29994 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINTPENONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PHRMU'NO. ^(') /� /I
BUILDING DIVISION'. APPLICATION/PERMIT PLunfewG-MECHANICAL LJ xj4
BUILDING PROTECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO.. APPLICATION SUBMITTAL DATE
uCWAr. � "�n 0 6--tb116
OWNER'S NAME'. .� PHONE'. CON" 0R'SNAME: — LIC NO:
NIC ////C1111ffffO�NTRR�OO1.,#
RC ITECf/F;NGINEER: I LIC NO ADDRESS: f 11 n 62"
CONTACT - PHONE: 4 BUILDING PERMIT INFO
"
[51G Consultant Fees.Paid by Applicant(Initial) _ BLDG - ELECT PLUMB' MECH,'
a LICENSED CONTRACTOR'S DECLARATION . C PERMIT FEE -
I hereby affirm that 1 am licensed under provisions of Chapter 91(commencing QTYELECTRIC 'JOB DESCRIPTION -
1"1� Z watt Section 9000)of Division 3 ofthe Business and Professions Cods,and mylicenxei RESIDENTIAL:
FOOal r nfullf mean ,�. vzz PGRMI'I'ISSUANCE s„ ❑SFDWL . El KITCHEN REMODEL
Z Li tense Class a' Cnntramnr APPLIANCES-RESIDENTIAL ��,{,pfxDDITION gq - ❑PLUMBING RE-PIPE
t H�CT'SDECLA A IJMGLTI-UNIT. :.P ❑STRUCTURAL
PANELS - y
Z O m Z 1 under,mnd my plans shall be u.ed :P bl' e .Ns' MODIFICATION
O Z F O .' UP TO 200 AMPS El INTERIOR•. p CHIMNEY REPAIR
F.h, W Licensed Professional - - 201 IWIIAMPS IM EM t
2 OWNER-BUILDER DECLARATION , 99f�
W 6 I hereby affirm that I am exempt from the Contro
actrs L cense Law for the OVER 1000 AMPS ❑B 0 E R AIR DEMOLITION
i0$y�d U follawlag m rme.(Smtion 7031 5,Business and Pmres,mr,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
O
which"aides.permit m construct,alter,improve,demelisM1, fi repair any swam. ii,j,j si Ur GCO
VC1 n•v
prior to is issuance,also requires aha applicant for snot pennluotilev eigncd mmemeat SPECIAL CIRCUIT/MISC.
jt that he is llceused putsnant to the provisions of the Commences License Law Cloutier 9
dC) (commencing with Section 7")ef Division 3 fifths Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL' '
that he is exempt therefromand the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant f permit subjects theapplicant 1 l penalty of POWER DEVICES
m - ❑TENANT ❑FOOD SERVICE
[[F...Z p+ not more than f rt hand e dollars y employees
• IMPROVEMENT
O ❑1,as theowner
wm,mid pn pay y ploy with b as their 1 p mien SWIMMING POOL ELECTRIC .'
wi 11 do the work and the structure tintended R df r (SecAW4 Bu'ness DOTTER
S and Professions Code The Cummarcas License Law does nrn apply to an owner of GO(LETS-SWITCHES-FIXTURES
NO
Property who builds of improves thereon,and who does such work himself or through -
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale.If,howeveq the building or improvement is sold within one year of completion,the SQ.FE FLOOR AREA $/SQ.FT
slder will have the hurtles of proving that he did not build or improve for par-
of BaI ® ,'•1LY'1I
pose of sale.). '
E3 1,as Owner the property,am excessively contracting with licensed comredod m
COW
construct the indoor(Sec.9044,Business and Professidns Code:)The Conwmnr's Lk
ase Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who concocts fm such Projects with a contmctnrof licensed p...mat to the Cantarchm's
License Law. •` PERS/ISS E '
Flm I aexempt under Sec. ,B&P C for OIs mason _
ALTER-DRAIN T- ATER(EA) - - . VALOA'PION
Owner Date
WORKERS COMPENSATION DECLARATION - BACK FLO CO rm E r'`^�
Ihereby affiunder penalty of perjury one of,he following dcclturnims y` xL 1
�.I have and will maintain a Certificate of Consent m self.imure for Worker's Compen- DRAINS-PI. I�IEO F.ARE ND. STORIES. TYPECONSTRUCTION
even,as provided for by Section 3900 of the Labor Cale,birdie performance of the
worklbrwhiehthispemtili,memd. _FIXTURES-PER TR P
❑ 1 have and will meaning Worker's Compensation Insurance,as refined by Section
37M of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-PMC. O S a OCC.GROUP APN
My Workel�6oyy+ o In a mer and lidboy nu h
Cornice `•X1 n ��Policy No.: 5���7I �^� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR
- s t ' °y 13GILDING DIVIg10N FEBS ' -
(This section need not be completed ifthe sarmitis Ensue hundred dollars($101ry GREASETRAP or less.) ? PLANCHECK FEE `�. 0
I ramify that in the performance nitre work for which this permit is Issued,I shall SEWER-SANITARY-STORM EA200 IT. '
not employs,person in any anomer so as m becomn.object to the Workers'Curacao- .pen- " 'ENERGY FEE I Q 'i2O
O Z sign.Laws of California.Dam WATER HEATER WNENT/HLECTR x•
Applicant GRADING FEE
aIII NOTICE TO APPLICANT:if,after making this Certifcme of.Exemption,you should WATER SYSTE CREATING
5 -
t- become subject m the Worker's Compensation provisions of it,Labor Code,you must - SOILS FEE
yl4a forthwith comply with nidi....mines mitis permit shall be d....i nevoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR SQ.FT PAID -
U7"Z 1 hereby affirm that there is a construction lending agency for the performance of De ceipttl
TP the work for which this permit is issued(Sec.3097.Civ.C.)
