26908 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD I : .L. RI A PERMIT NO.
APPLICATIONTERMIT PING PROD CT IDENN'ICAL 26908
BUILDING DIVISION BUILULU PROJECT MECHANICAL
BUILDING ADDRESS: SANITARY NO. APPWCATIONSUBMHTALDATE
LOTIf I �1�1�
NF N P E CO ORS NAME: LIC NQ:
` J
' /IV N/C CONTROL N
ARCIIITEeTj1U,IGIbl I LIC NO: AD .FSS:
CONTACT: RJONE
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT LUMB MECH
r- � PFRMRISSUANCE 0 ❑
LICENSED CONlRAC1 ORS DECLA"RON APPLIANCES-RESIDENTIAL
❑.z Ihertby aff mu run srnvisioruofChWea9(caomeucing with JOB DESCRIPT10N
li100 Seedorr7")MDivision 3nf the llunne.aN Pmfoeithv Curie.end mY license i,in PANELS
yW full fume end o[f¢I.
¢ZW I�cm,eCW+.U,=cJ�4� Lica UPT02W AMPS
u~i=y Dale emtrocl« 201-HAY)AMPS
1
S TION OV IR 1000AMPS SQ.FT.FLOOR AREA
1=.M�W SIGNS ELECTRICAL
�y�j c
dy�u W -BUILDER DECfARATON SPECIAL CIRNIT/MISC.
XOa I her y oleo .-BUILDER
from the Come ''v.Lew for Be
1+131'-�i following rem 1 - 7031.3.Buirca ud Pmfeuiov Code:Any city«munlY TEMP.METER OR POIE INST.
whim rtquilve '110 conumcl,aha,improve,drneliah,or relair any uroctma
!(}� prior to is lx,uulee,ulw myuims the applirrvn for such permit to fik a.igmJuwemml POWER DEVICES
W app thu Kulimn,N Pmvanl to lha pmvisiom of ln[Cmmcl«'s lims law(
ax0.o� 9(comineneinR wish Fchim]lNq)It Divi,lohhJnf lfe Buxinaa end RofevtioJc) S MMING POOL ELECTRIC VALUATION
W=ot «that he u cumpt ttereflam aM me l r«do,alleRN ex vdaem of
FZ �
_Q kun70313 by my epplinnl f« Tm
• nil,ubjcm.tM Ito acivil paWly of N OIJIL S-SWITCHES-FIXTURES
rexrt xe(bun rive hunh dollar
❑ L.—ns,roftJe s.,my.«mycreplco will ¢,tbc'uwk ' _SQ.la.
STORIES TYM CONSTRUCTION
d3— will Jomewmk.aM theeu, rtu
uctun« uzdcd in «nf( fm.ole(Sec.]044,Berainesa
and ITnreuinn,Cork:ToConwctnr'a Liccnae docs not apply In m u mr of
prapenrwWWtd,«i mptnvalnae«,,.Nw wcnw«k nimaefr«1nm"gnnn
owncmplgaa,proviJed,hu auchinfoveme are notinladcd«nffcrtdfur We.IL OCC.GROUP RIS.0 IIS
hnweva,tbe buildingmimprvvertent l.n imin«e yrar afc«npkilm,Ibe ow a- TOTAL
buildrr»ill love the doter of prminR did.Wild«Improve for nu f
sole.).
ElI.vawler d'IM1c propeny,amrxcl 'vdycontrenin'.41thccnral to QTY. PLUM NG PERMIT FEE FLOODZ Al
co .me project(sa.7w4,Bteun No Cole: tor'.
LitrncLewd—tuo ap�lymwtownnofpru nywW Wi ...d ISSU Cli
wW mnlrn,f«mch projens with•conwct )li ConVactm' ALM' - AIN&VENT-WANT EA
Liao..Law. �n ( ) FEE SUMMARY
❑ I nm exempt ow r Scc P C f u moron BA W PROTECT.DEV ICF, l
SANITARY YN
Owner De RI!CEIPTN
WORKMAN COMPENSATIONIHV
N '15RAINS-PLWR.ROOF.ARBA,CONU.
