31327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. a� ^ a.a�a
BUILDING DIVISION APPLICATIONIaERMIT PLUMBING-MECHANICAL. -J{ 32 1/
BUILDING PROJ ECL'IDEM I'IF'ICATION
BUILDINGADDRESS: SANITARY NO. APPLICATON SUHMDTAL CALL
(083 oL aJILD1N( D cA F.I0 L� '1"
OWNERS NAME: '{ PHONG: CON'1'RACI'OR'S NAME: LIC NO.
0 Rgr� JF�I ] IO— — UG N,C CONTROL»
\ CHH'I»FFx��EFfCffTMI.MNGINEER: LIC NO ADDR?SS: ❑
C 1'Ll PHONE: BUILDING PERMIT INFO
FRIG C—m Consultant Fees Paid by Applicant(Initial) ELECT PLUMB— MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 5(I�Ey
1 hereby affirm that 1 tun licensed under provisions of Chapter 9(commencing g� DESCRIPTION
O0Z with Soc,ion]000)ofD,00.3.I Im Bmiuco,mdProfc„ions Gxlc,and my lleenxn is
�DOp 1'ERMIf ISSUANCE;
m� n full force unJ clfcct. Li #�/.�[�<�9r L j SFDWL �(1q� ❑KITCHEN NfiMOUIiI.
OUQ Q0. UYIcmC Clay�Conlru!or 'rp�c-' ru T1WJJ 71 ❑STRUCTURAL.
b �n �!/s� APPLIANCES-RESIDENTIAL. 1 ❑PLUMBING RE PIPE
ARCHITECTS DECLARATION
F�N IoA;JE45
Z p y I undersand.,,[.,,bull he used as public reenacts ,IT I - MODIFICATION
UPT0200MPS A/1 ROVEME{I,INO CHIMNEY REPAIR
1-.�FLL1 Licensed Professional ]BI-H1W gMPS IMPROVF.MENL
�a'�6 Ihcrehy aRrm thmNvmcxdmp FfomEthe CmuvOors License Lew fur the OVER IHfg1AMP$ [I BATH REMOUF.IIRF.PAIR El DEMOLITION
�L a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
R7 3 LL FNv'D which,ryuires a permit I,,c ueboo.aIle,,improve,demolish or repair,any structure
.F.,4.0y¢ priurmits issuance.also rcyuires IIIc applicant fur such germine lBra,limd,uncmem SPECIALCIRCUIi'/MS
'S y dmheixlicensedpursuam um the Lnwi um,of the Command Licenxn..uw(Chu. -
W-0� (comnencing aim Secdon)gA6 of Division 3 of the Business and Professions Code)nr IPM P.METER OR POLE INS, COMMERCIAL:
66 ay mho he is exempt Iherefmm and the basis for the alleged exemption.Any violation of QWW BLDG/ADDITION ❑DEMOLITION
^N Section 7031.5 by any appHeant for v permit subjects the applicant to.civil penally of POWER DEVICES ANT ❑FOOD SERVICE
not more than five hundred dollars(5500).
F Z IMPROVEMENT
_Q pLothe worofthe pmmntior mycmntendes with wagesrthm(Sm. 04,E Bsanoo, SWIMMING POO LECIRIC
will do the work arta me suucmmis not intended or offered for sale(Sec.]1N4,Business ❑OTHER
a�j and Professions Cade:The Conmacmr's License law d«s nor apply m an owner of IITLETS-S -PIX'FURPS
a 3— progeny who builds or improves theman,and who does such work himself of through
his own employee,,providnd that such imp mvemems we not intended or offered for NIiW RESID"TIAL FILE SQ FT.
ale.If,hownvnr,thc buildingnr inwnrso cut issold withinnne,no of enmplmisso,the SQ.FL FLOOR AREA $/SQ.I?
owner-builder will have the hardenof proving that he did not build or Improve for for, Q,,C) ����
,,,a of.sale.). & SQ u
I,as owner of the pmpeny,um exclusively contracting with licensed conmacmrs to
construct the pmynet(Sea 7044,nosiness and Professions Cede:)The Commcloe,Li-
cause Law does not apply toran owner f propnny wbo builds or improves moron,and QTY PLUMBING PERMIT FEE
who comrens for mch projects with o comranor(p Itcort punvans tothc Conhano,
License Law. - PERMIT ISSUANCE
❑1 cam aso
exempt under Sec. .H&P C fur this ren
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
.
