21381APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
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Building Acidrena:
O T ,12W til l—. J-
PERMIT NO.
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G 13 lei( I
ere aces: one:
V 2N1to Z)3'41q
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/ PERMIT .
BUILDING-ELECTRICAI.PLUMBINGMECHAMCAL
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Contracter'a Name: Lie. No:
CATEGORYCONTROle
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�P R3
Anehlted/Engineer. Lle No:
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Address: I2_5S KEe.3rq ClOO AVE S�, 9SIz
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
BLUG ELECT PLUMB Mh�rli
PP
PEIMAFISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(commene.
Ih,cran irthAl Imecof Dlvlslon3 ofthe Buslnemand ProfessionsCods, and my
license lain full force and effect.:
License Clam Llc.p
Date_Contrador
ARCHITECTS DECLARATION
I understand my plaru shall be used m public records.
Licensed Professional
OWNER -BUILDER DECLARATION
owing reason. twit] 731.5, Bhat I am exempt usiness he sad Proldoh License Law for the
followingichenq iredloernatto Buslnem and Pimprovns Code:Any city or
countywhich require. a permit to corutmct,alter, Improve, dens W h, or repair
znystmcmrepriortoiwiwance;aboregrimsiheappllcantforsuchperMtto
file a signed statement that he Is licensed pursuant to the provisloru of the
Contractors License Law (Chapter 9(commencing with Section 7000)of Divi-
sion 3 of the Business and Prafesslora Code) orthat he is exempt therefrom a nd
the basis for the alleged exemption. Any, violation of Section 70715lay any
NappEmnt for. pereatsubjects the applicant too civil parody ofnot more than
(Iv hundred dollars (ISM. '
I, as owner of the property, or my employees with wages as their sole
compenaation,will dothe work, and thestme um V not Intended or offered for
sale (Scc. 7044. Business and Pmfemlmx; Code: The Conlredofs License Law
does not apply town owner ofpropertywho Wilds orlmprovesthereon,and
who doessuchwork hineselforthroughhlsoweemployees,provldedthatsuch
improvements are not Intended oroflered forsale. IL however thebulldleg or70
Improvement la sold within oneyearofcomplelbn, the owner -W Ilderwlll have
that he did not WDd or Improve forpurposeofmkJ.
tben oowner
_Wenwner of the property, am exclusively ce-railing with licensed
contractors tocorotrud the project (Sm 7044, Business and Professions Code:
The Contmea Llmnw law does not apply to an owner of pmperty who
builds or improves thereon, and who contracts for such p(ojecls with a
cgg((ador(s)Iloon eed pursuant to the Contractor's License Law._
{]Ji am exe pt under Sac. B A, P C for this reason
Owner De Y'0
l 4 Ot f EFISATION DECLARA ON
❑I hereby affirm that L have o ceMfkate of consent to oelf-Insure, ora
ce00,La a of Workers'Compecoatlonlreurance ora certl(ted copythereof 6ec.
3NOJ, lab CJ
Polley Y
APPLIANCES. RESIDENTIAL
OBDESC ON
�.�;� IIIYYYOOOIIIVVV!!! '
-
PANELS
U13 TO 2DO AMPS
211-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
2 ♦�
yl
.
f/SQ. FT.
%� 4 Z
SIGNS ELECTRICAL
SPECIALCIRCUIT/MISC
TEMP. METER OR POLE INST.
POWER DEVICES
_
0U�-� �
VALUATION
O rte{} Y
�ITJ 1.
NEW RESIDENTIAL ELEC
STORIES TYPE CONSTRUCTION
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QTY. PLUMBI PER FEE
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WA
OCC.GROUP RFS. UNITS
-
FLOODZONE APN
,
FEE SUMMARY
BACK FLOW PR01T.CT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, CONTI.
SANITARY Y '4N
RECEIPT Y
FDCURES PER TRA
SCIiOOL TAX Y N
RECEIPT 0
GAS EA. SYSTEM -1 INCA
PARKIg Y N
T N
RECEGAS
EA. SYSTGbOVER 4
Com ray
BUILDING DI VISION FT. VS
DING DIV]
Certified copy Is heed with the
�Certi(ied copy V flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thus section need not be completed If the permit is loran hundred dollars
(310(d or less.)
I certlfyflem m the performanmof the work (orwhich thle permit is ]awed,
I shall not employ any person In any manner so v to become ad ject to the
Workers Compeneatlon Laws of California. Date
NOTICE
NOTICE TOAPLICAtote aftermakingthis Cedlflcro o(En. ftha L you
shwld becom subject to the Workers' Compenwtlon provisions of the Laher
Code, you must forthwith comply with such provlsloro orchis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hercbyafflnnthatthere ta a mrutmction lending agenq for t....... rry
arm of the workfor which this permit is laged See 3097, Civ.C.)
