19769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
BuOding Ad9 b i 19769
1so.rer, am�e�pn // qt yF, Phone; ------- p
VV�i'C6e� -I.QIf er /� 56 CITY OF CUPERTINOBUILDING DIVISION
c art«•Name: Lit. APPLICATION / PERMIT 2�
Cv I S f- U Lfiv a BOLDING-ELECTMCAIPLUMBING-MECHANICAL CATEGORY CONTR�
r 12)713 s or, QTY ELECTRI ER FEE BUILDING PERMIT INFO
Addrna�_'03MUCH
i Q / PERMITI A ❑ ❑. a
l"
LICENSED CONTRACTOR'S DECLARATION
Ihereby a((4mlhat lam BceneeduMerprovlelonsol Chaptvr9(mmmenc E IOD DESCRIPTION
ingwith Setlion7000)of DiWslon3ofthe Bu in mdBm(nsionsCA e,and " \
limn-I CI I Bto endd(ect. -,1
Dat Contretlor 1(/ 5'�' \�
ARCHITECTS ECLA ATION J 20"000 AMPS Y.
vs Z I understand my plem shall be used u public records r 1', SQ.FT.FLOOR AREA 5/SQ.FT.
6i IOZZd Licensed Professional S ELECTRICAL n\� .1"1\ o 3 a f oQ q1 c;L.as
�6 OWNER-BUILDER DECLARATION SPpCIALCINCUIT/M "W
p,24 IherebyafOrmthatlemexempt(rom Ne ContraRorb Llrenmlawfmthe �T
cgs" followNgrcason. SeR1on78715,BueinenandPro(enWnaCode:Mydtyorp,METtOR OLE ST. �/
countywhich mquimsa permitlocommuq alter,Improve,demolish,orrepair
anystme mprlorwiw Wuame,aLsorequUntheappBant(msuch Permltto POWER DEVICES l
5 file a signed statement that he in licensed pursuant to the provisions of the m
Contrader's License Law(Chapter 9(mnvrencing with Section 7000)of Divi- SWGTMINGPOOLELE l\\ ^1�onVALUATIO
Oa "'. 3 theeusl.1leged exemptions AnyvirthNhebeesmptlherefromaM ^�
<..t the baN•for the alleged exemption. Any ttolacon of penalty
on nor more
any OIIILE.ISSWI.fCFIESF7XfURpS
a 'bu. fora permit aubjecbtheapp8canttoativll penaltyofnot more than
Bun 1,as
dollars(SM. NEW RESIDENTIAL ELECTR SQJ.7 STORIES TYPE CONSTRUCTION
�n u I,as owner of the property,or he employees with wages r thele dole
mm(Sm.70KBusBess and rendthes Code:The�nm
intended oroffered for
p
sale(Esc. pply to Business Profetbt Code:The orimptlors Licensehereon Law
does$ .hent apply torn owner or property who Wildsorees,Imvieed that such
OCC.GROUT' RES.UNITS
whadaements.uch work hlmulorthrough Maown e.If,h employees, iIdimg h -
improvementiarenotintendedoroffered(arsi..If, owe builder klingor TOTAL:
Improvementbsold within oneyearo(complellon,lisp tuner-bullderwillhave I '
t Men of proving that he did nm build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
�L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094,Business and Professions Code:
The Commences License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bu0ds or Impravn thereon,and who contracts for such plujetls with a FEE SUMMARY
egnITactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
1 Lf I am exempt under Sec. B &P C for thin reason '
FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner Date RECFSPTN
WORKMAN COMPENSATION DECLARATION FD(TURFS PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o certificate of consent to pythelm,ora RECEIPT N
certifimteofWorkers Comperuatloniruurancemacerttfled copy Mertro((Sec. GAS,EA SYSTEM-1 INCA
OUTLETS PARK FEE Y N
3800,Lein CJ RECEIPT N
Policy N GAS EA.SYSTEM-OVER 4(EA)
Cam ny BUILDING DIVISION FEES
Ified copy is herebyth the d. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHL•CK FEE
or ift d copy b Ned with the city Wpectlon divldlon. 'X-1140
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID LJ—IiZ7 f'�/�
COMPENSATION INSURANCE SEWER-SANITARY-SII7RM EA 200F1' Date Re0.'irtN 5-'
(Thbaetlien need not be completed Ilhe permit is forone hundred dollars
($100)erless') WATER HEATER W/VENT/ELFJCTR ENERGYFEE Y_ N_
I mutifythat in the performance of the work for which this permit is timed,
I shall not employ any person In any manner o as to become object to the WATER SYSTPM/TREATING
Workers'Compenastion Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PCMB. SQFL Date Recei t#
Z O NOTICETO APPLICANT.If,after making this Certlficaleom Exern ion,you
should became subject to the Workers'Compensation provisioro of the Labor TOTAL:
F N Code,you rust forthwith comply with such provisions orthb permit a hail be D
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 4
IL O I hereby affirmthat there b a construction lending agency for the perfornFELECTRIC FEE
M Z ant ofthe work�rp ch tisyyermitid leaued(Bec.3097,Civ.C.) TOTAL:
(.) 0 Lender.Name !V�/�C�, PLUMBING FEE
i- Lender's Address QTY. MECHANICAL PERMIT FEE
0 W I cartifythat l have read thbappllotionand gaining theabove ws information MECHANICAL FEE
CL Is correct.I agree to comply with all tlce
tyand county ordinansand Nate laPERMIT ISSUANCE FEES PAID:
rca
W relating to building r ruction,and hereby authorize representatives of this '
H city to enter upon the above-mentioned property for Inspection purposed, ALTER OR ADD TO MECH.
