27809 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - PERMIT NO. O
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING.PROJECT IDENTIFICATION
BUILDING ADDRESS: / SANITARYNO. APPLICATIONSUBMfITALDATE
-753 G UNITY LOT#
OWNERS AAMMF.: HSONTO ' A
'E:l- - CONTRACME: `saw1 LIC NO: NIC CC
ROL#
ARCHIIF.CT(ENGINEER: LIC NO: ADDRESS: ❑'
Ilia
saw 'r
CONTACT: PHONE: BUILDING PERMIT INFO
OIL"
n l I QTY. ELECTRIC PERMIT FEE ELE PLU c
O L" �� 4' s �, �D$� L �7PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
camz I hereby affirmthal l am licensed underprovisions ofaripter9(commencing with
Poo Section7")of Division3oftbe Business and Professions Cade,and my license is in PANELS
25
Utr�ITEtG-;�. full force and effect. .-'f 0 D ter`
6u" License Class Lic.#—40—U V t UPT02WAMPII jl
are Contractor 201-1000 AMPS
SQ.FT.FLOOR ARE $/SQ.FT.
Z FO�•� ARCHITECTS DECLARATION � OVER IOOOAMPS -
O Z^O I understand my plws shell be used m public records.
ry W Licensed Professional SIGNS ELECTRICAL .2,6 ,Q�
q' ...AAA
�FJJ OWNER-BUILDER ei gn,C ATION SPECIAL CIRCUIT/MISC. I �p� l`91
O y U 1 following
(Se then I am exempt from the Co Professions
Cc :License Law for the !/ .31.�l V
613 u.y which ioname,reason. 703 after,land Rofessions Cod<:Any city structure TEMP.METER OR POLE INST.
I'J which requires n permit reconstruct applicant
improve,demolish,fie a sig any swment lr`
4� prionoire issuance,also requires the applicant forsuch Permit fileeeigned statement POWER DEVICES, /
ty G
that
he is licensed pursuant to the provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC a e 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) VALUATION
'p•.,ce or that he is exempnhereform million basis for the alleged exemption.Any violation of UTLETS-SWITCHES-FIXTURES las""
1. Q, Section 7031.5 by my applicant for a permit subjects the applicant ro a civil perulty of l�
^� O not morethan five hundred dollars($500). NEWRESIDENTIALELECB _SQ.FT. STORIES TYPECONSTRUMON
W ❑ I,asownerofNepmo ny,ormycmployeeswithwagesastheirsolecompematoa,
S _ 'willdo Ne work,and theswuctureis not intended proffered forsale(Sec.7z,l,Business
and Professions Code:The Communes License Law does not apply to an owner of
property wbobuildsorimproves thereon,and whodoessuch worlrhimselfortrough his
ownemployces,providedthatsuch imprevementamormintended oroffemd forsale.If..
OCG GROUP RES.UNITS
however,the buildingor improvementis sold withinoneyearofcnmpletion,theowner.
builder will have he burden of proving that he did not build or improve for purpose of
snlc.JPN
.
111,asownerofthepropeny,amexClusivelyconnactingwithlieenedconvactorsw QTYPLUMBING PERMIT FEE FLOOD ZONE
comwn the project(Sec.7094,Business and Professions Code:)no Commodities
License Law does not apply to an owner afproperty who builds m improves thereon,and I PERMIT ISSUANCE
who contmem forsuch projects with a connac[or(s)licens x1pursuantmthe Conmacmr's
License Law. ALTER-DRAIN&VENT-WATER(EA) p FEE SUMMARY
❑ I am exempt under Sec. ,B&P C for this reason OUTSIDE FEES
BACK FLOW PROTECT.DEVICE -
SANITARY Y—N
—
Owner Date DRAINS-FLOOR,ROOF,AREA,GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
�,I ,I hereby affirm that]have acerificawofcomsentto Self-inmr;,:,4rcmEam of FIXTURES-PER TRAP RECEIPT#
Workers Compensation lmumnce can certified copy thereodl Sec.3800,LbCJ whicM1 PARK FEE Y N
covers all employee's under this permit. GAS-EA.SYSTEM-1 INC.40UTLETS RE PI'
Policy# BUILDING 1 LEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is Bled wiN Ne city inspection division. GREASFJINDUSTRLWASTEINTERCEPTOR GRADING PEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE rW
COMPENSATION INSURANCE "
phis section need not be completed if the permit is for one hundred dollars($100) SEWER-SANITArk�9 M'EA.200FT. ENERGY FEE n(�Q
or less
I certify that in the performance of the work for which this permit is issued,T shall .ktgYREBTIEATEA W/VENT(EL
not e.Play any person in any..or so m t 1, t e Wor PAID
Compensation La s f California. Da a WATER SY TE Dam Reipt Y
Q z Applicant
NOTICE TO A (CANT:IL afwr making this ertiflcaw of Exem you ul P F'T. TO .'0 #
fA become subjecno the Wprkeh Compensation provisions of the Labor a y
�i forthwith comply with such provisions or this permit shall he domed a ked, mus'
e , BUILDING FEE
W us �* SEISMIC FEE
(� CONSTRUCTION LENDING AGENCY
z Thereby affirm that Uere ie¢construction lending agency For Ne perf�rnan of ELECTRI
V O the work for which his permit is issued(Sec.3097,Civ.C.) t
�-•. Lenders Name
Q U Lender's Address QTY. MECHANJCq(d$$ERMIT FEE PLU Nlb S&C
LUkI I certify that I have read this application and grew that the above info tion i ME IC FEE
cored.]agree to complywith all my suit county ordinances and state laws re pang to PERh1Pf1S5UANCE
�^ � building construction,and hereby authorize mpmsenmtives of this city to enter upbn t1pi CONSTRUCTION
U above-mentioned property for inspection purposes. + ALTER OR ADD TO MECH.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expensesw ' y in any way seems,against said City AIR HANDLING UNIT(TO 10,000 CFM)
in consequence of the grandrijI of thi pemrit.
AIR HANDLING UNIT(OVER 10000, CPM)
//.
Signature of Applican4Contacmr Dam EXHAUST HOOD(W/DUCq
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO IW,WO BTU) Daw eceipt#
Will the applicant or future buildingoccap.t score or handle hazardous mamrial HEATING UNIT(OVER 100,008 BTU) NOTAL:
m defined by the Cupertino Municipal Code,Chapter 9.12, it the Health and Safety
Code,Section 2553209 VENTILATION FAN(SINGLE RESID)
❑Yes ❑No
ISSUANCE DATE
Will lheapplicanmr fatumbuildingencupant useetuipmeotordevices whichend BOILER-COME(3HP OR 100,000 BTU) P
h s air contaminants as defied by the Bay Area Air Quality Management BOILER-COMP(OVER 1W,attBTU) A i D
::a y ❑Yes ❑No NEW RESIDENTIAL MECH. SQ.FT. 'ntlp(AV
1 have read the hazardous millennia requirements under Chapter 6.95 of the NAY ,,1995
California Healthffi Safety Code,Sections 25505,25533 and 25534.tundersrend Net /x
if the building does not currently have a tenant that it is my responsibility m notify the Uf
o occult
or the requir mens which must he met poor to issuance of a Certificate of
Occupancy. e - QYA.�Y
Owner or authorized agent Date ISSUED BY�
OFFICIZ