
Code, Section 25532(0)!
❑ Yes �(No
BOILER - COMP (311P OR 100.000 BT'U)
ISSUANCE DATIi
p p I D
Ir M
Will the aondantnrfmure building h,thentuuequip Air QJefity whichemil
huwicous air cnmaminanle as lined by the Bay Arca Air Quality Mnnagemenl
n;slria^
BOILP.R -COMP (OVER 100,000 BTU)
Cl Yes N.
I have card the hrNous reg.immm
mmaterials
e, trader Chapter 6.95 of the
California l lealth & Safety Code, Sections 25505, 25533 and 25534. 1 undepti nd that
NEW RESIDENTIAL MECH. SQ. IT.
r
Ut(G{Y%� _ 9 1 992
i the building ate not currently have a herewith., it is my resp.nsibilitym notify IM1e
CIIY OF GUI'cmiriv
re ant fesrwhich must be met prior to issuance of a Certificate of
;
Oc &
authorimdagem - Dam
ISSCP,DBY:
TOTAL:
OFFICE