25711APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINOT71LlI1NT.�F.IEC1'Rrf:A • FERMI rNO.
APPLICATION/PERMIT PLUMBING—MECHANIC I. 25711 � � el
1
BUILDING DIVISION BUILDING PROJECT IDEN'rIF'ICATION J
BUILDINGADDRESB: SANITARY NO. APPLICATIONSUBMMALDATE
VGX!S / I s, W Vs . UNIT# �LOT# 11
OWNERS NAML PIfONE: rRACI'OR'SNAME: LIC NO:
Viva- 4//6 / 9SW -c Pcz- 3 5NIC L 07 CONfRO1.M
\RCHITFCT(ENGINEER: LIC NO: DDR S: 0 w. ❑
nJ Zz aYv5 g� FaL « 9srl
CONTAc3': y pf'.Ahl�a ({ 4 6UILDING PERMIT INFO
i g Q TY. ELECTRIC PERMIT FEE
LICENSED CONTRACTOR'S DECLARATION
OyZ I hereby affrn that l am licensed underprevisionsofampters)bonmencingwith
4100 Section 7M))of Division 3 of the Businessand Professions Code, and my license is in
FFgrI1+C fall tome andd L, /v
FZW Licc C Lis,.# T / 3To7
rn<c. 13 Conlmr =—
O�'L ARCHITECTS DECLARATION
Z _ n 1 understand my plans shall be used as public records.
J
�.J
Licensed Professional
0 WIJ OWNER -BUILDER DECLARATION
06U 1 hereby ulllw that 1 am exempt from the Contractors License 1<w for the
��y followingrcmna(Section 7031.5. Business and Professions Code: Any city orcounry
which refures a permit to convect, alter, improve, demolish, or repair any swnure
YF ptiom iuissuunce.almnecuiextheapplicant forsuch pemtitmfileasigwd saterem
04<
O that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
9(commencing with Section 7")of Division 3 ofthe Business and Professions Code)
unbar be is exempt deacon. and the busisfor the alleged exemption. Any volution of
tZy Section 7031.5 by any applicant lot a permit subjects the applicant loacivil penalty of
CQ a more than five hundred dollam(S5W).
m n❑ Lazownero❑M1epmpcny.ormYemployees widewegesmthcirsolwompeneuon.
y3_ will doth, work, and the structure is not intended or offered for sde(Scc. 7034. Business
and Professions Cede: The Convenors License Law does not apply ro an owner of
property who builds or improvesdeewon, and who does such work himselfor through his
employees provided that such Improvements ave not intended or oRered forsaIts If,
huweveq the huddingor improveme it is sold within one year ef completion, the Owner -
builder will have the burden of proving that he did not build Or improve for purpose of
sale.).
❑ I, as owner ofthe progeny am exclusively convecting with licensed conwaorem
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
License Law does not apply to an owner of property who builds., ire pros. thereon, and
who contracts formom
such projects with a conaor(s) licensed purmanumine Contractor's
License Low.
❑ 1 am exempt under Sec. . B & P C for this reason
WORKMAN COMPENSATION DECLARATION
EII hereby dfrm that l have a cenificxm of consent to self -insure. or a certificate of
Worker: Compensation Insurance or a candied copy therod(Sac. 38W. Lab C.) which
I h
all employees under this permit.
Policy 4
nifed copy is hereby famished.
Certified copy is filed wide the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Lfbis seclion need not bewmpleted ifthe permit is for one hundred dollars ($10u)
or less.)
I candy that in Ne perm.re of the work for which this pewit is issued, ) shall
non employ any person in any manner so . to become subject to th< Weakens
Compenmtion Lawsof California. Dam
Applicant
O 0 NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
F)become subjectto the Workers Compensation provisions of the Labor Code, you must
�> forthwith comply with such provisions to this permit shall bme deeed revoked.
0. (] CONSTRUCr10N LENDING AGENCY
U Z I hereby affiw that there is a convection lending agency for the pedortnmme of
U O the work for which this Wool is issued (See. 3097. Civ. C.)
Leader's Name
u" F' Leader's Address
U U 1 certify that 1 have read this application and state than the above information is
correct, l agree to comply with all city and county ordinances and slow laws mlaling to
f^ � building<omwaion, and hcmhy audeorixc apnsrntetive.wfthie city reenter upon tM1e
U Z above-mcmiorted propenY for inspection Puryoses.
