27250 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B ILD[ T RI
A PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHAN27250 7 X 0
NUILIIIN4 PROJN:CI'IUEN'f[FIC1E1CATH3N G J
BUILDING ADDRESS: DD-,u[,�� SANITARY NO. APPLICATIONSUBMHTALDATE.
�V ` OMIT# LOT#
NERSNA R: , 405-�y��—� 4I OMf ,'ORLSyp E: 1.0A9_r V4/NO:
7 G i w`Y/ N/C COM'ROLp
/ENGINEER: LIC NO: D ESS: ❑
Ge I
C NTACf: PHONE: BUILDING PERMIT INFO
I` QTY. EL RIC PERMIT PEE
F E PLU MECH
s�
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DEfLARATION APPLIANCES-RESIDENTIAL' LOB DESCRIPTION
D=Z Ihereby offirmthat l sum licensed undcrpmvisionsofChVter9(commencingwith
roo Section 7000)nf Division 3 ofthe Business and Professions Code,and my license is in PANELS�tyy n��
full force and effect.
,ZW License Class Lie,It UP TO 200 AMPS
on<N Data Contractor 201-I000 AMPS 5 PT.FLOOR AREA E/gQ.PI',
Zoo,- 1 RCIIITE nglexpCLARATION OVER 1000 AMPS Q
OZ-0 land nd pl ssh used toe public recoNa. /(1k
F rod; g, SIGNS ELECTRICAL V /1
Q .LI can a
s
Nr G Wm fro
BUILD front
DECLARATION SPECIALCIRCUIT/MISC. 1
X aU I hereby action that am exempt m the Conaacmrs e:Anne Law for the 4�
m3LLy following which
Permit
to
Business and Profession Cde:Any city structure
TEMP.METIER OR POLE[NST.iil �V"r
ON; which requires u permit to roresdie ahem improve,demolish,or rcpuig any struaue POWER DEVICES —`vl-
C C)
Prior he is licensed poinso requires Re applicant fersuchdw Co pemtor.filLie a signed statement
CC) that he is licensed pars Section
the provisions of the Oomrtctors License law(shaper VALUAIION
dLo�' 9(rommeis ixemith Secfican an the Division Dmf theed exevand.An Professions Code) SWIMMING POOL ELECTRIC � a
p -,y itust 7031.5 by uherefromnt for
baspermit subjects
thedexemant to civil penalty
of OUTLETS-SWITCHES.FIXTURES
a net more than five
any hundred
doll Rn$S00),tsubjects the applicannuucivil penalty of
M,LC not more than five M1undsed Dollars(5500). NEW RESIDENTIAL ELECTR —SQ.FT.
C� ❑ Lnawnrnfthc properly,ormyempluyaswiNwege+ntlxirsolecampcnvtion. STORIES .TYPF.CONSTRUCTION
2. will Jo the work,und the structure is not imendedoroffered forsa[e(Sm.9094,Business
and Professions Code:The Cotmmcmrs License Law does not apply to un owner of
pmpcny who builds orimproves thcreon,anJ whodoes such wohhims<Ifnr throughhis OCC.GROUP RES.UNITS
ownemployees.provided thin suchimpmvemenu atonal itnenddoroffered favle.If,
however,the buildingor improvement is sold withinoneyearofcompkrion,tbeowner-
builder .will have the burden of proving that he did not build an improve for purpose of
gale.).
❑ l,nownerof Repmpeny,amesclusivelyconteclingwiRlicensdcon=tmmto QT' PLUMBING PERMIT FEE FLOODZONE APN
consumer the project(Sat.7014,Business and Professions Code:)The Contractor's
License Lawdoesnotapplytonnownerofpom nywhubuildsorimpmvmtherean,end PERMIT ISSUANCE
whocontmcrs forsuch projects with aconeamur(s)licensed pursuant touhe Contractor's ALTER- A ENT-WATER Pct)
Liccne Law. ( FEE SUMMARY
❑ 1 sat exempt under Sm. ,B&P C for this reason BACK OW PROTECT. ICE SANITARY UU Y L N
Owner DateRECEIPT#
WORKMAN COMPENSATION DECLARATION D S-FLOOR,ROOYWREA,COND, SCIIOOLTAX Y_N_
❑ I hereby affirm that l have s cenifica¢ofcmnsem mself-insure,ora cenificate of RECIl1PTN
Waken'Comprnvtion lnurarceaaunifid copy thereof(Eec.3800,Lab C.)which R RT PARK PIKE Y 4 N
coversallemployee'sunderthiapemut, GAS- -IINC.40UTLETS RECEI #
Policy# _ BUIL ION FEES
Company GAS- SYS •M-OV[R4(EA) PLANCHECK AEN
❑ Certified copy is hereby famished. IF
❑ Certified copy is filed with Racily inspection division. R STRL WASTE INTERCEPTOR GRADING FF
CERTIFICATE OF EXEMPTION FROM WORKERS' AP SOILS& F.
