24113APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Navildin Pro'ed Identification
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PERMITNO.
24113
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A
Z
ontnctor. N. me: Lit. No:
—
BUILDINGELFCTRICAlePLUMBINGMECI IAMCAL
CATEGORY
CONTROL N
rchltect/Engineer. Lie. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
_
PERMITISSUANCE
54 ❑
Imo{
Address:
LICENSED CONTRd BDECLARATION
under
Iheh Sxdtoirmshatlam BernardunderBusiessan Profit apler9(e,and c
1nersin Sed1ullfor )of DiWpon3 ofthe Busineuand Pro(CsponaCode, and my
Ilanse is In fuI fora and
APPIlANCESRESIDENT1Al
JOB DF�IiB N� �
Lnl W
PANES
License Clam Uc.N
It. Is
Date Contractor
ARCHITECTSDECLARATION
I understand my pisco ahold be used ail public recmrds
D V _
00 AiMPS
OVEROVER 1000AM00 AMPS
.FLOOR AREA
5/SQ. FC.
SIGNS ELECTRICAL
Licensed Professional
OWNERDECLARATION
BUILDER DECLARATION
I hereby affirm that I am exempt from the LContractor. License Law for the
following rcason.(Semon 7W1$BmIneu and Profeselons Code: Mydty Or
county which requlrenm
a permit torstruct, slid, Improve, demolish, orrepair
any structure prior to its Issuance,alwrequimtheappllant forsuch permit to
file a signed statement that he it Bernard pursuant to the provisions of the
SPECIAL CIRCUIT/M15C
ff
" �(--
'
([[[ff%}%���aa
�
�
�
r1
TEMP METER OR POLE INST.
POWER DEVICES
SWNSMING POOL ELECTRIC
Contractors License Law (Chapter 9(commencing with Sodlon 7000)of Divi-
slon3ofthe Bun mand ProfeaimmCWe)orthathebexempttherefromand
VALUATION
the basis for the alleged exemption. Any violation of Section 70713 by any
applimnt fora permit subj,d. the applcant to a evil penalty of nal momtMn
OUTLETSSSWITCHESFIXTURES
Xfi a undreddollan($500).
I, as owner of the property, or my employees with wages as their sole
NEWRESIDENTIALEL SQ.FT.
ES
STORIES
TYPECONSHUCTION
m satlon, will do the work and the structure is not Intended or offered for
idle (Sec. 7046, Business and Profcnbm Code: The Contractors License Law
ee
does not apply to an owner of property who builds or improves thereon and
who does suchwork himself or through his own employees, provided that such
OCC.GROUP
RFS. UNITS
Improvements am not Intended or offered for sale. If, however, the building or
TOTAL:
Improvement Issold withinoneyearofcompletiogtheowner-W fiderwill have
trysjnIden of proving that he did not build or improve for purpose of sale.).
LJ 4 as owner of the property, am exclusively commeling with licensed
contractors to crostruct the project (Sec. 7044, Business and Professions Code; Code:
QTY. PLUM GPE 1
FLOOD ZONE
APN
ppgM1T ISSUANCE
The Contractor's License law dues not apply to an owner of pmperty who
Wilds or improves thereon, and who contracts for such pioJects with a
do a) Bmnse.d pursuant to the Contractor. License Law.
I am exempt under Sec. B h P C for this reason
ALTER -DRAIN kVENT - WA
FEE SUMMARY
BACK FLAW PROTECT. DiQ46E•
OUTSIDE IT I'S
DRAINS. FLOOR ROD D.
SANITARYY N_
REC13FT N
ne Date
WORKM COMPENSATION DECLARATI
❑I hereby affirm that I have a certificate of consent to self-Insum, a a
WxrtlficateofWorlaos Compensatlonlnsurance oracertifled mpythereof(Sec.
lab C.) _
Oc
pD(TURpS PER TRAP
SCHOOL TAX Y_ N_
RECEIIaf N
GAS EA. SYSTEM -1 INC.60IJILET
PARK FLE Y N
RECEIPT M
Policy p
cram any
EA. SYSTEM -OVER 6 A)
GAS (E
BUILDING DIVISION FEES
[PCertNed mpybhereby furnished.
❑ Certified copy is filed with the city Inspection division./��J
GREASE/INDUSIRLWASIEITOR
NIFRCEP
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEM PTION FROM WOR KERS'
PIZ
�s{—
COMPENSATION INSURANCE
for hundred dollars
(This section need not he completed if the permit con
SEWER-SANITARYSTORMEA. 200FT.
Date RCCCI t#
WATER I-�.ATFR w/VENT/ELFJCTR
ENERGY FEE Y_ N_
(9100)or les)
1 certify that In the performance of the work for which this permit Is Issued,
WATER SYSTEM/TREATING
1 shall not employ an person In an rmnner so m been �uIft to the
Woplican o n> rng Date 6
PAID
Applicant iT
D0[C RCCeI t#
NEW RGADCNTIAL PLMB.SQ.FT.
NOTICETO ICANT:ILa after makingthin Ceeffira ,you
should become subject to the Workers' Compensation provisions of the Labor
Code, you most forthwith comply with inch provisions or this points shall W
deemed invoked.
CONSTRUCTION LENDING AGENCY
TOTAL:
BUILDING FEE
OQ
SEISMIC FEB
TOTAL:
ELECTRIC FEE
I hereby affirm that thea h a edmmudlon lendingagencyforthe perform
Vsu
ance of the work for which thin permit teed (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address -
1 certlly that 1 have mad t isapplotlonand pate thattheabove Information
Iscomed. l agreetocomplywith allcityand cesuntyordlnanmsand pate lawn
PLUMBING FEB
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relining to building construction, and hereby authoKze representatives of this
dtyto enterupon the above-mentioned property for Inspection purposes.
