29886 A LICANZTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEEVE EN029886
. /J(J O O8 o[M1
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L J o
BUILDING PROJECT IDENTIFICATION
BUUIILnDIING:SGAN ADORE .: u 1 NTSANITARY NO, APPLICATION SUBMITTAL DATE
OWNERPHONE: CONTRACTOR NAMii: LIC NO:
NIC COM1TRR�OL�x
CHITF.0 r,NG+EER: LIC NO: AUDRIi55: ❑ Ot` l
CON ACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD0 ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE ffr�Jj��� IeK.
�aZ
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION sa
with Section70(x1)of Division 3ofPc Business and l'mfessintrs Code,and my license is
HRC 0 111iRMIT ISSUANCE
U r to full forec and cf eel. ,FOWL ❑KITCHEN REMODEL
UU License Class Lie.as APPLIANCES-RESIDENTIAL ❑ADDITION EI PLUMBING RE-PIPE.
ti a dDae Connector
F Ovs ARCHITLCT'S DECLARATION PANELS [I MULTI-UNIT ❑STRUCTURAL
Z 0 H Z I understand my plans shall bo used as public record MODIFICATION
Oy
41 a- UPTO 300AMPS (2 INTERIOR ❑CHIMNEY REPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT
' aye; OWNER-BUILDER DECLARATION OVER III(10AMP5 El BATH REMODEVREPAIR
(-1DEMOLITION
DEMOLITION W 6 I hereby uffnm that I am exempt from the Contractor's License Law for the
py V following reason.(S=clion 703 1.5.Business and Promoocns Calc:Any city nr cmumy SIGNS ELECTRICAL ❑OTHER
'31a,y which requires a permit to ommoso ct,aIle,.improve,demolish,or repair any structure
F�•OQ
poor o in issuance,also requires the applicant for such pcmtit to file a signed statement SPECIAL CIRCUIT/MISC. F
C�Qf (hot he is licensed pursuant to he provisions at he Cnntracmr's License Law(Chapter 9 I
n1�C0 (commencing with Secdon7(XX1)ofDivinion 3ofth.Bunmrsxand Professions Code)or TEMP.METER OR POLE:INST. CA MEI(alf) .Gr
d that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEWy BLDG/ADDITION[15 U2F OD SERVICE
CE r
0
Seetimt 71y-115 by any apPli=ant lin n pmtit sub]ats the opplicam m n civil pcnuhy of POWER DEVICES
of more Um five hundred dollars(8500), -U
FZY11 TENANT,
IMPROVEMENT
S6 �6o the worofthe propcny.structure
yemntended m with for alei(See.compensation, SWIMMING POOL ELECTRIC S I„O and Prom work,and Code: he Contractor's
is tots License
Lur down of apply o GJ,Boniness ❑O"('HER
63$ and Promotions Code:imp Conlmcto a and
do Jeernmapply self owner of 0l1TLET5-SWITCHES-FIXTURES
properly who builds or improves therms,end who Jtms such work himself or through
his own cmployeen,provided that such stem kemann sere o. intended or offered fm NEW RESIDENTIAL ELECfR SQ E.
.wIe.lLhower withe have the bur int offorcint isat hedidaarse yld r improvettog'he i SQ.IT.FLOOR AREA 5/SV.BE.
owner-builder will have the burden of proving Na he did not build or improve for put- 2 lO cr t Lt��
p sec n s own.