(We) agree to save, indcmady and kap harmless the City of Cupertino again
liabilities,judgments,costsandexpenca wh¢ hmay inanywirysceneagainstsaid City
to conse9ugce f the grunting of this pprph.
1 -a
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous material
as defined by the Cupenino Municipal Cods, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)'l
❑ Yes ❑ No
I
Will theapplicanturfuumbuildingoccup cut useequipmentordevices whichemit
�harnmem dr connivers as defined by clic Bay Arent Air Qudity Managemem
District?
❑ Yes ❑ No
r I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilcultb & Safety Cede, Sections 25505, 25533 and 25534. 1 understand dem
if be building does not currently have a armed, do, it is my nesponsibllity to notify the
occupant of the requirements which must be met prior to ixsuanre of a Cmifrtac of
Occupancy.
Owner or authorized agent Date
PERMIT ISSUANCE
APPLIANCES - RESIDENr1AL
PANELS
UP TO2W AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
UTLETS - SWITCHES - FIXTURES
NEW RESIDENTIALELECIR SQ. FT.
PLUMBING PERMIT
PERMIT ISSUANCE
ALTER -DRAIN & VENT- WATER (EA)
BACK FLOW PROTI?CT. DEVICE
DRAINS - FLOOR, ROOP, AREA, COND.
FIXTURES - PER TRAP
GAS - EA. SYSTEM -1 INC. 4 OUTLETS
GAS - PA. SYSTEM-OVIiR4(EA)
GREASFJINDUSTRL WASTE INTERCEPTOR
GREASETRAP
SEWER - SANVEARY-0 f1RM EA.2IXIFC_
WATER SYSTEM)TREATING
NEW RESIDENTIAL PWB. SQ. FT.
MECHANICAL. PERMIT
PERMIT ISSUANCE S
ALTER OR ADD TO MECH.
AIR IIANDLING UNIT (TO I),oW CFM)
AIR HANDLING UNIT (OVER 10,0110 CPM)
EXHAUST HOOD(WIDUCI)
HEATING UNIT (TO 100,000 BTU) 19
HEATING UNIT (OVER IM." BTU)
V EN'I'ILATION PAN (SINGLE RFSID)
BOILER - COMP (31IP OR 1W,000 BTU)
BOILER - COMP (OVER I Ilf" BTU)
NEW RESIDENTIAL MECH. SQ. FT,
FEE
FEE
U-4 G►511LIS
fu utITD�
SQ. 19'. FLOOR AREA SISQ. FT.
1
FEE SUMMARY
ME
PAID
Date Receipt If
TOTAL:
BUILDING PCI:
SEISMIC PEE
ELECTRIC FEE
PLUMBING FEB
MECHANICAL ITE
CONSTRUCTION TAX
PAID
Date
PA 1 1)
DEC -2 1993 21993
01 y 1',_.
ISSUED BY:
0
6
12/iblY4
PE N77N5PECTION`ACTIVTTY"FOrPERMIl
1"25711 aa?
10655 MARY AVENUE
DATE DONE
TYPE OF INSPECTION
Inseector
Cade PASS/FAIL COMMENT
----------
INSPECTION
------------------------------
CATEGORY
----------
--------------- -------------------
F BLDG
INSPECTION
CATEGORY 304
12/17/93
ELECT -R
JV
P
INSPECTION
CATEGORY 305
1210B/93
FRAME
JB
0 UNABLE TO LOCATE
�
JV
12/OB/93
INSUL
JB
0 UNABLE TO LOCATE
INSFtUll N LAI L R7-706
12/09/93
INSULATION
JV
P
INSPECTION
12109/93
CATEGORY 311
SHEETROCK '
JV
P
N'CATEGORY—'`U
12!22193
FINAL ENERGY
JJ
INSPECTION
9
12122193,
FINAL PLBG
JJ
INSFLLHUN
CATEGOR u,
12/22/93
FINAL MECH
JJ
f
12/22/93„,=
FINAL ELECT
JJ
P
N'CATEGORF-5
.
12/22/93
FINAL BLDG
JJ
F
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