19496 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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CITY OF CUPERTIN66UILDING DIVISION
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_ PFRA4TISSUANCE ❑ ❑ ❑
WCF.NSF.D CONTRACTOR'S DEGLARATION
IherebyelOrmWtlamllmneedunderprovWomo(Chapter9(mmmenc �I'PLIANCFSRE9DEN1'fAL JOBDCSCRfIT10N
IngwltM15ectlon 7000)0(DlWyon3 oftheBuslneuand I'm@ssloneCode,anC my
limnse Is in lull fo[q� qff�Q.. ,. l I'ANFlS — ^ — �
I.IcenuClaseG^:lV 4[(j�M� / � j�(�
Date ContnRo / 6
ARCHI SDECI RATION p�"�����
�7 Iundenbndmypiamelull uxdupubli<rccorda OVERIOOOAh1P5 SQ.FT.Fl,ODRAItFA 5/SQ.Ff.
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u Llcensed Profesclonal 51GNSELECIRICAL
Q� OWNF.N-BIIILDER DECLANATION
�n�Fn SI'LCIALCQtCU[T/MLSC '
7�., � Iherebya((IrmtAatlamezempfmm�heCnntnieorbUmnul�w(mthe
folbwing rcawn.(SeR1on 7m15,Buslncse and Pmfenlom Code:My tlty or
� �"'� cwntywhlchrequlrnaperMt�oro�xwe.almr,lmpmve.demolbh,arrcpalr ��'.ME7QtOR['OLEINS7.
G��[�,�L,i anyetructurepdormitatceumm.aborcqulreslheapplicant(orauchpertNno ppyygRDEVICES
K 4� Ole a slgnM slatement Ihat Ae Lc Ilmnud pumuant to the pmvbio�u o! the
3q ConlnRoreLi<evelaw(CFapter9(mmn¢ndngwltM1SeaS1an7000)o(Divl- VALUA710N
��' slon3oftheBuelnmandPMexiofuCode)or�hathebemm therefmmand �'wNGITIOLFl.[CTRiC
��S.'� ihe basb(or the alleged exempHon. Any vlolallon o(Senlov 90315 by any
Q ¢� 0[I'fLE'ISSWITCHFSI7XfURCS
(� � uppliantloraperMtsubjectstheappllcanuoacivllpevltyo(notmorclhan
E �� llvchundrcddollan(5500). �WRESIDPNMLELEC7A
�I,asowneroflM m 1 eeawitAw� nasthelreoic —�'ET' SfOW6S TYI'ECONSTltUCTION
pmpercy,or my e p oy g
�'a compensatlon,wllldothewarkandthesw�[urcbnoHnteMNoro((emdfor
�r O s�e(°me 7044 eualnear and Pro(eeeloeu Code:TM Contranofe Llceme Law
�$� docs not apply m�n owner of properly who W Ilde or improvn lhereon,and p�C,GROUI' IiF�S.[INIl5
whodassuchwmk Mmcelforthlvugh Flaownemplvyees,pmvided�hatwch
ImpmvemenbarenoHn4ndedoro(fertdforeale.I(Aowever,�hebuilEingor TOTAL: �^'2
Improvementbeoldwithlmn<yearo(complelbM�heownerbulWerwllihave �
it�Q�rdenotpmv�ngthatMd�dnotbw�dor�mprove�orp�rpoeeo��N.), Q7y, pLUMBINCPERMIT FF.E
LJ 1 aa avner of the Prope�ty,am evciuelvely mntracYing w1�M1 Ilttnxd �.�D 7ANE APN
contncconmromwa[lhepmject(See]OCyBueinesvaMPrafeaeWmCode: �FRMR65UANCE
7fic Contnttor'e Limnx Iaw d«e not apply�o an owner d Pmperty who AL]IILDRAIN k VFM-WA'IF]i(EA)
bullda or Imprwn thercon,and who mntnaa(or sucL p�ojeM wltA a FEE SUMMARY
�nt�acmr(e)IlceneedpunuanttotFeContranorfLiceneelaw. BAQCFI.OWPI20T[CT.DEVICE
u I am exempt under See B k P C (or thb reaon
Owner Dare DRA[NSFlAOEt,A00F.AREA,ODND. SANITARY Y_ N_�
. RFGpI'I'N
WORKMANCOMPkNSATIONDECWRATION �.��,��.�i� $CJi00LTAX Y_ N_
❑[hereby affirtn tFa�I Fave a certififace o!cwsnt m aelfAnaure,or a RBCEp'7'M
mnlflcateofWorke�%Compe�a�lonlreuranreorarenlfiedmpy�M1ereof(Sec. CASFA.SYSI'EM-11NC60[ITLEfS 1'AFUCFEE Y N
3BOO.Isb C.) RECm'f M
1'olicy p CAS U.SYSI'EM-OVER 6(FA)
Com any BUILDINCOIVISIONF[BS
�Certlfledcopylshercbyfumished. CRFASE/INDUS]RLWASIEINTFRCFP'IOR P�.f1NCH�CK�CG
�Ceetifled mpy lv(Iled with�he clty le�spectlon dlWslon.