❑x as owner(if the See7property,am exclusively contracting with:XIII..C mmit.clnm i-
oLaw the project(Sec.law,Business and Py who
Code:)The Cmhemem. LA02 Z
Li-
come Law does nmapply man ilharofpmpeny whoseddrsuant bele ommn.and QTY. PLUMBING PERMIT FEE
i who contmcrs li+rsuch Projects withaunnrucntr(s)Ilcansed pursuant mthe Cnmrucmr's
License law. PERMIT ISSUANCE
Ej I am exempt under Sec. .B&P C Binds reason
Owner Date
ALTER-TRAIN&VENT-WATER DA) _ VALUATIO�Lei
1/'/ r) A
WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE: v� /P V
dec
1 hereby ill maiunder penalty to perjury mmofthe following
or Workers
(have and will mainmine CeOificate of Conserv mself-inmrcfor Workers Compen- DRAINS-FLOOR.ROLE,AREA,COX-.. STORIES TYPEC NSTRUCHON
xation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is rowel, FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Cade.for performance of the work for whichthis permit is issued. GAS-EA.SYSTEM-I INC.(OUTLETS OCC GROUP AYN
My Worker's C'ompers:aion Insurance curler and Policy number are:
Cardec Policy No.: GAS-EA.SYSTEM-GVHR 4(CA)
CERTIFICATE 01s EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMP17NSATION INSURANCE BUILDING DIVISION FEES
(Thissction need not be completed if the permit is Boone hundred dollars 1$100) GREASETRAP
ter lase:) PIANCHECK ITE x Ix
I certify that In the Performance ofllm work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200E.
not employ any person in any manner sen ns to txcnme subject m Ne Wnrken'Cnmpen- ENERGY FITE x r—i
zz xation Laws of Califumia.Dam WATER HEATER WNENT/ELECTR
12 Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Ceni icate of Exemption,you.should WATER SYSTFMlfREATING SOILS FEE
beemtm subject to the Worker's Compensation provisions of the labor Code.you mull
f1aronhw an comply with such provisions or this permit shall b,deemed revoked. WATER SERVICE
Q
�Z CONSTRUCTION LENDING AGENCY NEW RESID PEAL PLMIL SQ.FE PAID Tae Receiptp
V O (hereby affirm that is a commaoion lending agency for the performance of
Q. the work for which this permit is issued(See.3097.Civ.C.) TOIAL:
VLenders Name
f Lenders Address BUILDING FEE r
E•-' y 1 certify that 1 have read da%application and state that the abuse infmmamn i,
to correct.l agree to comply with all city and county ordinances and shim laws mind,to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby authorve representatives of Nis city to enter upon the f SEISMIC FEE
abovcanennanal pntpony fill inspersion parpasas' ` PERMIT'ISSUANCE
s
(We) mmve.indemnify and keep harmless the City of Cupcnimoaginsl ELECTRIC PIiG
liohilitics.j me is ons expenses which may in any way accme against said City ALTER OR AUD TO M[CH.
anemfey n cgramin of thin lvnnit. PLUMBING TEE
APPI.IC DERSTA S AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ELM)CFM)
MSCI{gNICAL FEE
i SOURC �.CATION
AIR HANDLING UNIT(OVER 10,(X10 CFM) CONSTRUCTION TAX
tg IicanUConuacmr Until EXHAUST HOOU(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will mapplieanl or future handing occupant store or handle haeadous material HEATING ON EP TO 100l00 BTU)
s def y the Cupertino Municipal Code,Chapter 9.12,and the health and Safety
Ca • ,train.25532(a)'I HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑Nu VENTILATION I'AN(SINGLE RESIDE PAID Dom RecciPt X
Will the applicant or future building occupant use equipment or devices which
tit lumandmua air contaminants as defined by the Huy Arca Air Quality Management BOILER-COMP(3HP OR 100,(X10 BTU)
TO'T'AL:
timet^
E]Yes BOILER-COME'(OVER 100.100 BTU)
'•
1 ha -re lacks.mm rialsAIR CONDITIONER
requiremenrs under Chapter 6.95 of We Cali- ISSUANCE DA'Z'E
fomite H. shot 'ale.Scai s 25505.25533 and 25531.1 undcrsmnd that if the NEW RESIDENTIAL MECH. SQ.FE
building) late endylevo mn6 the his my refpnnsiMlity a+natily thu oavpnnt
of the whi be met prig{missmnce nfe Certificate of Occu ncy
OwI n ed agent J1 Da c o T ISSUED BY:
OFFICE
INSTALLATION CERTIFICATE o\
Use of this form to eelinfy the requirements of the Administrative Cede le optional. DN the Information must be provided eno , p.