❑ Ihaeby affirm that l have a catifeme ofc«uene,«amnif to or FI%TURBS-PFA TRAP SCIIOOL TAX RECEIPT. N
Workcrv'Cnmpmaatitm lmumrccmemnifiNcopylggl.lab C.)wbic PARK 183E Y N
era dl emplo GAS-EA.SYSTEM-1 INC.4 OUTLETS RECEIPT'N
Policy. BUILDING DIVISION FEES
C"r"pe"y GAS-EA.SYSTEM-0VER 4(EA) PLANCHECK FEE
❑ CeuifiaJ copy i,
$aCrniMul copy i.filM with the city inspection divi,im. GREASIVINDUSfRL WASTE INTERCIJTOR GRADING RD!
l/ CEATIRCATE OF EXEMPTION FROM WORKERS' GRGASETRAP
COMPENSATION INSURANCE SOBS FEE
('mi,,ecton neN ml hcomplclN ifJx pcmm i,fm one hundrtd dollen(f 100) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
m lea,)
I cenifylha,inlhe peorrumm 0fthe v,rk fmwhicb miapem...is is,ocd,I,JWI WATER HEATER W/VFNTIFLEC(R y D�
not mnfloy any penin in my onorl w u mIb
Io become subject to e Wohcli 7 PAID
O z Compenwi0nlaw3of Celifomia Date WAMSYSTEM/f TINO pre ReLeipl N
z C) NOTICE TO APPLICANT:If..ftm makiltg NU Catleem,of Excmption.yor sbouW NEW RESIDENTIAL I'll SQ.FT.
TOTA
1-- OC h«ome.wb,,Iy tth,toch /s Cmn.or$is cmni.innsoflhe Lobar C,.o,J.umuv
!Y ; fOMwim comply with sucM1 provisl0ru«min pemtit shell be JeemN mvOkN. BUILDING FEF,
dQ CONSIRUCIONLINDINGAGENCY SEISMIC ITS
z I nMbr erlirm mat 11�m is a e«.rwNan Ie,dinR agar r«to r<rfarn®na ar
U O the wohf«wnien rola pamil is issued(Sm.309].CIv.C.) TOTAL ELECTRIC FEE
IrnJcr'x Namc E
U Lerda',Addrtv QTY. MECHANICAL PERMIT FEE PLUMBING FI
1 certify low I tuve rod thea"hemon ud mut,thu the.d,ve infanratim i.
cu-..Iagltt In comply wish nll uty and uwnly o�dilumaw.rd aero laws reluinR to MRMITISSUANCE MECIIANICALEEE
I"^ b Win{mmtrucvon.uW byewh mmpraenWivwoflhucitywmtaupootc CONSTRUCTION TAX
U Z about-mrntiarhN PmlertY rm insp cueen ALTER OR ADD TO MF,CH.
(We)nglec Io.wv - Ify «P Iry the City of Cupatnn nailw
Iiabili et'jw ex may inmyw.y.cau Umhv Bl,ICiry AM HANDLING UNIT(T010.000 MD
in cora,. lin m' w it.
i AIR HANDLING UNIT(OVER 10.000CFM)
mh "Conlr""I« PXHAUSTHOOD(W/DUM)
PAID
IJZ% WUS MATERIALS DISCLOS E HEATING UNIT(TO 100,0(10 BTID Due Berri,N
h the arrobe nlmfuture WilJing«..vpanl.mre«hudlehamrtl0us rhwerial
as dcfirNd by the Cupertino MunicyW Code Chapter 9.12,.nd the Health and Surcry HEATING UNIT(OVER 10),000 BTU) TOTA
Cade,Sector 25532(p'I
❑yea ❑ No VENTILATION FAN(SINGLE RESID)
Will me. licanl«fmumbuildin y 'pmenlmdeviceswhich aril BOILER-COMP(3HP OR 100,000BNj
ISSUANCE DATE
pp g«cupuntuxc uh
hvaNau,yr couamironn as dcfinN by the Bay Area Au Quality Malagcmll BOILER-COMP(OVER 10%000 BM S
• F A 1 D I3 u 7
❑Yes El N,) NEW RESIDENTIAL MECH. Q.FT.