CERi1FlGTF.OFIX[MPf10NFROMWORK[RS' GRFASE7itAI' PAID
COMI'lNSATIONIN511RANCE 56wEa-SaMi'nRY�s'roRMEn.Y�o1T. Datc RCCCI IN
(I'Alsecnlon nead nal M complelN If Ihe permlt L+(ororc hundred dallan
(simlortev.) �yA.�.p��AY.Fxw��FN7.�tyF.C7.R BNGRGYFEE Y N
lcertify�hatlnthepeRormanreo(Newmkforwhichthlepermltialawed, — —
1�hall no�oy an�pe�eon�y mapner eo u to ro �en to tAe WA.��,�.�/.�.R�.�� �Aln
Workera' n alfdnla CalllorMG o.« v
0 Applican / /�! ..fifN 6 �' Date Recei 1#
2 �--��1 NEWRE9DFN71ALPLMB._�FI'.
Z O [�077CE M ICAM:If,aNerma ngtl�LCertiflateofExempibn,you
:nwid mceubjenm�heWorkere'Compcuatlonpmvialovofthelabor TOTAL:
� W Code,youmuatfonhwlthmmpiywllAm<hprovbloroortFL+perml�shallM BU �1
W j decmed revoked. �
WNSTRUCf10N LENDING ACFTCY SEISMIC FGE
a � IherebyafllrtnHuuAertbammwalonlendingagrnry(or�Lepedorm ELfiCTRICFEG
� Z anceoflhework(orwhlchthbperMtlstss�ed(Sec.309],CIv.CJ i07AG
V O ��„ae.aHa� PLUMI3INCFEE
LL H �<naer'snddmm Q7Y. MECHANICALPERMIT �E MECHANICALPGB �OO
U I¢nl(y�hatlhavereadthbappllatbna�suMthatlheaboveN(ormaHon
� W LscormctlagreeroromplywiNalld�yandmuntyoedinanmand�tahlawe �FRMRLSSUANCE PLLSPAIU
} N rela�ingtobWldingmeuweclon,andMrebyawhorlereprtecntaHvcaofthb
F Z cltytoeNeruponNeabovo-mentlonedpropenyforlvpectlonpurpoxe. AL7IItORADD70M[:CH.
Date Receipt#
(We)agrec ro vve,IndertW fy an d keep harMess the Cly of CupeMlno NR HANDL7NC UMT RO]0,000�M)
U �gawtllabllitln,pdgmenta,awbandespeneeawLkhmaylnanywayaccme SUBTOTAL:
aq��ret,a�a ciry m mnuque�«ot the gr+nn�g ot inia perm�c CONSTRUCTION TAX
AIR HANDLING UMT(OVER t0,000CFM)
Sigvmreo(AppunnUContnctor U+m IXlinUSTHppD(W/DUC'n CONSTRUCTIONTAXPAID:
HAZAFDOUS MATENIALS UISCLOSURE
WilltheappllcanlorlumrebulldingoccupantstoreorAandlcAazardous �AT�nGUWT(7U100,0008"IU) Q i[� na[e RCCCI f#
malerialasdetlnedbytMCupeninuMunlclpalCudGChapter9.lZandthc �
❑ealtF and Safety Code Sceion 25532(a)t HGTING UM2(OVER 100,000 OTIA TOTAL: I� O�
�Yn No
Wiiltheappllrantor mrebulldingoccvpamuuequlpmentordevicn �FNf1LA770NFAN6WGLERESIUI �$�q'�'E
whlcF eMt havardous alr contaMnanta aa detined bythe 9ay Area Nr
� QualityMamgemcntDlsWd7 BOILER-COMP(3H1'OR100,OOOBTIn
4Y� nN� ,1�1N � o i�9J
luvcrcadthehaz r�Ou�materlabrequircmenb�nderChapter6.95of 00IIERCOMP(OVFR100.00OBIlJ)
thc Californla Health k Safety Code,Scaio�u 75505,5533 and 25i34. I
unders[andthatitthebulldingdoesmtcurrentlyhavea�ewnqcM1a�itismy I�'EWRFSIDFN71ALA1GCH. �2��7. O:I�I ���I�1{�rtIIID
respo 'bilitymnotifytheoccv a thercqulrcmemswAlcFmus�bemet Kt� -�-.