I.ender: Name
LendeYSAddress
I renlfythat l have read this application and statelhatthe .hove m(omation
Incorrect. I agreeto comply with all city and county ordinances and state laws
relating lobullding cmwtrudlon, and hereby authorlee representatives of this
city to enter upon the above•mentioned property for inspection purposes,
(We) agree to save, Indemnify mi
and keep harew the City of Cupertino
agamstllabllitles,jrdgmenI costsandexpenses whi hmaymanywayacerue
lagala said City tare lee �nce oflM grantingofthlsperrent.
Q
/` 77pate
GREASE/INDUSIRL WASTE I TO
PLANCIIECK FEE
PAID
Date RCLCI I#
, .L� 7Q
UOr-v
GREASE TRA ''
SEWER SANITARY STO
WATER FIFATEt W/V aLEC
ENERGY PEE Y N
PAIDAppli
Date Reeei t#
2QE�
'K
WATER SYSCEM/Tlt[ATI
NEW RESIDENTIAL PLMB. Fig
TOTAL:
I
�aa
`
T
ISMIC^FEE -
Y '
4
ELECTRIC FEE
{
`W
QTY. MECHANICAL P IT at FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEE -PAID,
ALTIRORADD7OMECH.
AIR HANDLING UNIT (TO IO,000CFM)
'DOIC ReCCIPf#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
L
®mreof Appdb Contractor
HAZARDOUS MATERIALS DISCLOSURE
Will theapplle"d or mture budding occupant store or handle hazardous
meted.) as defined by the Cupertino Munidpal Code Chapter 9.IZ and the
I ealth and Safety Code Sedlon 25537( a)'
❑ Yea. - No
Will the epplieam or tore building occupant use equipment or devices
which emit hacardous air contaMtonts as defined by the Day Area Air
Qua Iity Management Dist rict7
4 Ym No
have read the hoer ours materials requirements under Chapter 6.95 of
the Callfomla Health&Safety Cod, Stolons 25505, 75533 and 75534. I
understand that if the building does not=mly have a tenant, that it is my
mporulbady to notify the occupant of the requirements which must be en t
prior to issuance of a Cedtficate of Occupancy.10
E%HAUSTHOOD(W/D(KT)
CONSTRUCTION TAX PAID:
/
la
HFATINGUMT(T0100,000131U)
Date Reeei b#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
rl
VENTILATION PAN (SINGLE RESID)
_
1$$UANCEATE
/
16� 9Qa1
JAN �✓N
ISSUEDBY _ ^e
BOMEER-COMP MIT OR 100,00k) BTU)
BOILER-COMP(OVE4100,000 BN)
NEW RESIDENTIAL MECH. SQ.FT
Owner or authorixedagent Date
TOTAL:
OFFICE COPY
4
21 /9� ,��jj,jNSpFf.TiNN pf.TfU1TV FfIR PFRMj,j� i7 SS6
Pdpa 1
20596 KIRNIN LANE
INSPECTION CATEGORY 104
K
DATE DONE TYPE OF INSPECTION
INSPECTOR
CODE P/F
COMMENTS
5/27/93 PRE-GNNITE
JJ
P
INSPECTION GATE6DRY 107
DATE DONEOF INSPECTION
INSPECTOR
CODE P/F
COMMENTS'
TYPE
GRD-ELECT
JJ
N
6!09/93 ELEC W6ROOND
JJ
P
i
;8!02/93 POOL,BDNDIN6 JJ' ; ' ;XP..
?B%20/73 `'
DECK BONDa`:
INSPECTION CATEGORY 304
tti1 ,
(TATE DONE= TYPE OF-INSPECTION
INSPECTOR
CODE P/F
COMMENTS
b�
7/12/93 BONDING'--�P
INSPECTION CATEGORY 507
DATE DONE TYPE OF,INSPECTIOM';,
INSPECTOR
CODE"v yrP/F COMMENTS
-S/09/93 "." AWAY)
v
P.
,�GAS-R000HfDOGGIE
JJ
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TYPE OF;;,INSPECTIGN,,
INSPECTOR
VDADONE
'6/03193
0—GRD" E'
6/09/93
ELEC U/BROUND
ji
P
8/02/93
POOL BONDING
ji x
P
8/26/93
DECK BOND
P
1A
1,14
Yll
DATE DONE
TYPE OF INSPECTION
INSPECTOR CODE
P/F
COMMENTS
12193
BONDING
LH
P
7-7777
INSPECTION',CATEEORY
507
1
4
DATE DONE
TYPE OF INSPECTION
INSPECTOR CODE
PIF
COMMENTS
6/09/9,3
OAS—ROUGH(DOGGIE AWAY)
ii
P
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