WORKER'S COMPENSATION DECLARATION BACK MOW PROTECT.DEVICE: s IpODrQQ(�
hand will mai mWm penally rte c(Co one o(the following dcelan',Cur.
ons
❑ have and will far by Se Cion37yc of the LattrrCae.for the
Wwkcrsce of B4
DRAINS-FLOOR,ROOP.AHFA.CONU' STORIES TYPE,CONSTRUCTION
r salon as provided for ndi lection 3]1X)of me Labor Cole,for the perinrmance of N
walk far
have
thispcmtiin issued. FUTURES-PER TRAP /� ONE
I have and will maintain Worked Campensaion Insurance.as required by Section'�of eche tabor Codgfor the performuncc of me work fnr xbich this permit is issued. GAS-EA.SYSTEM-1 INC.4OUTLETS OCC GROUP APN
My Work CQmQe mi n�l9s7W�ncc cr and Policy ylr^�'e a¢
Cumcr: �FIFS J,IJJdVS(L� Policy No.:LErr�5ZD34(r�I GAS-EA.SYSTEAI-OVER4(CA) Y -Z
CERTIFICCOMPE COMPENSATION
NFROM WORKER$' GREASEIINDUSTRL WASTE INTERCEPTOR 1�
COMPENSATION INSURANCE BUILDING DIVISION PEES
1Thissection need not heenmplctcJ ifthe Acromio is fnr one hundred dollars($I W) CRhASETRAP
or loss.) PLANCHECK PER
Icmily tha in the perfnnnance of the work for which his permit ixis.x.ed,l shall SEWER-SANITARY-STORM EA.2001'I'. �1w
not employ any Noon in any annmr so as m nerome object ,, he Wnrkerd Campcn- ENERGY PEE: L CDC, LV
scion laws of Cwifn-m.,Darn WATER HEATER W/VENT/ELECTR
z ,Z Applicant GRADING FEL'
tryNOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
F' 7became,union to me Workers Compensation provisions of the Labor Code,you must SOILS FEE
fnnhwith comply with such provisions or this permit shall be deemed teml ed. WATER SERVICE
CONSTRUCFLONLENDING AGENCY NEW RESIDENTIAL PLMN. SQ.FF. PAID
UohcrehY uffirmtha memiaunmswctiunlendingagency fnnM1epc omance ipl»
H the work lin which this Permit is lsoual(See.3097.Co,C.)
D' Lemla''s Norm 'LOYAL"
QWLmJnr's Address T '
1 I certify that I have read this application and irate that he abwc information is BUIL /r
N donut.I agree m comply with all rimy and county ominances and slum laws relating m QTY. MECHANICAL PERMIT
f> Z bmidingconnructim.and hereby amhorire mpn-cha c,tAbi,eiy menarupon me SEISb1 E
above-momioned property fur inspersion pmpuxs. PERMIT ISSUANCE
(We)agree m ave,indemnify and keep nannies,the Cly of Cupertino agnin>t ELECTRIC
Iiabd'viecjudgments,enslsanJ expenses which.,ionnywny accrue againsm said Citr ALTER OR ADD TO MECH. �- PLUMBIN 'EE
in nnxyuence of the growing of this Penrod.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.HIg)CPM)
SOURCE REGULATIONS. MECHA EE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTR 1 ION TAX
Signature of AppbconVConvnnor Date S EXHAUS9'HOOD(W/DUCT) HOUSING MIy ATION FEF.
HA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handl hamlous material HEATING UNIT(TO 100,000 BTU)
as defined by me Cuper ino Municipal Cade.Chapter 9.12,and me Health and Safety
Cut,Section 255321ap HEATING UNIT(OVER I01d100 BTU)
C:)Yes 0N PAID
VENTILATION PAN(SINGLF.RESID) Dale Receipt#
Will the appllcanl or move building o enismt use equipment or device,which
umh hae.Mous air contamim ns ns defunct by the Bay A.Air Quality Mamgemun 1101 LHR-COMP AHP OR I01.1NN1 BU7
TOl'Ah:
Naito?
❑Yes 0N BOILER-COMP(OVER 100.I»0K)HTU)
I have read the haendou.x maeriws cemmmena under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Salary Cole.Sections 25505.25533 and 255Y1.1 undema J mm if the NEW RESIDENTIAL MEC". SQ.FT.
Wilding does not currently have a tenant,that it is my m%pnnsihiliy to notify,the occupant
of me reyulmmenzs which roux he tun poor to ismanee of a Cenificam of Occupmcy.
Owner or authorized agent Date ISSUED BY:
OFFICE