22005 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'erf Identification b L O�e PERMITNO.
Building Address: �U O O
00 411.4>J r se Z�3� o b o J
wnera a re 5 VA COMPAJx/r CITY OF CUPERTINO-BUILDING DIVISION
Contractor's N. c ie APPLICATION / PERMIT "C
l GO' S UCr`0,;J /..Jc 2 O a BUILDINGEf ECTRICAL paU.MBING-MECHANICAL CATEGORY COrji qla
q /Engineer. Lie.No: lD`�[
AY7MIA)GRT CT Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 20 �OeC 3i Y1 PEPMITISSUANCE ❑ ❑ ❑
LICENSED CONTRAC DR'S DECLARATION
I hereby affirmthat l am Ilemsed under prove onaofChapter9(commmc APPLIANCESIREADENTIAL IOBDFSCKPDON
Ingwlth5 dion70W)of Division3ofthe Businessand PmfessionsCo andmy rr
lire.is in full fyffrad effect. pp PANELS
Lire. as_L_ Lc.# 5 I /
To
Dat Contractor ch t/�- 201-11XI2DOAM
PS
ARCHITECT'S DECLARATION OVER IOW AMPS TA D ' FF.
WWpp o I naemt m all wwe ` 01751
Fi z�j tensed essloml SIGNS ELECTRICAL n []
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/Ie ® tl V' T
7 L., ereby a(fimnthatl amexemptfrom the Contractor's License Law for the
� ^ tollow reason.0icctlon 7lDI.S,Business and Pmfeabns Code:Any city or P. O NST.
c�. countyw blerm rcaa perMtto meats M.1ter,4npmve,demolbh,orrepalr
q any.eronu rlarm lb bmrance,also requbestheapplicantforsuchperedtto TO DATE
E 0 V aIle a signed k ment that he at Ilcenxd pursuant to the provisions of the as
0�,, Contractor's Lice (C r9(mmmentlng with Section 70DO)of Dlvl-
30�^ alon3ofthe Buaineas Pro(te Code)orthat hebesemptthendmenand d'E� VALUATION
QUI
the baab for the alleg d emptlon. My violation of Stolon 7Q31S by any En TCDIEstT Fs �"Z f7 OU O
O eppilcant(ora permit aubjr the applicant toadvil penalty of not more than
five hundred dollar(5500). ESIDENIIAL ELECTR
$, SIOWFS TYPE CONSTRUCTION'
❑I,as owner of the property, r my employees with wages their door
compensation,Boschthe workand thyamctureh Contractor or iofferedfar
sale(Sec.7044 Bosomed and Profs®ions code:The Conlractofe License Law
$$ does not apply to an owner ar pmpeny obuikb orimproves tuereon,and OCC.GROUP RES UNITS
eahodoe...chworkhimselforthrwgh hiso employees,provided thatsuch
Improvement....Mlntendedoroffered(w .[(,howevep the building or TOTAL:
Improvement iewid within oneycaro(<ompoelion, towner-buRderwlllhave
trytL�a rde.of proving that he did not build or.lmp for purpoaeofsan'. QTY, PLUMB M FEE FLOOD wNE APN
"L as owner of the property,am exclusively sen ding with licensed PERMIT ISSUANCE
contractors to mmtmn the project(Sec.7044,Busmen an fes 1 Code:
Ile Contnctoe.License law does not apply to an owner property who ALTER-DRAIN&VENT WATER(EA)
builds or Impmees thereon,and who contracts for such p with a FEE SUMMARY
cgtLtTactor(a)licensed pursuant to the Contractor'.Lt so Law. BACK FLAW PROTECT.DEVICE.
LJ I am exempt under See B krenP C for th
rescan DRAINS FLOOR A,ROOF,AREGOND. SANITARY Y_ N_
Owner Date RECEIPT X
rot WORKMAN COMPENSATION DECLARATION FO(Il1RES I'ER.IRAP SCIBOOLTAX Y_ N
RECEI
u1 hereby affirm that I have a nklBcate of.con seed to self-Insure,or a PT X
certificate of Workers Compensation Insurance wa certified copy thereof(Sec. GAS EA.SYSTEM-1 INC.4OUTLETS PAI9K FEE Y N
38 W,Lab C.) RECEIPT X
Policy# G 0 GAS EA.SYSTEM.OVER 4(EA) BUILDING O I VISION FE ES
Co anv i 7 ! /
ErCeklfled copy b hereby furnished. — I GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCertlBed copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAIDA�C'
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA.200DT. Date Recd t
ionneednRb compldcdlfthepen tbforomhundreddollars
(SIW)-or e ! WATER DIFA'TEIt W/VENT/ELECTR ENERGYFEE Y_ N_
Icerti(y that pekormanre olthe work forwMch this penNtatluued,
I shall not employee on In any manner so as to become subject to the WATER SYSTEM/TREATING
Workcra'Compensation L California.Dae PAID
O Z Applicant NEWRESIDENTIALPLMB. QFT. Date Recei t#
Z O NOTICETOAPPLICANT:If,after making that Certificate of Exemyption, ou
shealdbecome.ubjecttothe Worken'Co matlon provblom ofthe Labor TOTAL: _ _
W Code,you moat forthwith comply with auNp Tom or that penNt shall be -BUILDING "E L
W j deemed revoked.
