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S 4354APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY C.V,_nv •`no V x, TGoa l BUILDING - F.LECI R BUILDING DIVISION APPLICATIONIPIERMIT l+ m 2- G ( op, -r 2 5-:31,gG6 LICENSED CONTRACTOR'S DECLARATION I hereby affirm that lam licensed under provisions of Chapter 9 (commencing with Section 7(Xd)) of Division 3 ofma Bboinersand Prof ,lions Cale.anJmy license is in fall force and effect. License Class Lic.N OWNER BUILDER DECLARATION I hereby annual that I am exempt from the Contractor's License law for the following reason. (Section 7031.5, Biomass and Professions Cedm Any city or county which reyuirea a permit In annWd, uke, milliner, demolish, nr repair any structure prior m its issuance, also requires the applicant for such permit to file a signed statement thin he is licensed purstaind to the provisions of the Commctors License Law (Chapmr9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant m a civil pvmlty of not more than ❑va handed! dollars (S501). Las owner ofthe property, or my employees with wages as their sole compensation. will do the work, and the srucmm is not intended oroffma l for sale (See. 70,41, Business and Professions Came: 'Me Contractor's License Law detes not apply to an owner of property alta builds or Improves Ihem.n, and who deals such work himself or through his awn employees, provided that such Improvements me not intended or offered for sale. If, however, the building tar improvement is add within one year id completion, the owner bailder will have the home. of proving that he did nm build.. improve for par- ofsale.). I, as menu of the propertb am exclusively contracting with ]accused convectors to -'trum the project (Sou. 7044, Belli ness and Professions Code:) Ibe Gmtactor's I.[ - raise Law Jets not apply man owner of property who hold, or improves thereon, and who examucts for such projects with n nmwemrod licensed pursuan0o the Commnor's License Law. ❑ I am er�mpt utrr Sec. • y f ,H& P C for this reason ❑ Consultant Pecs Paid by Applicant (Initial) hereby affrin udder penally of perjury, one of the following declarations: vc and will maintain a Certificate of Coment m sdf-insure for Workers Compen- odmin. as powidhl for by Section 3900 of the LoMlr ode, far he poif area of the work for which this peril is issued, E] I have and will heirloom Worker's Compensation Insurance, as required by Section 37M of the Labor Cole, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number are: Carrier: Policy Na: CERI'I FICATE Op EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This action need ran be complcted if the pemtit is faro., hundred dollars (SIM) or less.) 1 certify that in the performance of the work for which this peril is issued, l shall nnl employ any pero in any mennnrsnnato bacnnte aubjeel I. use Workers, Compen. OZ sation Laws of Colifmnin. Date Z 2 Applicant e .N. NOTICE TO APPLICANT. If, goal making this Cenifiam of Exemption, you should