29887 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
'•BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. /J O O
BUILDING PROJECT IUEN'PIPICA'I'ION G Q o
BUILDING ADDRESS I 'a�/ Sl..f64 SANITARY NO. APPLICATION SUBMLTTAL DATE
OWNER'SNAMEE PHONE: CONTRACTORS NAME: LIC NO:
N/C .CONTROLp
CHITECP/ENGINEER: LIC NO: ADDRESS: ❑ �OC;"�
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QaZ with Section 70(I(Bmf Division 3ofthe B.,ames,rod Profession,Code,andmy license is
Floc PERMIT ISSUANCE IAL
a tW r in full force and cBbet. SFUWL ❑KITCHEN REMODEI.
t;-,W
License Class Lic.R APPLIANCES-RESIDENTIAL ADDITION El PLUMBING RE-PIPE
W G W Date Contmcmr
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O LS I understand my dim—hull he used as public records MODIFICATION
Oz-0 UPTO 2M AMPS ❑INTERIOR El CHIMNEY REPAIR
f=�nt:W Licensed Prol'exsinnal 201-10A)AMPSIMPROVEMENT
�yf; OWNER-BUILDER DECLARATION OVER Iqt AMPS ❑BATH REMODEL/RF.PAIR ❑DEMOLITION
C C Q 1 hereby affirm that I am exempt from the Conlossamt License Law for the
°%%• a following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
V.1 LL C N which requires a permit to construct,alter,improve,demolish,or repair any structure
}� prior to its is uust,al...m,aireu the applican,t,,,,O,h penmen file a.vignrd staciamil SPECIAL CIRCUIT/MISC.
that he is licenced pursuant n the provisions of the Contractors License Law(Chepter9
1CQ (commencing with Section 7")of Division 3 ofthe Business end Professions Code)or TEMRMETER OR PULEINSi COMMERCIAL:
A.a c C that he is exempt therefrom and the basis fir the alleged exemption.Any vi bsum of - ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section 7031.5 by any applicant for a Permit subjats the applicant to a civil penalty of POWER DEVICES
w not more than five hundred dollars($51X1). []TENANT ❑FOODSERVICE
IMPROVEMENT
6 0I,us owner mf the propmYar mY mnpinyae with wages as theirsolc nmtpcnxaenn, SWIMMING POOL ELECTRIC
$a�O will do,he%ionv Code:
The
License
to
an Business ❑OTHER
yl m coed Pnmfessions Code:The Contractors Licenu Law dues not apply m an owner of OUTLETS-SWITCHES-FIMURES
�'3_ pmpeny who builds or improves thereon,and who dues such work himself m through
his own employeex,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELEC R SQ PT,
sale.If,however the holding Or improvement is veld within out year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
caner-builder will have the burden of proving that he did not build or improve for pun 7&6 % 10 11
�� ^
lase Of mI,J. �. ,
1,aser of the progeny,conexclusively commeding with licensed commem s to
construct the project(Sec.PEW,Business and Professions Code:)The Comments Li �/N` AUGJ O
c e 4 (,V/k Law does not apply to an owner of property who builds or improves thereon, QTY, PLUMBING PERMIT FEE 9
whocontacts I'or such lmjects withuennwnmr(s') Imn,wA pursuanunthe Commemrs ��
License Law. PERMIT ISSUANCE
❑lam exempt under Sce. .B&P C for this ream.
Owner Dare ALTER-DRAIN&VENT-WATER(EA) 1 -56 VALUATION V
WORKERS COMPENSATION DECLARATION RACK FLOW PROTECT'.DEVICE i 56 663, r'-
I hereby ufl'mn under Penalty of perjury one of the following declarations, V
I have and will maintain a Certificate ofConscnt In self-insure for Worker's Compere DRAINS-FLOOR,ROOT,AREA.COND. STORIES TYPE CONSTRUCTION
sation,as Provided for by Section 37M of the Labor Code,for the pcommurance of the
work for which this permit is issued. FIXTURES-PER TRAP
Fl I have and will maintain Worker's Compensation Insurance,as required by Section
3900 Of the Labor Code.kaffic p afomancc of the work In which this panni,is issued. GAS-EA.SYSTEM-I INC.40UTLIUS (WC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF E%EMITION FROM WORKERS' GREASE%INDUSTRI.WA STEINTERCF.PTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('Tbk section need not lo,completed iRhc permit is forma,hundred dollars($100) GREASETRAP
or lova.) p1.ANCHECK ItiE �P
I ectify that in the performance of,hc work forwhich,hi.spermit ist,sued,I shall SEWER-SANITARY-STORM EA.200 fT.
