22534 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification _ PERMIT NO.
Building Address:
_ 10-7L-tom so%� K � 22534
wner(,arras;c l L nre:s� CITY OF CUPERTINO-BUILDING DIVISION A
Contracror'e Name: P+ uo N. APPLICATION I PERMIT I
�� BUILDING-ELECTRICAIIPLUMBING-MFGHAMCAL CATEGORY CONIROLR
Architect/Engineer. Llc.No:
- QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE _ ❑- [ILICENSED CONTRACTOR'S DECLARATION
I hereby affimr that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIALIng JOB DESCRIPTION
lices.h 1fiallformection 7000)afdeDivision 3ofthe Buslneasand ProtesslonaCede,end my I
licence Is(R hrLL form end cited. PANES
License ClassLcont -
Dale Contractor
ARCHITECTS DECLARATION 201-1000 AMT'S
µo!ex ZZC I understand my plans shall be used as public records. OVER 1000 AMPS R $/SQ.FT.
E' tj Licensed Professional SIGNS ELECTRICAL P U T E R
�<N OWNER-BUILDER DECLARATION SPFGIALCEtCU[T/MISC
following Z" -4Iherebyaffirmlhatlamexemptfmmthe Contmdoes LicenwUwforthe
pp owing reason.(Section 7031.5,Business and Professions Code:Any city or
i"'q county which requires a permit to construct,alter,Improve,demolish,or repairI ATE
TEh1P.MEl73t OR POLE INST.
E1 7 anyat mmpdortoitalsauancgal mquimstheappllcantforsuchperMtto EWER DEVICES
C file a signed statement that he Is licensed pursuant to the provisions of the
3w1� Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
�O sion3 of the Business and Professions Code)mthat bele exemptthere(romand VALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHESFIXf URFS �x
O
applicant fora permit subjects the applicant to a civil pemmre
ltyofnct othan
5J five hundred delta.(11500).C"v NEW RESIDENTIAL ELECTR
�n ❑I,as owner a(the property,or my employees with wages as their sok SQ,F[, STORIES TYPE CONSTRUCTION
compensation,wWBothework andthe et odurehewhat Contended or offered for
C O sale(Sec.apply
to Business and f property
Code:The Contractors her e n Law
does$ whoclocs such torn owner ofpropertywhonembuilds or imperannot yees,povidedrronand OCC.GROUP RES.UMTS
whodoementsa not Intelfedorough hlsownemIf,hcx xprovidedilding that h
Improvementsarematintended earofco for sale.the mnveg deer ill have TOTAL:
i Improvement ksold within one yearofcompletion,theowner-bullderwlll have
ttd.
en of proving that he did not build or improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE FLOODTDNE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ers to commid the project(Sec.7094,Business and Prof xislons Code:
Committees License Law does net apply to an owner of property who ALTER &VENT-WATER(EA)
r Improves thereon,and who contracts for such p(opda with a eFEE SUMMARY
cc LII[[aelti)licensed pursuant to the Contractor's Llcenss Law. BACK FLOW PROTECT.DEVICE
IJ I am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
. Owner Date RECEE'C p
WORKMAN COMPENSATION DECLARATION FIJ(.I.URES-I'ER TRAP SCHOOL TAX Y N
❑I hereby sill
rm that I have a certificate of consent to self-Insure,ora RECEIPT_ Na
certificate mWorksm Compemrtlonlosamece or a rertifled copy there°((Sec.
3800,LabCJ GAS EA.SYSTEM-1 INCA 0UTLETS PARK FEE Y N
Poli p GAS -OVER4(EA) RECEIPT
Com any BUILDING DIVISION FEES
Certified copy b hereby fumlahed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city int edlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE-ASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WhT. Date RCcei t#
(This section need net be completed lithe permit is for one hundred dollars
($]°°)°`less') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certi/ythat in the performance of the work forwhich this permit Is Issued,
10.11 not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Lawsof Callfomla.Date PAID
ZZ Applicant NEW RESIDENTIAL PWB. SQ.Ff. Date Recei t#
p NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
should become subject to the Workers'Compersatlon provisions of the Labor TOTAL:
W Code,you at forthwith comply with such provokes or this permit shall be BUILDING W > deemed revoked.
