S0001B0340 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO BUILDING-ELECTRICAL PERMITNO/3 #0340
. 0 3 4 0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING..MELHANICAL 5����
BUILDING PROJP,CT I'llibL'IFICATION
NUIhDING ADDR135S: SANITARY NU. AVPLICAI'[ON SUBMI PIAL DA]%09 Z IUO f1jX L
OWN' :S NAME: PHUNG CO RACTOR:S NAME: LIC No
C �E/NcC1�6 ¢4'SOj LL NIC corvrRa.a
ARCHITECTIENGIN ER: LIC NO: ADDRESS; ❑
CONTACT. PHONE: BUILDING PE ZMIT INFO
❑ Consonant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC FERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under provisions of Chapter (commencing
CMZwith Senior 7000)of Division 3nfthe Business and Professions Code,and my license is RESIDENTIAL'
,08 PERMIT ISSUANCE
in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
QOrJ License Class Lica APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING BE PIPE
N a a Dam Conavam
ARCHITECTS DECLARATION PANELS C1 MULTI-UNIT STRUCI'UkAL
❑
Z MODIFICATION
C)-z I understand my plitm,ludl heuscdas p.hire record<
OZ=- UP TO 200AMPS [I INTERIOR El CHIMNEY REPAIR
I 4ta1 Licensed Pronewmtol 201-1000AMPS IMPROVEMENT E]SWIMMING POUTS
OWNER-BUILDER DECLARATION OYER 1000AMI'g ❑BATH REMODEL/REPAIR ❑DfiMQLITIDN
I hereby nflirtn Ihat 1 am exempt Gant the Common.,license Law for he
�L O L U toll 6 (Section 01131 S 13 ' J I f ,Code Any city or county SIGNS ELECTRICAL []OTHER
413
�rw WIOr)F MM1yml( :I ( h p I Sa rery,tu,nam
Yi Omen(
MISC.
yQ pt I I .Is y 0 PPI II hq'unit II g JaateSPECIALCIRCUIT
that IN tip aoan,ho Im lowilinuounta,Contractor License L (Chapter 9
C6a6A (cart , ,in Seel '9WI) IO' ed 1 fah lie. 's. 11 I .:'on,Code)-1 T EMP M E117 R OR PULP I N S'T, COMMERCIAL
W p,o a 'but he Is esOaT1 there,,)-,'and the basis fm the alleged even, Any vaAalia.of ❑NEW BLDGIADDITION DIiMIOLITION
X,. Section 90315 byany upplicam Torn Permit subjects t heapplicant toacivil Ireahlof POWER DEVICES []TENANT ❑FOOD SERVICE
not more Ihun Eve hmWmd dollar.155000. IMPROVEMENT
SSG ❑ 1.a,owner of the P...perY•-,r my mnph,cu,with wages as doo,ole compem'anw, SWIMMING POOL lihliC'IRIC
will do the work,and the structure:.not Intended or offered for sale(Sec 91114.Business ❑OTHER
CFm
13 anderry whiob Cedc'Neoves Count,
mo Liccmelaw does nn(apply Inlf .,act of OUTLETS-SWI'TCf1ES-FIX'TDRES
ho own who built,or Ivided that
t sac i and who rites such awork himself.rem,f h
his own employee,,provided(hat such intprovnnems arc no'intended m,)Dcred for NEW RESIDENTIAL ELECT SQ IT.
sale IC however.the Wildingmimprovement is sold within one year ofcompletion.the SQ.FT.FLOOR AREA SISV�14.
nerhuilder will have the Walla IA proving but he did not build or improve for pur-
po'5
eq.afiowne 'I UTAK
r of the rpenr,am e,du.ivery contracting who fiancee compactions'a
'mtrucl theeprojeet(Sec.70,W.Business and Professions Cade)The Contmentos--
cease,Law doe,not apply u'an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEF.