not employ any person in any manner so as to become subjescr to the Workers'Compere ERGY FEE
ZZ sarm.laws of Califomia,Dam WATER HEATER WNENTIELECTR
O Applicant INC,FEE
Vf NOT'IC17'In APPLICANT:If,after making this Cenilic:ou of Exemption,you should WATER SYSTEMORFAI'ING
Necrotic suhjcct t.the Wnrkcr's Compensation provision,of the Ulm,Code,you mus, SOILS F>EE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. SQ.FL PAID
U Q I hereby affirm that there is a construction lending agency for the performance of Dateip
the work It,,which this permit is issued(Sec.3097,Ci,C.)W Lender's Nome TOTAL
U LendersAddress T
I anify that 1 have read this application and stare that the above narration is RUILDINC PEE Aj
F" VI turret,.I agree to comply with all city and county ordinances and state laws relaing to QTY. MECHANICAL PERMIT FEE
U building consouaion.and hereby aathmi'r.0 representatives of this city to cnmrupon,he SEISMIC FEE
nhnvc�ineminned cry lin Impec,inn purposes. , PERMIT ISSUANCE
(We) sonify and keep beardless the City of Cupenino against IiLECfRI
liabilities. are
costs n expenses which may in any way accrue agaimtsaid Ciry ALTER OR ADD TO MECH.
in con. thegmin offluspermit. PLUMBING
em
APPL AN'T
,NDERSY DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(fO to CFM)
SOU Y IULNI'1 LM1�__`` M[CHANI 'AI FEF.
1_sa•Aa+r H 0.s AIR HANDLING UNIT(OVER 10,000CPM)
N CONSTRUCTION TAX
tum. A LieramCmiarrum s Uom EXHAUST HOOD fed/DUCT) HOUSING MITIGATION FEE
a HAZARDOUS MATERIALS DISCLOSURE
Will heappdicant Or future buildingomeupentame orhandleh...Mo.,material HEATING UNIT(TO 100.00 BTU)
Bred y be Ca,suino Mmmclpol Cotler Chapter 212,end,he Heahh nod Selly
tion 25532(0) HEATING UNIT(OVER IIX),IXId RTU)
❑Yes ❑Nm PAID
VENTILATION FAN(SINGLE RFSID) Dam Rcceiptg
Will the applicant or future building occupant use equipment it devices which
,lhuaurdouvOireoulmahm.a as detincd by the Bay Arco Air Quality ManagementBOILER-COMPQHPOR IW."B'1'U)
OTAL'
tsuicTr
❑Yes ON. BOILER-COMP(OVER 100.000 BTU)
I have read the hmurdous mamrlals requirements under Chapter 6,95 of the CanAIR CONDITIONER ISSUANCE DATE
fomiu Health&Safety C,sk.Sections 2.5506.25533 and 25534.1 undersand the If the NEW RESIDENTIAL MECH. SQ.FT. &-
buiWing does not curen,ly have a tenrnt,that it is my responsibility t.nobly Ne occupant
of the require amor,which must be met prior to issuanec of a Certificate of Occupancy.
Owner or authorized agent Dole TAL: ISSUED BY:
' OFFICE
r .
INSTALLATION CERTIFICATE o
a use of this form to "Italy the requirements of the Administrative Code Is optional, but the Information must be provided ana
T2, cr ,822 Lc-r It'd- 1wsI Fk tl,.IsQA Avu
• 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. J 'C
HVAC SYSTEMS: WEED
Heating
Heating Equipment FEB 2 7 1997
Heating Equip. CEC Certified Actual Distribution Dud or Heating Load Heating
Type (Packaged Manuf.Make& Efficiency Type and Piping 8Bef6re4)vg.,Tl0jEquiipment
heat oumo. etc) Model Number (AFUF ee-tcryl Location R-Value �q����� Gaoacity�l8tuhti'
�(>Rnl< AAW (�C/OY�A DST CK . 51 Z $IZiDG _'tiUr.7�l��m�
Cooling Equipment
• Cooling Equipment Actual
Type (Packaged CEC Certified Compressor Unit Efficiency Dud Duct
heat pump- etc) Manuf. Make&Model Number L$FF$)` LQ=dmi— R-value
ep. /Lie. 524eCO !mac.
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
Wrap Insul. Standby Light Input Wood
lypealk -621R value — Loss I%) IBtuh1 X etu Credits
FAUCETS & SHOWER HEADS:
All faucets and showerheads installed are listed in the Commissions Directory OI Certified Faucets And Showerheads,
pursuant to T' a Subchapter 2, Sectio 111.
Sig ure Plumbing Subcontractor(Co. Name)
OR General Contractor OR Owner
Insulation Certificate
_10081 t�E�Itas�IW RyP-r.IUE CvPE.�"t�S>7
Number and Street City
5 P,tJTA LL-Q aro
County Subdivision Lot Number
Description of Installation
ROOF
Material Brand Name
Thickness(inches) Thermal Resistance(R-Value)
CEILING
Batt or Blanket TypeBrand Name
Thickness(inches) l //Y /O Thermal Resistance(R-Value) –/
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
Material Brand Name
Thickness(inche ' %2 " Thermal Resistance(R-Value)
RAISED FLOP
Material Brand Name 61r �=.— !��
• Thickness(inche /I 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 certify that the above insulation was installed in the building at the above location in conformance with
the current Building Energy Efficiency Standards for new residential buildings contained in Title 24 of the
California Adminiskrative Code.
T-lcr�1 83RS�t2
gub-Conyytor
tractor(Builder) License Number
p c c Mcg
G and Title
to,
Installer) LicenseN ber —
.e L ��9
S ignarure and Tide
Drite
Comptinree Forma Janunq 1, 1995