30826APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
, PERMITNO.
DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
30826BUILDING
11 W 1A1NG PROJFQI' IDKNTIFICATION
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
Ail b U04CVyX\OeX
OW 'S NAME1'IIONE:
C NTRACTOR'SNAMH: LIC NO:
NIC
EJr
CON'1ROL p
-t S
frHCHITECT INHEH: LIC NO:
DRESS:
c W&tK Q . LU-, 0.CONTACT:
PHONE:
t
BUILDING PERMIT INFO
%S1 J -1 4 ^'O lO
l
E3 Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICHNSED CON'TRACTOR'S DECIARA'I'[ON
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PER FEE
JOB DESCRIPTION
with Section 90110) of Division 3 ofthe Business and Professions Code. and my license is
in full fume an R /. c L+i�e/
Licen. lass Lie.» Y91V -�F�
Date—Conuac C 'rte
SFDWL ❑ KITCHEN REMODEL
ADDITION El PLUMBING RF. -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
pERMIT'ISSUANCEDENTIAL
APPLIANCES -RESIDENTIAL
ARCHlm vise DECLARATION
1 understand my plans shall M uxJ us public rea+Ns
PANELS
UPTO200AMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT
Licensed Professional
201-10s)AMPS
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contmaors License Law for the
following reason. (Section 711315. Business and Professions Code: Any city or county
❑BATH REMODIi1JREPAIR El DEMOLITION
[]OTHER
OVER IU(XIAMI'S
SIGNS ELECTRICAL
which requires a permit to censtmct, aIle, improve, demolish, m repair, any swcmrc
SPECIAL CIRCUITMISC.
prior to it%issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant o the Provisions ofthe Commodes License Law (Chapter 9
TEMP. METER OR POLE INST
COMMERCIAL:
(commencing with Section WXp) of Division 3 ofthe Business and Profession. Code)or
that he is exempt therefom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
I, as owner of the pn+peny. nr nmy employees with wages ax their sole a+mgcns:nion.
will do the work, and the souaued is not intended ormffercd for sale (Sec. 109. Business
❑TENANT [I FOOD SERVICE
IMPROVEMENT
[]OTHER
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
and Professions Code: The Commenr'a License Law does oat apply man owner of
propcny who builds or imposes thereon, and who does such work himself or through
his own employees, povidrd that such improvements am not intended or offered for
sale. If, however, the building or improvement is sold within one yemoflompletion,the
NEW RESIDENTIAL ELECTRi SQ FT.
SQ. .FI: RARER
SISQ. FT.
ownerbuilder will have the huNen of proving that he did not build or improve for pur-
pose Uf sale.).
❑1.min, owner of the potimty. am exclusively canneaing with licensed cnntrenomm
O s DECII
r�A�p (d RECII
TOTAL:
stmm the project (Sec. 9(94, Bosoms, and Professions Cade,) The Commeon s Li -
van Laos doesnotapply munow nor ofp,.,nyishohiildsoriape,...thermal, and
NU
QTY. PLUMBING PERMIT FEL'b,
who contracts mrsuch projects with a comrnemru) seemed pursuant to the Contractors
/s'TV U� �a
t
PERMIT ISSUANCE
License Law.
lam exempt under See.' . B & P C fonhis maven
V 1
Owner Date
ALTER -DRAIN&VENT-WATE I
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEV E
I hereby affmmm under penalty of perjury one ofthe following declarations:
DRAINS- FLOOR, ROOF. AREA. C N
ve and will maintain a Certificate of Consent to self-insnm for W'orker's Compcn-
us provided IbT by Section 3700 of the LuterCode for the pmfmma—, o1'tbe
STORIES
TYP[C(INSTRIICT]ON
work or which this permit In issued,
FIXTURES - PERT RAP
C] 1 have and will moinmin Worker's Comgensdion Imuronce, ao required by Section
37M ofthe labor Code. l in the Performance ofthe work for which this permit is issued
GAS -EA.SYSTEM-I INC.4 OUTLET'S
OCC. GROUP
plied
MyW 'S Cgmpcnsmion Insurance carter and Policy X%2r �i�6 �C) /
Carrier `(> Policy No.: 2CU
GAS - EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASFANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION RIES
(this section need not hcomplemdif the Permit is femme hundred dollars ($ 100)
nr bass.)
CREASE TRAP
1'LANCHECK FE13
SEWER -SANITARY- STORM HA. 200 FI'.
I sen By that in the pdrhanmauccofthe work for which this permed.is.wed, l shall
not employ any person In any manner ro as m been, mg�uYjm node Workers' Cooper.
ENERGY FEE
WATER HEATER WNENT/ELECfR
'min. Lows of Califoola. )aid /
Applicant
GRADING FEE
NOTICE TO APPLICANT: Iffier making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
WATER SYSTFMTREATING
SOILS FEE
forthwith comply with such provisions or this permit shall he deemed revoked.
WATER SERVICE?
CONST' RUCTION LENDINgp�
I hereby affirm that there i. a on ,Wearn Ing uyvncy for the perfonn:mm of
NEW RESIDENTIAL PLMB. SQ, FT.
PAID
Doc Receipt
the work for which this permit is isac cc 30)7, Cia C.)