who contracts for such projects with a contractors)licensed Pursuant to the Contractors
Liccnu law. PERMIT ISSUANCE
❑tom esemp erS c. _ .B&P C for this reason
ALTER-DRAIN&VENT-WATER(IiA) VALUATION
Owner VAIZ,rDam
W'ORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby atrium under penalty of perjury one of the following declarations:
I have and will maintain a Cenlficme of Consent to self-insure for Workers Compen- DRAINS-FLUOR.ROOK AREA.COND. STORIES TY IT CONS1RUCIOt
cation,as provided for by Section 3700 of the Labor Code,for the performance of he
work for which Nis permit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
370p tithe Labor Code,for the performance ofthe work for which this permit is issued. GAS-G.SYSTEM-1 INC.4 OUTLETS OCC.GROUP AI'N
My Workers Compensation Insurance currier and Policy numMr are:
Currier: Policy No.: GAS-EA.SYSTEM ON ER4(EA)
cEaLH71CAT E OF EX Em PDON FROM WORKERS' GREASIVI N UUSTRL WAS TE INTERCE111 OR
COM PENSA'1'ION INSURANCE BUILDING DIVISION FEES
(Ih-cenon mcdon,bucun:pked bit. -at is f-,mne hundred dollars is IW) GREASETRAP PLANCHECK FEE
m less)
Iecnify but titathu any listener
s t become
this Penni'i,issued,'Coro-,shall SEWER-SANITARY-B'TORM I?A.21X1 PI'.
nm ctnPlny any Iroonn in any Iuummr sen n,m M1ceotnc mhjcn In'he Workers'Comptn_ 13NBRGY PLG
G/
taboo Laws of CIJiI'nrnln.Duro WATER IIF?ATER WNIiN'I'/I11.IiGTR GRADING FEE
C) Atplicunl I
'Z' ^ NOT ICE TO APPIICAN'L IL a let mnk'mg Shia Ccnilir„mor Esma,ien,Y-,u should WATER Sys'IRM/TREATING SOILS FEE
(ti b iso rte xnotes,m the Worker's Camlamnaum provisions of Ne Labor Cade,you must
forthwith comply with such provisions nr(his Perini(shall he deemed revoked. WATER SERVICE
E Q
IY
CONSTRUCTION LENDING AGENCY NEW RESIDEN PIAL PLMB. SQ.14. PAID
`7 'z Ihereby afrim'that there is a combuction lending for Nc rformance of Date Receipt Or
U O g agency pe
l r . the work for which this pennil is issued(See.YN7.Civ.C.) - TOTAL:
O U Lender's Name
I coders Address ICTAL:
>. I certify that I have read this application and state that the move information is BUILDING FEE
F' a' g TY, MECHANICAL.PERMIT FEE
N Goddin(agree Incomply withal(city and countyrialonce,and sattlawsretainhe Q SEISMIC FEE
C?Z building construction,and hereby authorize rcpmumetivcz of Nis ci(ymenter aeon the
aove-ormanuma property for inspection puarpi PERMIT ISSUANCE ELECTRIC FEE
(We)agree m.mvc,indemnify and keep hmmless Ne City of Cupertino against
liabilitics,judgmen(c,ants and expenses which may in any way accrue against said City ALTER OR ADDTO MECH. PLUMBING FEE Sn
in conaquem'e of the granting of this permit.
APPLICANT INDER��LSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111.000 CrM) MECHANICAL FEE
SOURCIi 1 (((444S.,a
GAIR HANDLING UNIT(OVER 10.(X0 CIM) CONSTRUCTION TAX
Signature of ApplicanVCommcmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
fIA]ARDOUS MATFRIAL S DISCLOSURE
Will me applicant or future building occupant store or handle Immunous material HEATING UNIT(TO 1110.001 BTU)
as defined by the Cupeninn Municipal Code.Chapter 9.12,and Ne Health and Safety HEATING UNIT(OVER[00,OM)BTU)
Code.Sectints 25532bo?
❑Yes VENTILATION FAN I SINGLE RESID) PAID
Date Receipt a
Will the uPPli,am or furore building occupant use c,antient or devices which BOILER-COMP 13HPOR 100,000 BfU) G e
emit himahm,air communicant,as Jefired by the Bay Arca Air Quality Management TOTAL: �.
Dlairic(Y / BOILER-COMP(OVHR 101,000 B'I'Of
EIYes t7-'Igt(
AIR CON1,11IONGR
1 have mad IM hamnlum Inatcri;ds myuircnmms under Chapter(.95 of the Cali- ISSUANCE UATIi
cosh IIwOh&Sate Cale.Sections 25505,255.33 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.PR
building hw taco 'cntly h'v• mnnla,(h my ruspunsihlllly In notify the occupant
of Nem 'stitch Ism a .utmc /f�pcltificu(cut C%cupancy.
`�1 '{A Date TOTAL ISSUED BY: �®
()warttra I n agent
OFFICE