I hove rtad the hvomill hamunala nxecionnene,under Cll 695 of the JA
C.Ilfomiu Hcnith&Safely Cole,Secl6a 255115,25533 and 25534. 1 urde,nend met
i!trc Wilding Joe,m mrreNlY bout•tvwC lhnt it d my rcap«uidlitY w Iotfy the
occapnnl none Iaryirarcna wnicb mhul W met pti«m u.aaee ar a cm,ifi�,e or ��.�
" y' nI11vu
Owner or.utdxirsd aocl Duce TOTAL: ISSUED BY:
OFFICE
POST THIS CARD, NEAR DRONT OF BUILDING
regnuT NUMBER
CITY OF CUPERTINO 18668
INSPECTION DIVISION
JOB INSPECTION RECORD
C� _/ ,,/ �/1p PERMIT EXPIRATION
JOB ADDRESS
�,�IjI(D/�✓/�/�rr`�O�WyW�IIG f�HR a:.oI. UNIT# - LOT# ' '
OWNER / /IILJ[ ? cpr= so/4 CONTRACTOR ScUTFi eAY PLiIm&3 [(§ PERMIT NbT-STARTEDtVJ HRIN
INSPECTION DATE INSPECTOR INSPECTION RECORD. 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR.180 DAYS FROM
NOTE: LAS<ALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE TO COMPLY WITH THE APPROVED PLANS AND CIN OF Pcrmvr vauDATION -
CUPERTINOSTANDARDS. �� t
GARAGE SLABS -
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED N,�j`J` ,1
UNDERGROUND /SLAB
PLUMBING • c - -
ELECTRICAL up Z'21989 - .
ISS LANCE UA r E
MECHANICAL 8 G ELECT rLG. MECH.
!f! �+, eNl+n 1:1 [:] '� - ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING
VALUATION $/FT.
,
MECHANICAL
ELECTRICALPiR MIT TO
FRAMING '
INSULATION - STORIES TYPE CCNSTR
OCC GROUP RES ON ITS
PLACE NO SUBFLOOR UNTIL ABOVE.HAS BEEN SIGNED i11
'L n
ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE 5(].r L rWII AUTA 101AL C.EAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
BUU-DrNG USE
ROOF SHEATHING Res rND coN Pe Go-
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. , . '5 6 a D
nSSESSORS PARC.Ll.NO.
PLUMBING ROUGH sANs ELECT.ENERGY
TRACT NO. PARCEL NO
TUBS 8 SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY _ ACC DATE ACC FILE No
FRAMING - ELECT.FINAL TEST
ZONING ENG SITE NO.
INSULATION - PLUMBING
GASTEST GAS
MECHANICAL'
FIRE SPRWK ENERGY T24
- '
.COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y "0 NE]
EXTERIOR SHEAR ELECTRICAL RELEASE .FLOOD ZONE A L U.C.
INTERIOR SHEARFIRE DEPT. Y❑ "❑ _° ❑ N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING — BUILDING
INTERIOR LATH .TEMPORARY APPROVAL SCRATCH COAT ELECTRIC PLAN CHECK i
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING ISNOTPERMITTED UNTILBUILDING FINALISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC -
H ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING IY
PLEASE GIVE JOB ADDRESS WHEN PHONING.
MECHANICAL
CONST.
. — SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT! coNST.Tnx
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION. TOTAL ICK)
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BOI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING ' APPLICATION & PERMIT T
ANDRETLOWERIW6 KFARV. BUILDING - ELECTRICAL-PLUMBING -MECHANICAL s. . 18668
OOC8
OWNER'S PLAN CHECK VALIDATION
NAIrny�,/IAE /+ncC+c,O./ ���'']]yr Ana- CITY- ELECTRIC PERMIT FEE
/EII CVC! C/CWU /'! PHONE �W �W'
CONTRACTOR'S
NAME �/ ���/�•� OUTLETS-SWITCHES-RECEP 10.00/1.00
M �/ pLUMI/t'.No. LIGHTING FIXTURES 10.00/1.00
nooness rov's PPLIANCES-RESIDENTIAL 4.00 gr-22
PHONE PANELS 10.00 DATE OF APPLICATION -
ARCHITECT PLAN CHECK FEE P.C.NO.
OR PANELS (OVER 200 AMP) 20.00 -
ENGINEER
Llc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADOREIS SPECIALCIRCUIT 5.00 `
ZIP EMP.METER OR POLE INS. 20.00 1 �C
APPLICANT `'$ ` �
ACOREAS �r� MOTORS SEE FEE SCH.
