30477 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 30477
BUILDING PRojECr IDENTIFICATION
BUILDING AOURESS: SANITARY NO, APPLICA ON SUBMITTAL DAI
05 2 ��.s� vcp� 6
OWNER' NAME: T V I VU PHON CONTI{ACfOR'S (!'}
NA7 i 'S _ I.IC '0 Z- N/C NTR N
49,ARCHITECT/ENGINEER: LIC NO'. AD KESS:J7-1 -l -) fq
❑ .
D I ONi E4[l� C
CONT CT: PHONE:
LA, BUILDING PERMIT INFO
LD-�/ 2y'?3 3 -7 ❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT UMP. MECH
L R 7 {� / ❑ ❑ ❑
ueENSED¢ONTRACrORSDBCLARAnoN QTY. ELECTRIC PERMIT FEE
I Hereby affirm thin I nm licensed under provisions of Chapter Y(commencing pyz p g JOB DESCRIPTION
X00 I.Ld' .ianndeI of Divisi n3of the uzines.and Professions CrNe,andmyliecn%cis PERMIT ISSUANCE ]RESIDENTIAL
H n full force and eft't.
't-u License Clens ❑SFUWL ❑K CHEN REMODEL
F ZwDae - o acro APPLIANCES-RISIDENTIAL ❑ADDITION BINGRI PIPE
p.,pN ARC TECTS ECLARATION PANELS ❑MULTLUNIT STRUCTURAL.
z O y Z 1 understand my plain shall be used as public records MODIFICATION
OZ- UPTO 200 AMPS
1 4t:W Licensed Prnfe,00nal ❑fill ERIOR ❑CHIMNEY REPAIR
`yg X.'..J.i OWNER.RUILDER DECLARATION 201-0000AMPS IMPROVEMENT
2 C W Q I hereby action that I am exempt from the Contr-acmrs License Law for the OVER 1000AMPS OATH REMOD (REPAIR ❑D,�E-MOLITION
3 06 V following reason.(Suction 7031 5,Business and Professions Cove:Any city or county SIGNS ELE AI. OTHER w� P�
LL y which requires a permit to connmm,alcor,improve,demolish,ar repair any aromurc �-
NEf,�Og prion)ill issuance,vBorcquires lheapplicao formch permit m fileasignedsutement SPECIALC UIT/MISC.
y that he is licensed Pursuant n the provision%atilt Contractors License Law(Chancre
CO (commencing withilection]WO)afDionion 3ofthe Businessand ProfessionsCodeptr TEMP. •INST. COMMERCIAL
d 6pC that he is exempt Ihcmfo m and the b;n'is for the alleged exemption.Any violulion of
W N Section 7031.5 by any applicant for a pcmtit subjects the applicant to a civil Penalty of POWER DEVICES ❑NEW BLDG/ADDITION ❑DEMOLITION
not more than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE
SSG01,as owner ofthe Property.(IF my employees with wages as their sole compensation. SWIMMING POOL ELECTS IMPROVEMENT
F will dothe work,and the structure is nm intended orocfereJ for sale(Sec.7044,Business ❑OTHER
13 and Professions Cale:The Contractor's License law does not apply to an owner of OUTLETS-SWITCHES-PIXTU 'S
propeny who huilds ar improves thoraco,and who does such walk himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS 5 FT.
sole.If.however.the building or improvement is sold within oncycor ofcomphamn,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-amider will have the burden of proving that be did not build or Impmvc far pu-
pate of Baled. s
❑ I.as owner of the pru vrly,am exclusively controlling with licenced contractors to TOTAL:
construct the project(Sec.7044,Business and Professions Cade)The Contractor's 1-6 Sep
came Law deals not apply to an owner ofpmpeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE !� Ij
wnocontractsfor such projects with sconmteort,loaned Punuam tothe Contractor's �� U Q
License law. PERMIT ISSUANCE 1996
❑1 am exempt Fail,,Sec. ,B&P C for this reams
ALTER-DRAIN&VENT-WATER(EA)
•Owner Dare r VAV AI'[ON
WORKER'S COMPENSATION DECLARATION
1 hemby affirm unJer penahy of perjuryone of thBACK FLOW PROTECT.DEVICE
e fallowing declarations:
Ihoveand will maintain-CenificareofCansent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND.