(nst)agree to save,indemnify an d keep Z atDate Reeei t»
es which
the Cltyy Cupertino
L.I against liabilities,judgments,ms and expenses whichh may anywayamxue AIR HANDLING UNIT 10,000 CPM) SUBTOTAL:
against Id City In ronschlen ofthegrantingafthispe
n IMM
a� M -f� v AIR I-uNDUNC UNIT rovFx lo,000CFM) CONSTRUCTION TAX
Slg3nam�re o(p�ppfiia/et/CCorttmetoorr Duette SQiAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO URE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CFO 100,000 BTU) Date Recei tq
material as de0ned by the Cu no Municipal Code,Chapter 9.IZ and the p�
HeakhaniSafetyCade Se n75532(a)7 HEATING UNIT(OVER 100,000 SM TOTAL: /
[:]Yes Na
Will the applicant or future building occupant use equipment or devices VFNIILATION FAN(SINGLE RESID) Fl M!ZE DATE
which emit hazarlous Nrcnta nroas defined by the Bay Area Ab b �
Quality Management Dlatri BOILER-COMP DEI'Oft I00,0(D BTU)
❑ VMD LI
(have readthehan oudmNerialsrequirementsunder Chapter6.95of BOILER
-COMP(OVFR 100,000 BTU)
the California Health&SafetyCode,Semon•75505,75533 and 75534. 1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MEGA. SQ.FT. ,,.y
responsibility to notify the occupant of the requiremenlasoh hrtwsl berM - CitY of CUnpo.irfI
Frio to issuance (a Ceali at o(Om panty. �j'-
Owner or author/ud agent to ISSUED BY:V k�r/'Yr-i'A.��
TOTAL:
OFFICE'COPY
POST THIS CARD NEAR FRONT OF BUILDING PERMIT.NO 19769
CITY OF CUPERTINO A`
INSPECTION DIVISION-xJ�OB INSPECTION RECORD 2�
]OB ADDRESS ^O c..+�v�.6'�. 1� �P UNIT# L�yOT# cnTEcoaY coNrrspi.A r
OWNER hCCc 4— ' CONTRACTOR Q ?V— iT BUILDING PERMIT INFO
.
[INSPECTION " ' ' " DATE :' INSPECTOR INSPECTION RECORD - �•
FOUNDATION/PIERS NOTE ALL GRADING AND DRAINAGE• '
UFERGROUND - SHALL BE INSTALLED TO COMPLY WITH JOB DESCRIP770N
PAD SETBACK-CERTTHE APPROVED PLANS AND CITY OF, �.
. CUPERTINO STANDARDS. � !t� t I,tl '�" .
GARAGESLABS PREGUNITE
POUR NO CONCRETE UNTIL:ABOVE HAS BEEN SIGNED r•I =1/1 t.` Z..+ %y � )j J
" UNDERGROUND SLAB INSPECTION DATE" INSPECTOR
PLUMBING
ELECTRICAL "
MECHANICAL
DO NOT.POUR:FLOOR UNTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR.
PLUMBING
MECHANICALL
ELECTRICAL -
FRAMING VENTS CLEAR
INSULATION '
r
'PLACE NO SIIBFLOOR UNTIL ABOVE"HAS BEEN SIGNED '-
ROUGH
PLUMBING
TUBS&SHOWERPAN -
MECHANICAL - -
ELECTRICAL ACUZZI BOND -
FRAMING/STAIRS -
INSULATION/VENTILATION
EMERG.EGRESS
SEWER WATER
CQV R:NO'WORKUNTIL ABOVE HAS:BEEN SIGNED
EXTERIOR SHEAR HOLD DOWN'
INTERIOR SHEAR/HOLD DOWN
SHEETROCK/SHEETROCK SHEAR -
EXTERIOR LATH/W-SCREEN
SHOWER LATH. - -
SCRATCH COAT.
NQTAPE.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 -
'OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL - ISSUANCE DATE
'(BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR
ARRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN R
I 12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND �(
PERMIT# ARE NEEDED WHEN PHONING. 01�l '�-•
IMPORTANT! ISSUED
BY:'
PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION
OFFICE COPY