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE l
I hereby affirm that there is a construction lending agency for the perform, ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ,Q TOTAL:
V O Lcnder's Name PLUMBING FEE
LL 1— Lenders Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcrAffythatl have reacithisapplicatlonand statethat the above Information
IL is corms.I agree to comply with a0 ws city and county ordinances and state laPERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives ofthls
F. U) city to enter upon the above-mentioned pmperty for Inspection Purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cu pert loo Date Receipt#
O against liabilities,pdgments,mite and expenses which may In any way accrue AIR HA NIXING LIMT(TO 10,000 CFM) SUBTOTAL:
agabst said City in cons yuence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of App ant/Contractor pay (W/DUCT)STHOOD(W/DUC
CONSTRUCTION TAX PAID:
IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(T0100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I Inalth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - - TOTAL: L
rI Yes MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air - r
Quality Management District? BOILER-COMP DHP OR 100,000 BTI]) t
4Yes U No &®
havc
head the haze To us materia srequlrcmenhunder Chapter6.95 of BO LER-COMP(OVER 10,0000 U) 41�Q
the Califemia Health&Safety Code,Sections 25505,25533 and 25534.I Ave
a`
understand that ifthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. Ave IGr q 1^^?—��4i$,
responsibility to notify the occupant of the requirements which moat be met
prior to issuance of a Certificate of Occupa hey.
Owner or authodred agent Date
TOTAL: ISSUED 6Y:
OFFICE COPY
PFIMT NO.
POST THIS CARD NEAR FRONT OF BUILDING 22534
CITY OF CUPERTINOLi
A A
INSPECTION DIVVIeISION- JOB INSPECTION RECORD fS2-r9
B ADDRESS
UNIT # LOT # CATEGORY C OLp
OWNER C Q L �J CONTRACTOR C� 3��_� BUILDING PERMIT FO
INSPECTION DATE INSPECTOR INSPECTION RECORD rtQn
FOUNDATION/PIERS - NOTE ALL GRADING AND DRAINAGE
UFERGROUND SHALL BE INSTALLED TO COMPLY WITH JOB DESCRIPTION
PAD/SET BACK-CERT THE APPROVED PLANSANDCITY oF
GARAGE SLABS PREGUNITE CN'EATIUPERTIN05CANDAADS.
c
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND/SLAB INSPECTION DATE INSPECTOR.
PLUMBING
ELECTRICAL
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR
PLUMBING
MECHANICAL
ELECTRICAL
FRAMING/VENTS/CLEAR
INSULATION
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROUGH
PLUMBING
TUBS&SHOWER PAN
MECHANICAL
ELECTRICAL ACUZZI BOND _
FRAMING STAIRS
INSULATION/VENTILATION
EMERG.EGRESS
SEWER WATER -
VER NO WORK UNTIL ABOVE HAS BEEN SIGNED
TERIORSHEAR HOLD DOWN
NTERIOR SHEAR/HOLD DOWN
SHEETROCK/SHEETROCK SHEAR
EXTERIOR LATH/W-SCREEN
SHOWER LATH
SCRATCH COAT
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
NOTE:NO FINAL INSPECTION SHALL BE MADE BEFORE
THE CONSTRUCTION TAX IS PAID.
FINALS DATE INSPECTOR
SAN.#
ELECT.ENERGY
PLUMBING ENERGY
MECH.ENERGY
BUILDING ENERGY
ELECT.FINAL TEST
PLUMBING
GAS TEST
MECHANICAL
HEATING
ELECTRICAL RELEASE
FIRE DEPT.
GRADE
OCCUPANCY
TEMPORARY APPROVALS
ELECTRIC
GAS
BUILDING I DATE
OCCUPANCY OF BUILDING IS NOT P 1FTT IL
BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR Oa 2
ARRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN 19"a-l
12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND
PERMIT# ARE NEEDED WHEN PHONING.
IMPORTANT!
PLEASE READ REVERSE'SIDE BEFORE CALLING FOR FINAL INSPECTION j ISSUED BY:
APPLICANT'S POSTING COPY