27731 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 111,ms.NG-erec1711CM" PBRM'TND'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n �JQ1
BUILDING PROJEI%TIDENTIFICATION G r J 1
B .DING ADDRESS: /�� � ,I // �/d t� SANITARY NO. APPLICATION SUBMfITAL DATE.
mss/s/f//�7PA ,f ✓J�5/01— G' UNIT#�1 /7 LOT# /�21 L�4-q�
O�vaSNAME:e� J 44,u PAU[�ONE: C /'#OL(JACCf' C-OUST LOLL V_YS43 NIC CONTROI.p
ARCIIITRCT/ENGINEER: DRESS: PS1oTT[Z2 6 �LcA so37L65 ❑
%RITACD PHONE:
rI /�/� 1' Q, _ QTY. ELECTRIC PERMIT IEC BUILDING PERMIT INFO
ads 1XIf D4yIS �� /�S�Oz� ELECT PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL TOB DESCRIPTION LTJ
❑Wz Ihereby affirm that l ant licensed underproamourrsof Chapmr9(commencing with
[900 Section 7000)of Division 3 of the Business and Professions Code,and my]let.is in PANELS
' dE toll l ince and effect. f-
rnZW License Class `'/ ConlnctT�J J s UP TO 200 AMPS
DutF y Z ARCHITECT'S DECLARATION 201 1000 AMPS SQ.Ff.FLOOR AREA 5/SQ.FT.
02�❑ I unwound my plans shall be used or public records. OVER I000 AMPS
stn W SIGNS ELECTRICAL
<y Licensed Professional
�yW< OWNFR-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
xdOyF 1 hereby uffimt than I am exempt from Nnn
e Coamola License Law Law far the
Wit+-y followingrencon.(Section 7031.5,Easiness and Pmfnsions Code:Any city of county TEMP.METER OR POLE INST.
17l1l NO; which requires a permit to construct.alter,improve,demolish,of repair any stmctu e
Priormitsissuance,alsorequirestheapplicantforsuchpemuttofileasignedswwment POWER DEVICES
Bull 00 that he is licenced pursuant to the provisions of the Commnots Licmx Lew(Chapter
a 9 with Section 7fgl(I SWIMMING POOL ELECTRIC
e (commencingwi )he Division 3.fthe Profusions Code) VALUATION
Sectioor that 7031, by my refrom and the Permit
for subjects
the
exemption.Any violation of
FZQ am mor,
by hundred
licant forSSUE),tmbjecm the applicant tact civil Pendry of OUTLETS-SWITCHES-FIXTURPS
$,S not mortthm fivevfthe preddollormyarn). NEW RUIDUMALELECR —SQ.W � ❑ oche wrk,an theotraclure orm otlamoyedornfwagesasthe(Sole compemmion, Q STORIES 'TYPE.CONSTRUCTION
L will do the Co rhesuu Courrsnots License
Law
eoes not apply
to an volor of
ss
and Profucioln Code:The w.ttheree a License Law dans not apply lf m nwntt M
ownenywyersho ,pdvidedtroveathertan,andwhodoasuchwoodoruferedthrough Nc OCC.GROUP EA
howemployes,p orimprovement
prove ant is semcrosarcne earoemopleered far sowbml - _
huwevcgillhathe building teburden
of proving
that
he withiniot build or improve
omm efor the owner- 'TOTAL: I �• _s
builder will have the burden of proving than he did not build or improve for purpds.of
❑ I,aaownerofthepmpeny,ameaclusivelyconimctingw lh.icensedumwcton to QTY' PLUMNING PI TIT FEE FLOODZONB rcnnstruo the
project(Sec.7fW4,Business add Profession.Cow:)The Cmit.Lor's License Law does not apply te an owner of property who builds of improves thereon,andwhanmvacufmsuchprojccmwiNaamwactoKs)licenaedpursumrto the this is v Pasroehee com le 11
License Law, � AL FEE SU MARY
❑ I am exempt under Sec. .B&P C for this
awn BA
r Ownera ce YEN_
Owner Dam RE E;ivr#
WORKMAN COMP17NSATION DECLARATION DR LTA, Y.y�.N
❑ l herehyaffmn that l have a cenifcate ofconsem to self-insure,or a cenificvtem' FI RE LC tIPI'#
Worker(Compensation lnaurpnce Urn certified copy thereof(Sec.3g011,Lob CJ which PARK FEE Y I N
overs WI employee's under this permit. GA RECBIPf#
Policy# BUILDING D ISION FEES
Com❑ Certified copy is wo,by famished, OA ) PLANCHECK FEE j
❑ Ceniried copy is Bled with the city inspmsion division. GREASE/INDUS'TRE,WASTE?INTERCEPTOR GRADING FEE Ji
Ji
CERTIFICATE OF EXEMPTION FROM WORKERS' SOILS FEE 0
COMPENSATION INSURANCE
(This section need nor becompleted ifthe permit is fur one hundred doi.am(11a0) SEWI?R-SANITARY- 0 .200F1'. ENERGY FEE
or leas. ��gk '
I certify that in the performance of the work for which Nis permitis issued,. hall W gy �'
not employ any person In my manner so u m become mbjat m Ne Wap p p
O .Z Cpppmlpoanmmn L.uwsof Celifomie. Date 11 WATER SYSTEM/ITiFATINO Data R ptq
t a—
z CE NOTICE TO APPLICANT.If.aflermaking this Cani6cale of6xemption, mr,lulld NE TOTAL:
I-+ fA became subject u the Worker's Compensation proahmm of the labor Code,you must
�i forthwith comply with such provisions or this permit shall be dcemcd revoked. BUILDING IRE
0. Q CONSTRUCTION LENDING AGENCY a # gEISMICPL'L
a z Iherebyaffirridnaahertisacomwetionleadingagencyfmtheperfmmenceaf TOTAL: ELECTRIC FEE
(, OF�+ rhe work for which this permit is issued(Sec.3097,Civ.CJ
r. Lendcra Name
C) Under'a Address QTY. MECIIANICALPHRMIT FEE PLUMBING FEE
U 1 certify that 1 have mad this application and state that Ne above information is
r1^ 93. correct.l agree to comply with all city and rounytoninances and state laws minting to PERMIT ISSUANCE MECHANICAL ME
U) buRdingconsvuction,and hereby authorize mpoesensasivesof Nis city in enter upon she CONSTRUCTION TAX
U 4 above-mentioned property for inspection purposes. ALTER OR ADD TO MECII.