O U Lender's Name TOTAL
Lenders Address _
I comfy that 1 have read uns appl nation and state that the b information Is BOILER FEE
rt V) cones Iagree to comply with all city and county ordinances and snace,laws rel ingto QTY MECHANICAL PERMIT FEE
U 4, building construction and hereby amhorlu mpostrutives of this city to enter upon the - SEISMIC PEE
above-mentioned property for inspection purposes.' PERMIT ISSUANCE ELECTRIC FE �� ,
(We)agrce m save,indemnify and keep hawless the City of Cupertino against
Iiahilities.judgmen6 momadexpensesw 'hmayin y way accmcagainst.said City ALTER OR ADD TO MECH.
I.crumd,oencco and of Nis n. s PLUMBING FE
APPLICANT 'T DS ILIC PLYWITH AWNON '01 r ARRHANDLINGUNIT(T010,000CFM) MECHANICAL FF.. l�
SOURCERE IO _ -
�� AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTIONTAX -
igvature A I¢aruscmhractof ,EXHAUST HOOD OVMUCT) HOUSING MITIGATION F
HAZARDOUS MATERIALS DISCLOSURP.
Will the applicant or future building ampinu matr handle haeamous mmerlal HEATTNG UNIT GO.100,0IX)BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety -
Code,'Section 25532(x)^. HEATING UNIT(OVER I00daga BTU)
❑Yes ONn - o .
' VENTILATION PAN(SINGLE RESID) PAID
_ - Dam Receipt#
Will r,air curnm fir ial,a building occupant use equipment.Arrof Management
which - BOILER-COMP QHP OR 100,000 BTU)-
Dmit hmuWnus air comnminsms as defined by the Bay Area Air Quality Management _ , TOTAL:
�DISIrI: . BOILER—COMP(OVER 100.000 BTU)
:�Ycs No
f'^IAave reed the hazurdousmutuinls re uimnsvis under Cha ter 695 oflhe Cali- AIR CONDITIONER
9 understand _ ISSUANCE DATE.
fomiv Healthg does a Safety Code,eations 25505,is my and 25534.,toacthat if the, NEW RESIDENTIALMECH. SQ.FT.
building does votnumen0y have xtevanLthat it is myrespnnslhllity.notify the acupaat -
oftherequimmenlswhichmusthemetprieneissuancenfaCertificateofOccnpancy., � '
'Owner or xu^Ihoriud agent' _ Date1102 1;� ISSUCO BY:
�' OFFICE "
LABORATORY CERTIFICATE
SIGNET
7L-sting Labs
• ENGINEERS.METALLURGISTS.CHEMISTS.SCIENTISTS.MATERIALS TESTING.CONSTRUCTION INSPECTION
G 25064 Viking Street Hayward, California 94545 510/887-8484 Fax 510/783-4295
November 5, 1996
LAB NO. : 21029-02S STL NO. : 2109-001
PROJECT: No Residence Addition
19701 Auburn Court
Cupertino, CA 77xv
SUBJECT: Shop Inspection of Structural Steel
REPORT TO: Mr. Peter No
19701 Auburn Court
Cupertino, CA 95014
REPORT
INSPECTOR: Roy Hack (October 12 & 16, 1996)
FABRICATOR: National Steel, San Jose, CA
INSPECTION: Continuous visual welding inspection of fillet, par-
tial penetration & stud welds on plates, channels &
• beams, along with review of welder qualifications &
welding procedures. The following members are com-
plete & acceptable: A6, B6, A7, B7, A8, B8 , C8, D8,
A5, C5, C3 (2) , D3 (2) , B5, B2, Al, Cl, A2, G4, C2 ,
A3 (2) , A4 (4) , G4 , C2, AA4 , B4 , D4 & F4 .
WELDING VARIABLE (S) : FCAW
CERTIFIED WELDER(S) : Previously Identified & Recorded; plus,
Dale Hagarty
The work completed or in progress for'this
inspection period is in
compliance to the given project design drawings, specifications
and/or any approved change orders. This is a progress report of
our special inspections. A final report (ref. UBC Section 306c)
will be issued upon request at the completion of the special
inspection/testing requirements provided that all outstanding
issues have been resolved and/or corrected.
Respectfully Submitted,
SIGNET TESTING,,LABORATORIES
Mike F. Everson
Manager, Structural Dept.
1cC
cc: City of Cupertino/Bldg. Insp. Dept.
MFE/dd
21029-02S
FORM 101