p to uanceda of0 ncy •' �—
� r�-�s�+/i .a> p l 2.co ```y� (� t9J S
neroraut o udagent ate ISSl1GUBY_V`-'� • '
TOTAI.: �G�D
OFFICE COPY
- '► POST THIS CARD NEAR FRONT OF BU[LDING ��wT�� A
� CITY OF CUPERTINO A A � ��`��
WSPECT'ION DN[SION- )OB INSPECTIO[V RECORD
I � JOO ADDRESS 2o YJ'� U C��r�°"�C�l�l�G UNIT# LOT p carFr,oav connxo�x
OWNGR D�LU\ F�_ CONTRACTOR ��'� ��'�'�rvL� BUILDINGPERMITINFO
� INSPECTION DATE WSPECTOR INSPGCTION RECORD � � �
FOUNDATION/PIERS NOT@ ALL GRADMG AND DRAINACE �
UFERCROUND 9iALLBEINSIALLFDTOCOMI'LYWIIH JOBDLSCWI�IION
i}fE MI'ROVFD PI.AI�S AND C[7Y OF
I'AD SETBACK-CERT CUf'CR77NOSCANDARDS. � _ry,� �Rr.�yL[�
GARAGESLAI3S PREGUNITE ����- �Fu.P��-��_,
POUR NO CONCRETE 1INT(L AUOVE HAS IIEEN SICNE'D �NSPECTION DATE INSPECTOR
UNDERGROUND/SLAR
PLUMBING
ELGCTRICAL'
MEChIANICAL
DO NOT P011R FLOOR UNTIL AI30VE HAS BEEN SfGNED �
WOOD FLOOR
PLUMBMG
MECHANICAL
ELECTRICAL
FRAMING VENiS CLBAR
INSULATION '
PLACE NO SIIUFLOOR UNTTL ABOVE HAS UEEN SfCNED
ROUGH
PLUMUING
TUI35&SHOWHR PAN
MGCFIANICAL � .
LLHCTRICAL ACUZZ1130ND
FRAM]NG/STAIRS
INSULATION/VENTILATION
GMGRC.EGRESS
• $HWER WATBR .
COVER NO WORK UNTIL ABOVE HAS BEEN SICNED
EXTGRIORSI-18AR HOLDDOWN
INTGRIOR SHLAR/HOLD DOWN
SI-IGBTROCK/SHLE'fROCK SFIEAR �
LXTLRIOR LAThI/W-SCRGHN �
SHOWLR LATH -
SCIZATCH COAT
NO TAPE OR PLASTER UNTIL AI10VE}fAS RBEN SICNED '
NOTE:NO FINAL INSPECTION SHALL BE MADE UEFORE
THE CONSTRIICTION TAX IS PAID
FINALS DATE INSPECTOR
SAN.Jt
ELGCT.ENERGY �
PLUMI3ING[NGRGY
MHCIi.ENGRGY
I3UILDING ENCRGY
GLGCT.TINAL TFST y
PLUMI3INC
CA$TEST �
MGQiANICAL S
1-ICATWG
GL[CTRICAL RHLEASB
Il RG DEPT.
GRApE
OCCUPANCY �
TGMPORARYAPPROVAIS.
GLGCTRIC
GAS
I3UILDINC ISS ATG
OCCIlPANCY OF BUILDING IS NOT PE ITTED IfMIL -
� I7I/ILDINC FMAL !S SIGNED IIY BIIILD/NG WSPECTOR � JAr� 1 U ly9l�
AIiRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN
12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS � �, �� �
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND Clty i finn
PERMIT# ARE NF.EDED WHEN PHONING. �� I
IMPORTANT! �
PLEASE RGAD REVERSE SiDE BEFORE CALLiNG FOR FINAL INSPECTION ����ev:����
OFFICE COPY