Me) agree to save, indemnify an d keep harmium the City of Cupertino
agaWtlhbifides, pdgments,cutsand expenseswhlch mayln anywayacaue
ALTFJLORADDTOMECH.
Date Rixeipt#
AIR HANDLING UNIT (TO 10,WO CFM)
SUBTOTAL:
againdmid City In mm dna of the granting of this permit.
MR HANDLING UNIT(OVER 10,0130C III
CONSTRUCTION TAX
��
tum of Applicant/Contrador Date
IXHAUS'[IIOOD(W/Dl1CT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
IMATING UNIT(TO 100,ODO BTU)
Date Recei t#
Will the applicant orfusum building occupant store or handle hazardous
material as defined by she Cupertino Municipal Code, Chapter 9.1; and the
Ifealthand Safety Cod cion 25532(a)i
HEATING UNIT(OVER 100,000 BTU)
TOTAL:
-�
❑ Ye �No
Will she applicant or futurebullding ocevpant use equipment or devices
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
which emit hararlous air contaminants as defined by the Bay Area Air
a lity Ma rmgement a7
pp
P PA
BOILER COMP DIM OR 100,0(00 BTU)
Yea No
Thav ,eadthebaz ousnuteriabrequlmmentsunder Chapter6.95of
California llealth&Safety Code, Sections 25505,25533 and 25534. 1
nderstandthatifthe Wildingdoesnotorrrentlyhaveatenantthatitumy
%u 17 iO09
AUGe
u '992
BOILER-COMP(OVER 100,000 BTU)
NEWRESIDENTIALMECH. SQ.Ff
respomibIB y to notify she occupant mf the requirements which at be met
priors use enlace Tic o(Occupanry.
/6-gz
Lq�
C1 I I,I L'fllllvlJ
ISSUEDBY:A-
Ow cr rauthon agent Date
TOTAL:
OFFICE COPY
A/c
C
NO. STREETLOT NO.
DATE / d1'3 Z 19 FILE NO,
CITY OF CUPERTINO T�dBa:i=�� LYcrl?yS
OWNER �- RECORD OFINSPECTION
APPROVAL�-IJ
64X6:O-v(NS(�-
l- v -Nr Acca 1)
PROJECT x0o/ jl Un1 y j\90 P-1, /J C-,7
c L TELEPHONE: 252-4505
0
ELECTRICAL INSPECTION RECORD
RESIDENTIAL I DATE I [INSPECTOR I COM Ek;'W DATR I INSPECTOR
FINISH WIRING FINISH WIRING
FIXTURES INTERIOR FIXTURES
MOTORS EXTERIOR FIXTURES.
FINAL MOTORS _
FINAL
PLUMBING INSPECTION RECORD HEATING & A/C INSPECTION RECORD
DATE INSPECTOR I DATE I INSPECTOR
FLOW REQUIRED
FLOW INSTALLED
UNDERGROUND ROUGH I IFLUES & COMB. AIR
PARTIAL ROUGH CONDENSATE DRAINS
ROUGH COMPLETE FINAL APPLIANCE
ROOF DRAIN & LEADERS
MAIN DRAIN
FINAL
NOTE: INSPECTOR MUST BE GIVEN 24 HOURS NOTICE FO PECTION.
CHI. BUILDING INSPECTOR
NO. STREET .� LOT NO.
I DATE .2J 19 f FILE NO.
CITY OF CUPERTINO
� _ / RECORD OF INSPECTION APPROVALS
w *y JOB COPY ,
PKOJEC'
TELEPHONE: 2524505
i
FOUNDATION
_C�
PRE-GUNITE
BOND BEAMS
UNDER -FLOOR
TIEDOWNS
DIAPHRAMS
BUI
FLOOR STEEL
FRA AE
LATH {';i✓AI'''"Vt'
WALLBOARDS - INT. & EXT.
FIREWALLS
LANDSCAPING '7
ELECTRICAL INSPECTION RECORD
DATE
RESIDENTIAL / DATE I INSPECT R COMMERCIAL /AE INSPECTOR
'i
UNDERGROUND ROUGH ( UNDERGROUND ROUGH i' I
ROUGH WIRING --7, 17 [ 6 ROUGH WIRING ! T
FINISH WIRING FINISH WIRING
FIXTURES INTERIOR FI URES
MOTORS EXTERIO IXTURES
FINAL MOTqRS
PLUMBING INSPECTION RECORD
DATE
BACK FLOW REQUIRED _
BACK FLOW INSTALLED
UNDERGROUNDROUGH ?
PARTIAL ROUGH p
ROUGH COMPLETE
ROOF.DRAIN 8 LEADERS
MAIN DRAIN
FINAL GAS
FINAL PLUMBING
HEATING 8 A/C INSPECTION RECORD
INSPECTOR DATE INSPECTOR
UNDERFLOORS M.
_ DUCTS 81NSULATION _
FLUES 8 COMB. AIR
CONDENSATE DRAINS I.
FINAL APPLIANCE
xonnc eumxcss ronrnsivc.0 / � � � a r
NOTE: INSPECTOR MUST BE GIVEN 24
n
DURS ^:: i; FOR INSPECT:,D. I. I
CHIEF BUILDING INSPECTOR
I