27331 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RICAL APPLICATION/PERMIT PERMIT No.
BUILDING DIVISION PLUMBING
BUILDING PROJECT IDENTIFICATION 27331
BUILDING ADDRESS: SANITARY NO. APRLICATIONSUBMITTALDATE
303 '' /ckv� �fiu _ LOT# 123-ti`P
OWNS Ft
� NIC CONTROL#
RCHI '?ENGINEER: LIC NO: D "f /��� � ❑
:ONfACf: PHONE: T
QTY ,ELECTRIC PERMIT FEE BUILDING PERMIT INFO
T. BLDG ELECT PLUMB MECH
PERMIT ISSUANCE - 11 Cl 0
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
czwz I hereby affirm that l um licensed underprovisions of Chapmr9(commencing with
K100Section 7000)of Division 3 ofthe Business and Professions Cade.and my license is in PANELS
_
Fy-U 1-. full f�meand effect.
FZW License Clens Lic.# UPT0200AMPS
F,6,v0.i Date Conn.", 201-1000 AMPS SQ,FT.FLOOR ARCA 5/SQ.FT.
ZOyZ ARCHITECTS DECLARATION OVER 1000 AMPS
O y—O 1 understand my plans shall bs used as public records.
rr-Y,t,.4 SIGNS ELECTRICAL
Licensed gd6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
rs C)W' 1 hereby affirm that 1 am exempt from the Comre ar's License law for the
1+13 a y¢ following manna.(Section 7031.5,Business and Professions Cade:Any city or county TEMP.METER OR POLE INST.
t LL ON J which requires a permit Io canatmct,alter.improve,demolish.or repair any structure
P� prior o its issuance,also mquim the applicant for such permit o file a signed emmment POWI]R DEVICES
<O that he is licensed pursuant no the provisions ofmc Contractars License law(Chapter
a Oo� 9(commencing with Section 7000)of Division 3 ofthe Business and Professions Cade) SWIMMING POOL ELECTRIC VALUATION
Iy_y or thin he is exempt therefrom and the basis for the alleged exemption.My violation of OUTLETS SWI'1'CI{ES-FIXTURES
QSection 7031.5 by any applicant for a permit subjects the applicant w a civil penalty of
O not mare than five hundred dollars($500). NEW RESIDENTIAL FIECTR 5 .FT.
off' m [II,asownerofNepmo ay,ormyemploymswiNwagesulMirsolemmpn 6., —SQ.FT. TYPE CONSTRUCTION
a will Jo the work,and the smaturels not intandedorofferedforside(Sm.7044,Business
and Professions Code:The Convectors Liahu Law does not apply w an owner of
propmywhobtildsorimpmoes thereon.md w1n dwoomhwork himself.throughhis
ownemployeas,Provided Natsuchimprovemems werat intendedoroffesdforsNe.If, OCC.GROUP RES.UNi rs
however,the building or improvement is sold within one year of complather,the owner- TOTA,
.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
E] I,uownerofthepropeny,amexclusivelyemuactingwithlicehsdconvaeamw QTY. 'i�- PL BINE PERMIT FEE FLOODZONC APN
consumer the project(Sec.7014,Business and Profeuiaaa Code:)The Communes PERMIT I ANCC
Licensee Law Jces not apply ro an owner of property who bui Id s or impmvw thereon,and
who commets fm mch projam with a<ontncwr(s)lianud pursaanuothe Connecwrs
License Law. AL' -DRAINS,VLNT-WATER(EA) FEE SUMMARY
❑ 1 em acmpt under Sa. ,B&P C fm this reemn ACK FLOW PROTECT.DEVICE OUTDEFEES
SANITARY Y N
OwnerRECEIVI'M Date TRAINS-FLOOR.ROOF,AREA,GOND.
T WORKMAN COMPENSATION EF.CIARATION SCHOOLTAX YN
❑ Thereby affirm that l have a certificate ofeansrnt to ulGinsure.or a mr-fificam aV FIXTURES-PER TRAP RF,CEIPT#
Workers Compermetion Insurance or a certified copy thereof(Sm.3800,Lab CJw PARK FEE Y N
coverat all employee's ander this permit. GAS-EA.SYSTEM-IINC. Il'TLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-(L ) PLA HECK FEE
[I Certified copy is hereby fumishd.
❑ Certified copy is filed with the city inspection division. GREASEANDU. NTERCEPTOR RAD GFEE
CERTIFICATE OF EXEMPTION FROM W KERS' GR LS FEE
COMPENSATION INSURANCE
(This section hard not becompleted ifthe Permit is forone ondrcddollars(SI ) E R- ANITARY-STORM ENERGY FEE
ales'.)
I certify thin in the perfonrmnce ofthe work forwhaeb Nispe tit is iasued,lsha ATER HEA W/VEN/E
.at employ any person in my rearmcr so u m become mbjec w the Workers PAID
Compensation Laws of Califomaa. Date ATER SYS - TING Date Receipt#
O z Applicant
0- NOTICE TO APPLICANT:IL after making IN,Camrrcateaf a, inn, au should EW RESIDENTIA PCMB. .FT. TOTAL:
Vl become subject the Worker's Compensation provisions ofthe Labor Code, au mum
forthwith comply with such Provisions or this permit shall be domed res, . BUILDING FEF.
Z CONSTRUCTION LENDING AGENCY SEISMIC PEE
1 hereby affirm that them is a construction lending agency for the performance o
V O the wad fm which this permit is issued(Sec.3097.Civ.C.) TOTAL; ELECTRIC FEE
� � Lender's Name PLUMBING FEE
F Lenders Address Q , MEC ICAL PERMIT' FEE
V 1 minify that 1 have d this application and maw Nat the above information is
correct.l agree to comply with all city and county ordinances and sure laws relining to KRMIT[SHIIANCE MECHANICAL FEE
rat buildingcanstmction,and hereby authorize repreaenutivn of Nis city toenrer upon Ne CONSTRUCTIONTAX
V Z abovemcntiane petty for inspeZt 'lsa.. ALTER OR ADD TO MECH.
(W I o e to save,andoram"a the Ciry of Cupertino against
liamlir ,j mat ostsa exemay inanywyccrue agaanstseWCity AIR HANDLINGUNIT(TO 10.000CFM)q grinof th -
/ AIRHANDLING UNIT(OVER 10,000CFM)
ho of Applicarmc acmr Date EXHAUST GOOD(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(10100,000 BTU) Dom Receiptq
Willthe applicant or future building necupant store or handle hazardous swum.l HEATING UNIT(OVER IW,WO BTU) TOT
m claimed by the Cupertino Municipal Code,Chafe,9.12,and the Health and Safety
Cale,Section 25532(e)7
❑Yes ❑No VENTILATION FAN(SINGLE REBID)
ISSUANCE DATE '
Willtheapplimumfipwre miliiagmcupmmuequipmentmdeviccs whichemh BOILER-COMP(311P OR IW,W BTU) Pe,
`k hazardom air commitments as defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,00)BTU)
Uf�� r I
swmo
El Yee ❑No NEW RESIDENTIALMECH. SQ.FT. tido
V 2 3
1 have mad the hsmrdaus mmedala requirements under Chapter 6.95 of he ^/ 199q
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand Noil
ifthe building does not currently have a tenant,that it is my mponsibiliry to notify the r V(• 1.yrQ1,
occupant of the requirements which must le met prior to issuance of a Cenafcaw of LJ
Occupancy. /'�
Owner or amhor ead ri,ml Dau 1: ISSUED BYYT ►K1
OFFICE