CONSTRUCTION LENDING ACFA SEISMIC FEE a
(L I hereby afflrmthat thereat a mmtructlon lendingagency hepekorm TOTAL ELECTRIC FEE
D Z are a work for whiehthb permit 6 bseed(Sec.3097,Clv.C.
V O Lander'. PLUMBING FEE
LL ~ Lender.Addreas ___ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifytheilhaverea Is application and.tatethatthe above information
atmrrec.lagree to comply with agety and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating tobullding construction,and he authorize repreaentatives ofthb
city toenterupon the aWe'reentlonedp for mapection purposes. ALTQt ORADDTOMECH. Date Receipt#
Z (We)agree to save,Indemnify an d keep har the City of Cupeklna
V against liabilities,jadgmenb,msesandexpenaeawhkh nanywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaiIis Cltyin onsequence of the granting of thl.perm .
6 L AIR HANDLING UNIT(OVER IO,WOC M) CONSTRUCTION TAX
Signs rcnf Applic t/Contractor Da D(IIAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZARDOUS MATERIALS DISCLOSURE
Will the applicant or(utvre building occupant storeorhandle hazardous HEATING UNIT CFO 100,0DO BTU) Date Remi t#
materials.defined by the Cupertino Municipal Code,Chapter 9.12,and the —�'-'�
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL-1755 I(
❑ Yes M No
Wiilthe applicant or future Wilding occupant use refulperent or devices VENTILATION PAN 6INGLE RFSID) ISSUANCE DATE
which emitha=rdom mq air ��aminanas defined by the Bay Area Air gQB-FR-COMP OHP OR I00,000 BTU)
Quality Management District?
�rys�((ffes�
Iles ❑No BOILER-COMP(OVER 1W,OW BTU) ""'ersRrK
4havereaforets HealthallousmaeeSections cnb5533anhapler6.950(
the Cat.redtat fifth b.Safety Code,Sections25505,ve a tenant,that
1
rund osersmndthztn notify
the Ing doesoccupant not a roquirhaves which rustb mat NEW RESIDENTIAL MECH. SQ.IT MAY 9 9 P91
raor to lauarce of aCertcocte of sfpai requlrerrcntawhich must be met 'VI�AI N a7 L
prior to Lnuanre cats Certificate of Oavpanry.
Ow.erorauthoriaedagem Date
TOTAL: I55UHD
OFFICE COPY
I
POST THIS CARD NEAR FRONT OF BUILDING O�
HM1I F N 1 IEI
CITY OF CUPERTINO PKa.se, ,L:
INSPECTION DIVISION
JOB INSPECTION RECORD
P MIT EXPIRATION
JOB ADDRESS_Z✓iV 0 ` �� L�_UNITAt _LOT#k PERMIT EXPIRES IF WORK
OWNER S CONTRACTOR Q IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR I SPECTION RECORD 180 DAYS OF PERMIT ISSU�
FOUNDATION ANCE OR 180 DAYS FROM
NOTE: LAST CALLED INSPECTION.
LIFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PR EGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VAI.NATIUN
CUPERTINO STANDARDS.
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
PLUMBING
UNDERGROUND /SLAB
ELECTRICAL ISSUANCE LATE
MECHANICAL OLUG. I ELECT I PLG. MECII
A El El O
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION (f s)F T.
PLUMBING 22o Q Off
I
T TO
ELECTRICAL T r F M1ll a 1-�
FRAMING' 11 J- I"� J
SLOIIIES 1VPE CONSIR.
INSULATION
UCC GROUP RES TIMIS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
$f),FI.FLOOR fi11fA 1()iAI ACREAt:F
• ROOF NOTE:NO FINAL INSP.SHALL BE MADE BEFORE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID
ROOF SHEATHING Pun.ulrvN USE
RES INU CON Pli (Itlrc,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ' FINALS' DATE INSP. El El � 0 0
ASSESSORS PARCEL NO
ROUGH SAN.N
PLUMBING ELECT.ENERGY
IHACI NO. PARCEL NO
TUBS 8 SHOWER PAN ' PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ACG DATE ACC FILE NO
ELECTRICAL BUILDING ENERGY
FRAMING ELECT,FINAL TEST ZONING ENC SITE NO.
INSULATION PLUMBING
GAS TEST GAS
FIRE SPRINK ENERGY LpE
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ❑ NE] v ❑ N�
EXTERIOR SHEAR ELECTRICAL RELEASE I,FOOD ZONE A.1.uc
INTERIOR SHEAR FIRE DEPT. °❑ N� ❑ N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
BUILDING
INTERIOR LATH TEMPORARY APPROVALS
SCRATCH COATELECTRIC PLAN CHECK
FEE C>
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING ISNOTPERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
`• ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING Q
OPLEAS
� E GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT! CONST. TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
APPLICANTS POSTING COPY