11009 r [0AX JelW& P6e}R ZDQ• SERVICE CHANGE 20.00
00
o
Foo LICENSE:U,CON"1'RACTORS DECLARATION -
is u I hereby affrm that I am licensed under provisions of Chapter 9
Z: (con...encing will, Section 7000)of Division 3 of the Business and ISSUANCE DATE
D z Professions Code,and my license is in full force and effect. BLDG. ELECT. PLG. MECH.
Oi y,o License Class Lie.Numher
m H Uatc Contract.,
¢_ ¢ w a OWNER-BUILDER DECLARATION
BUILDING PERMIT
n'xu ;°'y 1 hereby infirm that 1 um exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
Fwo J law for the following reason.
(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION S/Fr.
Code:Any city Or county which requires"pear it to construct,alter,
a, ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC.
o LL requires the applicant for such permit to file a signed statement that TOTAL P MIT TO
e w es he is licensed pursuant to the provisions of the Contractor's License
F a a Law(ChapWr 9Commencing with Section 700().f Division 3 of the
4 o Business and Professions Code)or that he is exempt therefrom and
¢ H the basis For the alleged exemption.Any viuialion of DTV. PLUMBING PERMIT FEE Section 7031.5 STORIES TYPE CONSTR.
d3 by eny more
for apcmrt subjects 5000.)icam tuacivilpenalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hand,. ,ty,o ,5500).1:
❑ I,as owner at fileon,will do t,e my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
. their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 5.00
Calc:The Contractor's License Law docs not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 S¢FT.FEW.AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have the burden Of proving that he did not build or ins. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 W BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 RES IN❑O -.1 O Omar
ElO 1,as owner of the property',am exclusively contracting with 11
licenud contractors to ...sural the project (Sec. 7044,Braine,, LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL rvo.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 •
contracts for such projects with a contractor(s)Gcenwd pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I em exemptumder See. ,B.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Late WATER SYSTEM 5.00 ACC.OATE ACC.FILE NO.
WORK RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affrm that 1 have a certiricale of consent to scl-insure,
oraeertifcate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copylhercof(Sec.3800,LaoC L
Policy No. Company
O ❑ Cerlilledcopyisherehyfumished. FIRE SPRINK ENERGY E.]4
Z Cl Certified copy n tiled with the city inspection Division. � Y
FO 0 Applicant MISC.- REFER TO ORD. Y [D N IN
ir W CER'1',171GCI'Ir OF EXEM PrION FROM WORKERS' PERMIT ISSUANCE 10.00 GU FLOODZONE A.L.U.C.
W > COSIPRNSATION INSURANCE. PLC.CONTE. IDC.NO. PLG.
d 0 (]),is sccliun need not he completed it the permit is for one TOTAL Y❑ NEl Y [:] NF
Z) 2 hundred dollars IS 100)or less.)
U O '1 Certify Ihal in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE
H mit is issued,I shall nm cot I a Burson in un FEE SUMMARY
LL p oy any p y Inanncr so as to
Ed become subject to the Workers'Compensation laws of Californu.
C, Dal` nppllcam ALTER OR ADD TO MECH. 5.00 BUILDING
} Go NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emptiun,you should beconse subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Ichor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed rcvokcd. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE �-
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
rma
the perfonce of the work for which this permit is issued(Sec. MICROFILM
3097,Civ,C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender,Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating las building construction, and BOILER H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives of this city to enter upon the BOILER-COMP tDser 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection puny to
(We) agree to save, indenmify and keep harm 1. the City of MISC.- REFER TO ORD.
in
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 1000 CONSTTAX
may n any way accrue against mid City in conu9ucnce of the . -
mntingoC his permit. /1 MECH.CONE. LIC.NO. MECH. 1
cleuoh y r TOTAL TOTAL I W
ignature or A -li t/Contractor Datil
OFFICE COPY
�1
FF
CITY OF CUPERTINO c-OPYE
GAS SERVICE NOTICE
To
You are hereby authorized to connect the GAS service for s'`
Owner or Tenant . F= .IZvI C�LCs-soQ
At 1 I MR F9 o
New Service
No. of Meters �- Reconnect �—
No. of Add. Meters Move Service
Move Meter N
PLUMBING INSPECTOR — 1 co1 I� �„