(We)ogres m save,indemnify and keep harmless dm City of Cupertino against
liibildea,judgmenrs.co I index n swhich mayinany way..a against said City AIN IIANDLING UNIT(TO 10,(#10 CFM)
in co ce of she gmming is permit.
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contimlor Data EXHAUST HOOD(W/DUCD
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Data Receipt#
W 01 rhe applivem or future building accupam mum or Woo le hazardous mmeriul
m defined by rhe Cupertino Municipal Code,Chaprnr 9.12,and the Health end Safety HEATING UNIT(OVER 100,000 BTU) TOTAL:
Cale,Section 25332(a)?
El Ycs ❑No VENTILATION FAN(SINGLE RESID)
00ILIiR-COMP(711P OR IfNI,(Ig0 BID) ISSUANCE DATE
Ift Will dmapplicmmrfmumbuildingmcupanr use equipmealmdeviceswbieh emit li'9 p 0
hamNon air comaminan%as defined by the Bay Amo Air Quality Munaggmcna BOILER-COMP(OVER 1110,0110 ETU) I f I IW
nindct?
❑Ycs ❑No NEW RESIDENTIAL.MECII, SQ.FT.
I have read the hazardous material'requimmems under Chapter 6.95 of rhe tt�V
Calimmia Health&Safety Code,Sections 25505,25533 and 25534. L undersand that
if the huilJing Aoca not cuncnrly haveumnant.thvt it is my respnmibilirymnntify the co ser L;Ueizf�
eapnnt of rbc requirements which most be met prier rn issuance of v Certificate of V
nerorOccupancy, V CA • 1
Owner or vmhnriud agent Dam TOTAL: ISSUED BY:
OFFICE
� .ilUi�S rettrl!I 1PIJY[611Ute RLIlY11Y ;111( YGitNII 3 [/75t rase 1
• 10485 MIRA VISTA
6
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, DATE DONE TYPE OF INSPECTION Insoecter Code PASS/FAIL CONVENT
1 --------- ------------------ ---------- --------- ---- ----------- -----------------------------------
5 INSPECTION CATEGORY "
6 GARAGE SLAB JB H
7 ,� 9
H
e ,PIER HOLES JB T
9 2/01/95 UNDERFLOOR FRAME JJ P
UNUENFLUtnECH- "TJF
11 2/01/95 UNDERFLOOR PLMBG JJ P
2
13
4 12/28/94 PIER HOLES (LO) JV P
15 ![IS/95 'PIERS (10:00 - CC) CC P
6
. 11 INSPECTION CATEGORY 102
le 1/10/95 TIE DOWNS 110:00-CC-) CC P
19. 1
71 INSPECTION-CATEGORY 401
3: 2 4 TEVPOR'ARY P041tR "`— C
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PEKM:I ACT!VITY FO;-PERMIT # 2?731
10485 MIRA VISTA
6
2
DATE.DONE TYPE OF !,','SPECTION Lqsoector Ccde PASS/FAIL COMMENT
---------- ----------- ---
4 ---------- ----------- ---- -------
INSPECTION CATEGORY
6, SARAGE SLAB JS H
2
—1OT/95—GARAGESM
7 7
PIER HOLES JD I
2/01195 UNDERFLOOR FRAME
JJ P
to I195—[R7DER"r
[OOR-P.ECH—JJ—P
it �12/01 1?5 UNDERFLOOR PLMBC jj P
12
33 INSPECTION-CATEGORY-101
14 12,126/94 PIER HOLES (LO) jv P
is 1AIS/95 PIERS (10:00 - CC) CC P
INSPECTION CATEGORY 102
1110/95 TIE DOWNS (10:00-CC-) CC P
--------VER
1211-8794 v
p
p l4
INSPECTION
CATEGORY 401
I V 1'4/94—TEMPORARY-POWER—CC—P
23
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37
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41
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