COMPENSATION INSURANCE
Mil.lionncednoubecompleldifthepermitisforonehundrddollnv(S ) SEW S TARY-STORM EA.200FT. ENERG
or lev
I cenify that in the performance of the work for which this permit is issued.)she[ WATER 11 WNEM)F.LECTR
t not employ any person in any manner sat as m become subject to the Wnrketa' PAID
CompensatiomlLtwsof California. Dae EATING Dee H eiptp
Q Applicant
z7�I NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTW.PIXI3. SQ.FT. TOTAL:
!� (q become subject to the Workers Compensation provisions of the labor Cale,you must
Fes , fnnhwith comply with such pmvisinns in this permit shell be,deemed evoked. BUILD[ 1 �a
(.7^ CONSTRUCTION LENDING AGENCY SEES a
Z I hereby affirm that here is a construction lending agency for the perfortnanee of C
U O the work for which this permit Is issued(Sec.3097,Civ.C.) %MIMI2
E.2. Ls Lenders Name P M NG ECC
P lender's Address QTY. MECHANICALPERMIT FEE t
L) I certify that I have read this application and state that the above information is
a correct. I agree to comply with ail city and county ordinances and state laws relating to PERMIT ISSU MEC ANICAL FTE
correct. `
V) building construction,sad hereby authorize representatives of Nis city meant,uptm Re CO STRUCION TAX
V Z adsve-mentioned property for inspection purposes. AI.TERO ADDTOM. H.
(We)agree to save,indemnify and keep harMess the City of Cufammar again,
Ilubililin,judgmene sus undexpensee whichtray in any way accmeageinstvid City A10. ANDLING UNIT('TO 0011 CPM)
inconsequence aurin of permit.
AIR HANDLING UNIT(OVER I a0CPM)
gnat ancestor G EXHAUST HOOD(WNU
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNITRO 1 TU) Date Receipt#
Will the applicant m future building oecupanr,score or handle hazardous mee' HEATING UNITMkiBTU)
n Defined by the Cuparmar Municipal Core.Chapter 9.12,and the Ileahh and Safd
Coda,Sectio"2 532(a)1
❑Yes ❑No NTILA INGLE REEL
S
Wilhhea licantorfuwrcbuildin ruse L CO P(311POR 100, V) ANCE DATE
BLI
pp gcecupan equipmrnmrdevices which emit
ous air comominanls as defined by the Bay Area Air Quality Maugetrem 0 -COMP(OVER I 8711) p
I IPvricsP G1
❑Yes ❑No NEW 3SIDEN'DAL ME 11. SQ.PC
I have read the hazardous materiels requirements under Chapter 6.95 of the JA°(��
25
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a ennt.that it is my responsibility to notify the C�'y
accu V�y.the rcyuirentenw which must od met prior m issuance of u Cenificme of 1 /sF I.I -F
Occupancy. V
Owner unauthorized agent Dae T L ISSUED BY:
OFFICE
10300 Torre Avenue
(,i l` of
l; Cupertino, CA 95014
11��C ]' 111.0 Building Division
(408)777-3228
(408)777-3333 (fax)
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
--1 have and will maintain a certificate of consent to self insure for worker's compensation,
as provided for
--I have and will maintain workers' compensation, as required by section 3700 of the
Labor Code, for the performance of the work for which this permit issued. My workers'
compensation insurance carrier and policy number are:
(this section need not be completed if the pemtit is for$100.00 or less)
-I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so at to become subject to the workers' compensation
provisions of Section 3700 of the Labor Code, I shall fgrth /Ith co/ with those
provisions. Date /-2 �'�jS. Applicant( $
by Section 3700 of the Labor Code for the performance for which this permit
is issued.
WARNING FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS
UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES
AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ($100,000.) DOLLARS IN
ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED IN
SECTION 3706 OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES.
' Prinlnl nn f cry:L Irl l;spa �
w
ESTFALL ENGINEERS INC.
• Consulting Engineers
14,583 BIG BASIN WAv
SARATOGA. CA 95070
TFL: (408)867.0244
FAX (4081 867.6261
October 25, 1995
PROJECT:
NEW CONSTRUCTION
19916 Price Avenue
Cupertino, California
Lot 6, Tract 8332
To Whom It May Concern:
This is to confirm that the foundation setbacks and height for the above referenced project
complies with the approved Site Plan and Foundation Plan.
Further this is to confirm, that the pad elevations and grades were established in conformance
• with the approved plans for the above referenced project. The overall slope of the finished
grade is 2.2%, measured from the back of the lot to the front of the lot. The grade shots at the
back of the lot were taken at the toe of the sloping bank, and the measurements were taken on
Oct. 25, 1995.
ND
Ct�jP��.l BAe�c�?rs
No.4953
Harry Ba 'cka OFC L.S. 4953 #�
D
ECCE VED
FEB - 7 1996
•
BLDG. INSPECTION DEPgRTMENT
CITY OF CUPERTINO
SURVEYING CIVIL STRUCTURAL
I