s-tion,as provided for by Section 3700 la of the tim Code,for the perl'onnance vital J11,715STORKS TYPE CON4TRUCT01
Floods work for which this is issued. FIXTURES-PER TRAP
romance. �e
❑ 1 have and will maintain Worker's Compensation romance.as required by Section IT
3700 of the Labor Code,for the performance ofthe work for which this permit ki,awd. GAS-EA.SYSTEM,INC.4 OUTLET OCC.GROUP APN
C WorkeKRmntpamytinn Insurspaescaaa and Policy number me:
Cvoie; (TI CATS f/ Policy Nn.: GAS-FA.SYSTEM-OVER 4(EA)
CERTIFICATEOFSATIO NFROM WORKERS'
COMPENSATIONINSURANCE GREASFIINDU4TRL WASTE INTERCEPTOR
(This section need not be completed ifthe Pennil is for one hundred dollars is 100) BUILDING DIVISION PEES
ar loss.) CREASE TRAP
I coni fy thin in the percence n I,al the work far which this peonit is issued.I shall PLANCHECK FEE
notemploy any perms in any Fnmrw, o as at became sobject ,,the Worker,Conaen- SEWER-SANITARY-STORM ITA.200 Try.
,Z smam laws al California.Data ENERGY FEE
0 WATER HEATER W/VENT/ELECI'R
ZO NOTICE
y Ncome subject
APPLICANT.If,after making this Cisions of df E aborOon,you a mull GRADING FEE
I"
become subject loth Workers Compensation ' oaf the lade CsMe, WATER SYSTEM?BEATING
a Forthwith comply with such eravism you must SOILS FF.R
� 0 pYwi provisions or this Femtinhall he deemed revoked. WATER SERVICE
0.
CONSTRUCTION LENDING AGENCY
VO 1 hereby affirm that there is a consultation lending agency for the perfomancc at NEW Rf:STDENTIALPLMB. SQ.FT. PAID Date Receipt#
1-w the work I'or which this Ionic is listed(Sea3097.Civ.C.)
OU Lenders Name
W Lenders Address T TOTAL:
f+ 0. 1 cmily that 1 have read this opplicztion and stale that the above information is BUILDING FEE
V) coffees I agree to comply with all city and county ordinances and slate laws reaming to QTY MECHANICAL PERMIT FEE
C„),ZM building connotation,and hereby authariu npresenutivesofrhis city to enter upon the SEISMIC FEE
aMwomentione l propeny lin inspection putpows. PERMIT ISSUANCE
(We)agfee I,save,indemnify and keep hemcle,the City of Cupertino ugeinsl ELECTRII:t
Iiabilitiesjudgments,Casts and expenses which may in any way accrvc against said City ALTER OR ADD TO MECH.
in consequence of uming of thi colt. PLUMBI
APPLIC ,R TANDS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10.000 CFM)
SO ER O S. MECHAN� AIR HANDLING UNIT(OVER Ig000CFM) CONSTRof wnUC want Dam EXHAUST HOOD(W/DUCT)
H .ARDOUS MATERIALS DISCLOSURE HOUSING"Itheappli 1.1 boom building occupant swoorhandle bazardam material HEATING UNIT(FO 100.00)IsfU)
a.,Foamed h pertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code,Section 25532(-)1 HEATING UNIT(OVER Ilk,"BTU)
❑Yes ONa
VENTILATION FAN(SINGLE RFSID) PAID
Will the applicant or future buildng occuant use equipper,nr device.%which Uate Rece
mha
it zardous air immune ,as defined by the Bay Area m (J
Air Quality Managecnr BOILER OR 100,000 RTU)
District,
❑Yes ❑No BOILER-COMP(OVER 100.0110 BTU) TIEEi
AIR CONDITIONER
I Health
read the na7acau mm,nms tcg25533 ms ender .1 and h 95 al the crab ISSUANCE DATE
htmia Health&Safety Cevle,5¢siom 25505,25533 aM 255JJ.I undersand the if the NEW RESIDENTIAL MECH. SQ.FT.
building does not currently have a tenant,that it is my resp romility to notify the occupant
of the ngaimmems which must be met prior to issuance of a C•difica¢of Occupancy.
Owner or onhodxd agent Ome TOTAL:
ISSUED BY:
OFFICE