Lender's Name
TOTAL:
Lender's Address
'TOTAL:
BUILDING FEE
1 certify that 1 have read this application and state that the above infor cram is
QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
comet l agree to comply with all city and county ordinances and state laws miming to
building consuuction, and hereby authorize reprcsematives of this city to enter upon the
PERMIT ISSUANCE.
ELECTRIC FEE
above-mentioned progeny for inspection Purposes.
(We) agree u+save, indemnify and keep homeless the City of Coulon. against
ALTER OR ADD TO MECH.
PLUMBING FEL'
Iiahilities.judgences, costs and expenses which may in any way accord against said City
tscquencoof the granting of fus Admen.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL PEI: 15-
APPLICANT UNDERSTANDS AND WILL COMPLY WITH.L NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
I is V
SigifinufftoofAp ani1cmdocmr Da
HAIFARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stem or handle hamrdoun material
EXHAUST HIXYD(W/DUCq
HOUSING MITIGATION FIE
HEATING UNIT (TO 100A00 BTU)
as defined by the C.Nmrm Municipal Cale, Chapter 9,12, middle Health and Safety
Code, Section 25532(x)7
HEATING UNIT (OVER 100,00 BTU)
El Yes
lWill the applicant or future building occupant use equipment w devices which
N hazardous air conumiwms as defined by the Bay Area Air Quality Management
ioriki!
❑Yes ff&n
IA1U Date Receiptb
VENTILAT'I(IN PAN (SINGLE RES I D)
BOILER - COMP (3HP OR 100,000 BTU)
TOTAL:
BOILER - COMP(OVER 100,0IX1 BTU)
AIR CONDITIONER
I have rend the hazardaux materials requirements under Chapter 6.95 of the Cali.
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ, FT.
Rsmia Health & Safety Lode, Sections 25505, 25533 and 25534. 1 understand that if the
building does not cummulyIm:n' a tenure, Nat n is my de"anobildy m ratify the oem"an,
mf0 irc
uments which mus he sect prior to issuance oft Ccnific roof Oc u ancy.
'
ISSUED BY:
Owner or auffirany agent
I [Are
OFFICE
,c
CITY Or CUFRRrtivo I
funimoo olv moN
''' � I � �M ii�%'.'/�A iri.� l/� .' ,..NU •.n....• .... •: . . . �ySif
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WN
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POUNDwnoN/p�Rs/H.D.s.
C Ca ula lFa Pad b, AppUl ,(IdJal) _r:�i
.I
88.T.1!'�ROo�O •^ taga
0 4 rR ❑
INSPECTION RECORD ''
NOTE: ALL GRADING AND DRAINAGE
SHALL BE INSTALLED TO COMPLY WITH
THE APPROVED PLANS AND CIT'Y'OP
CUPERTINO STANDARDS. '•G!
TO ARRANGE INSPECTION
CALL AFTERNOONS (12330 PM - 1:00P
777- 3229 MONDAY TO FRIDAY 24 HOU RS,
FORE REQUUMO INSPECTION. JOB ADDR `'
AND PERMIT K ARE NEEDED WHEN PHONING.
UFER GROUND
JOB DESCRIPTION
❑SVD 0WORN RP]Ntl
OA =M. ''OP4U masa-a
❑umnlim` OeT►IR.TVRAI.
MaDWrArW
Oe+DaaR 0amaerRam
D4PRDv9bmr
��� O ll
,
PAD/SET BACK -CERT
GARAGE SLABSNREGUMTE
POURgo
UNDERGROUND/SLAB
PLUMBING
ELECTRICAL
.., I:NT
PLUMBING
•
ATTENTION CONTRACTORS: /
NOPERSON(S)SHALL PERFORM WORK ON,
THIS JOB SITE WITHOUT BEING IN COM-
PLIANCE WITH WORkW'COMPENSATIONFUMING
INSURANCE REQUIREMENTS. -
,�RCfAW..
�pNeW elmaDwDDMC 1t ❑p@IgJi1Q1
,j3nwANr :• 7 [ mmmmm
01 � ..,r,' '
:.:.
MECHANICAL
ELECTRICAL
VENTS
';,rr .' :;- :::•r
INSULATION..
KAWW
ROOF SHEATWDIAPHRAM ,.
-
INSPECTION £CIAL INSPECTION RUI
E RED ❑ r
'. :. .
,-' DATE
INa
.
PLUMBING
TUBS 3 SHOWER PAN
MECHANISAL
•.,C `;;'
y„
ELECIRICAL4KXX BONDlift
FRAMING/ST EGRESS
INSULATI OKlVENTdkTION
EX[ffiUAC SHEARNom DOWN
V117 Lor wronlov
U TERIOR SHEAR/HOLD DOWN
,...,' ... .
SHEETWROCK/SHEETAOCK SHEAR
-
..
.
EXTEMOR LATH/W-SCREED
SHOWER LATH
SCRATCH COAT '
'
SEWFJVWATBR •�
OCCUPANCY
ELECTRICAL
GAS
GAS TEST
GRADE
FIRE
HANDICAP
ELECTRICAL
PLUMBING
MECHANICAL
ENERGY
CERTIFICATE OF OCCUPANCY ❑
VISUAL FINAL ONLY
BUILDING /
IMPORTANT:
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION!!
ISSUANCE DATE
nstna er:
APPLICANT'S POSTING COW
Z0 39Vd H031 oinv VZNC3G 089S49880P TV:BT L66T/90/0T