a' become subject ht the Workers Compensation previsions of dee Labor Cade, you must W forthwith comply with such provisions nr lhl,l prout,hal be deemed revoked. Q P. CONSTRUCTION LENDING AGENCY I hereby affirm that hem is a combustion lending agency for the performance of the weak for which this perit is issued (Sec. 3097, Civ. C.) K � � Lender's Name Lender's Address ((yy I certify that 1 have mad this application and nate that the above information is '-s,TA correct. ) agree to comply with all city and county nminances and state laws tnlsling m QTy, V Z building consmmion, and hereby authorize representatives ofthis city to entob.N. the above"n rationed properly far inspection propos (We) .gree in save, Indemnify and keep hanulcss the Gty of Cupertino ugninst liabilities, judgments, costs and expenses which may in ery way acerae against sail City in consequence of the gmming of this permit. APPLICA tJ)�DF,JWTANDS ANPOVILL C(YdPL$ WITH ALL NON -POINT i ature.f Applicant/Conl dor 50�Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cuphti n. M.rdelpul Code, Chapter 9.12, and the Ileahh and Safety Code, Section 25532(n)l (2 yet [:J No Will the applicant or future building occupant use equipment or devices which hazardous air contamination as defined by the Bay Area Air Quality Management )islricf! ❑Ye+ E] No 1 have mad the hvemous maerials requbements under Chapter 6.95 of the Cali- famia health & Safety Cede. Sections 25505, 25533 ..1 25534. 1 understand Nat if the ELECTRIC PERMIT, PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP'10200 AMPS SPECIAL CIRCIJI'VMISC. RF TIAL FDWL TEMP. METER OR POLE ]NST. D POWER DEVICES C3 MULTI -UNIT SWIMMING POOL ELECTRIC OUTLETS - SWITCHES - FIXTURES ❑ INTERIOR NEW RESIDEN ]At, ELECTS SQ FI'. PERMIT ISSUANCE AIATR-DRAIN & VENT- WATER (EA) 13ACK FLOW PROTECT. DEVICE DRAINS - FLOOR, ROOF, AREA, COND. 171X'I URES- PER'IRAP GAS - EA. SYSTEM-] INC.4 OUTLETS - GAS - EA. SYSTEM -OVER 4 (EA) GRFASFJINDUSTR I. WASTE IN'I17RCEPI OR GRPASETRAP SEWER -SANITARY -STORM EA, 200 FT. WATER HEATER WNENTELELTR WATER SYSTF.M/TREATENG WATER SERVICE. NEW RESIUEN'1'IAL PLMB. SQ. Fr. C NO: NIC -Z;;- 9? 1 -5—/ J JOB DESCRIPTION RF TIAL FDWL I] KITCHEN REMODEL ❑ADDITION C3 PLUMBING RE -PIPE C3 MULTI -UNIT ❑STRUCTURAL MODIFICATION ❑ INTERIOR ❑ CHIMNEY REPAIR IMPROVEMENT DSWIMMING POOLS ❑ BATH REMODF.IJREPAIR ❑ DEMOLITION ❑ OTHER tax BW BLDG/ADDITION ❑DEMOLITION ANT ❑FOOD SERVICE IMPROVEM17NT ❑ OTHER STORIPPS TYPE CONSTRUCTION OCC. GROUP APN Y l j� y'6111LflING DIVISION FEES." , i § i`,e':` PLANCHH CFEE ENEN GRA19YIE SOI]. PAID Dam Rcccipl N 'T)(TAIJI PERMIT �� 'FEE - SEISMIC PERMIT ISSUANCE ALTER OR ADD TO MECH. AIR HANDLING UNIT CID 10,000 CFM) AIR HANDLING UNIT (OVER 10,030 CPM) RXl1AUST HOOD (W/DUCT) HEATING UNIT (TO IDa" B"T U) NESTING UNI']OVER IM.000131 GO VENTILATION FAN (SINGLE RESOD) BOILER -COMP (311P OR 100,003 BTU) BOILER - COMP (OVER I W.000 B'I'G) AIR CONDITIONER NI7W RESIDEN1 IAL MECH. SQ, Fs,. OFFICE MEC1I&I AL FEE r CONSI'R CTION'(AS HOUSINh MITIGATION FEE PAID Data Receipt N ISSUANCE DATE ----t_©9 CARD the FRONT OF BUILDING CITY'OF CUPERTINO" -"- -- - •_ ..