-F1Z4OLT P,Fj22 Lo-T-4-6 IodR-5 R—: r4t,1SUuJ Rvi 2�)A
• Site Address Permit Number
An installation certificate is required to be posted at the building site prior to the issuance of the occupancy
permit; this form may be used to meet these requirements. All appliance categories listed below are the actual
equipment installed. Note that the efficiency and type of the appliance installed must be equivalent or better
than the appliance specified on the certificate of compliance (Form CF-1 R). This certificate (or its equivalent)
shall be prepared and signed by the person(s) assuming overall responsibility for the appliance installation.
Refer to the reverse side of this certificate for an explanation of information required.
I, the undersigned, verify that the equipment listed in the category above my signature is the actual equipment
installed and that the equipment meets or exceeds the requirements of the Appliance Efficiency Standards.
In addition, I have verified that the equipment is equivalent to or more efficient than the equipment specified
on the Certificate of Compliance submitted to demonstrate compliance with the Energy Efficiency Standards
for residential buildings. 'RECO ^E.0
HVAC SYSTEMS: l� IIIc/
Heating Equipment FEB 2 7 1997
Heating Equip. CEC Certified Actual Distribution Duct or Heating Load Heating
Type (Packaged Manuf. Make& Efficiency Type and Piping BL06efoiall egCN lE uiptment r
heat oumo. etc) Model Number fAFUE- etc.I t ovation R-Value _ PE o�ci�y lBtuhl
Cooling Equipment
• Cooling Equipment Actual
Type (Packaged CEC Certified Compressor Unit Efficiency Duct Duct
heat oumo. etc) Manuf- Make&Model Number (SFERI t_ocation- R•vaiue_
_s 2
Signature, Date HVAC Subcontractor(Co. Name)
OR General Contractor OR Owner
WATER HEATING SYSTEMS
Distrib. Water CEC Certified Energy Tank Insul Internal Pilot Rated Solar/
System Heater Manuf. Make& Factor/ Volume Wrap Insul. Standby Light Input Wood
Jyg =Modehl I R-value R-value Loss f%1 (Bluh) �/�$�1uCredits
60
FAUCETS & SHOWER HEADS:
• All faucets and showerheads installed are listed in the Commissions Directory Of Certified Faucets And Showerheads,
pursuant to chapter 2, Section 111
Sign tura, Dale Plumbing Subcontractor(Co. Name)
<, OR General Contractor OR Owner
X
Insulation Certificate
Ic�r��-S ��tlt.lsVt�o A�N�S� �'�JPEf2.TtN�
Number and Street City
crOn)T•rJ CWQ10 TR.roC� Q,p,22 1r,
County Subdivision Lot.Number
Description of Installation
ROOF
Material Brand Name
Thickness(inches) Thermal Resistance(R-Value)
CEILING
Batt or Blanket Type
BrandName
Thickness(inches) 4 /A/ ° 16 Thermal Resistance(R-Value) -/ - /7" O
Loose Fill Type Brand Name
Contractor's minimum installed weight/ft Ib Minimum thickness inches
Manufacturer's installed weight per square foot to acheive Thermal Resistance(R-Value)
EXTERIOR WA L
Material Brand Name �.
Thickness(inches Thermal Resistance(R-Value) -
RAISED FLO R "-e-,N,2 ,%6 tr
Material ��C� Brand Name
• Thickness('mcheL Thermal Resistance(R-Value) -
SLAB FLOOR
1 Material Brand Name
Thickness(inches) Thermal Resistance(R-Value)
Width(inches)
FOUNDATION WALL
Material Brand Name
Thickness(inches) Thermal Resistance(R-Value)
Declaration
I hereby cenify that the above insulation was installed in the building at the above location in conformance witlr
the current Building Energy Efficiency Standards for new residential buildings contained in Title 24 of the
A
' Code.
Contractor(Builder) License Number
l'�i" 1.ACQ Z-/ za�9ature and Ti atec nr I -/-tion Installer) �l Lic5nse7umber
anrre and Tide -T—T/ Date
January 1. 1995
Compliance Fnrma