-,-... -_._ _.-_:_. ... _.,. - �� BUILDING DIVISION � :BUILDING 1'ItI1JF.CT IIIHNTIRICATION:, - . - PERMIT NO. I 4354 BDILDING ADDRESS: • • ,,✓/'- cA SANITARY NO; APPLICATION SUBMITTAL DATE I NAME: l ONE: jj •1.,f J C A TORS AME: LIC NO. N/C ❑ CONTROL# - 'WA I IN . LIC NO: �,.� 'S' P " ADDRESS: =-- ,ft - • INSPECTIONS `��-yy -'DATE INSPFC -- 11 CN,11, Hen F,"" Paid b, Appli'am 1111631)------ INSPECTION RECORD NOTE: ALL GRADING AND DRAINAGE SHALL BE INSTALLED TO COMPLY WITH THE APPROVED PLANS AND CITY OF CUPERTINO STANDARDS. BUILDING PERMIT INFO CH RL�DG•' ELEE}CT PLUMB MIEEC FOUNDATION/PIERS/H.D:S JOB DESCRIPTION '� , DWL ❑ KITCHEN REMODEL []ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT El STRUCTURAL MODIFTION CHIMNEY REPAIR ❑ INTERIOR ❑ SWIMMING POOL 4 IMPROVEMENT [DSWIMMING N ❑BATH REMODEL/REPAIR•yO DEMOLITION []OTHER'' Sig,•c `� ' I' ' UFER GROUND. �.2,r%$ �; PAD/SETBACK-CERT GARAGE SLABS/PREGUNITE 'POUR NO'CONCRETF UNTIL ABOVE HAS BEEN SIGNED- TO ARRANGE INSPECTION CA LI. AP'7'ERNOON'S (POO 1'11 - 4:3d1 I'M 777-3228 ONDAY TO FRIDAY 24 HOURS BE- FORE REQUIRED INSPECTION. JOB ADDRESS AND PERMIT #ARE NEEDED WHEN PHONING. UNDERGROUND/SLAB PLUMBING ELECTRICAL T y�,,,,,.'.. •', UNTIL`ABOVHASBEEN'S]GNED 'DO NOT POURFLOORE- OMM R IA • ❑NEW BLDG/ADDITION ❑DEMOLI'(ION , ❑TENANT ❑FOOD SERVICE IMPROVEMENT , t]oTxER _ .11 I'1'NIION CONTRACTORS: "fY!R5: NO PERSON(S) SHALL PERFORM WORK ON THIS JOB SITE WITHOUT BEING IN COM- PLIANCE WITH WORKERS'COMPENSATION INSURANCE REQUIREMENTS. PLUMBING MECHANICAL ELECTRICAL - FRAMINGVENTS s ,.-. INSULATION INSPECTION SPECIAL INSPECTIONF�-(}1 II IZ ILI) � DATE INSB PLACE NO'SUBFLOORUNTIL A13OVE HAS'BEEN SIGNED - ROOF SHEATH/DIAPHRAM� PLUMBING { V -V ECHANICAL Z. UJi BOND Z { .� iLECTRICAL/POOL Q 6 S �.. �4Fj�•-�� . FRAMING/STAIRS/E: EGRESS .f - i INSULATIONNENTILATION Z, a ;COVER NO;WORK.UNTIh,ABOVE HAS BEEN SIGN_ ED, C J K EXTERIAL SHEA_RIHOLD DOWN •e0 INTERIOR SHEAR/HOLD DOWN .. SHEETWROCK/SHEETROCK SHEAR B 1 EXTERIOR LATH/W-SCREED C—Q ,SHOWER LATH . +I . .'NO:TAPE�OR•PLASTER,UNTIL ABOVE HAS;BEENSIGNED .�d_[p - 71 ' _SCRATCH COAT;'ji - .��C �/ (� �� > •' i�• o/'— 14 ✓Y-Kp(�` e vllt - SEWEWWATEI . - �Z7 ©� t" ?•' �' ' CTEMPORARY,,.iApPROVAlA i,'4�t° ;!.. • .. r �....''r 1 I:ECTRICAQ.; -,"_M, r's" • GAS s..,xvA.y`.+': SF*�7�t;,• ' a .. - GRADE A�Wn l�.. ..Aid- a �- FIRE ' ;itwtt.. ;., HANDICAP..! -- ELECTRICAL': ,,', - ,;1•. �1 • MBING.^' CHANICAL LRGY - CER'i (I'IC.:1'I'�:. (vk' [)�; CUPANCY `'JI! VISUAL FINAL ONLY G, BUILDING - IMPORTANT: READ REVERSE SID&BEFORE CALLING FOR FINAL INSPECTIONI!B I pi• • :, . 2 gg ISSUANCE DATE " i55uED ( f , OCCUPANCY OFBUILDIN OTP RINTT DPLEASE UNTIL BUILDING FINAL IS SI NED YB LDING IINSPE,Ci6k:,.. i a.w s.";-�, w,fUy.� .:.+. t. � _ - '' . '.Mr:' v s' B�.• YxkPI?LtCIi�NT�F�OSTIIJGt�Or'Y,o.� # . ry�:'*T" ' !' � � .. .. +� .,,