20622APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Holding Project Identification
But ding Address:
S T asph
1 _ / PERMIT NO.
1_ 2 O 6 2 n
G G G
caner. am.: phone:
�%
CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICAI PLUMBING- MPLHAMCAL
A -
9D
cJ"'may/ LIc No
r a�a- ////�.5�/71L ac.sso9
CATFfAftY
CONTROL
Arthltect/Englru`er. Lic No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACFOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc
IngwithSMion7000)of DiA,d.n3ofthe Budnenand ProfeashumCede,and myA
[I...lalntuPlo.anddtect
Lt.Chi.L IG65_di5
Data 0 Contractor On�UP
ARCHITECTS DECLARATION
I understand my plana shall be used as public records.
Licensed Professional -
OWNER -BUILDER DECLARATION
m
I herebyaffrm that I aexempt fromthe Contractor'. Llan. Law for the
following reason. (Section 7MI.5, Business and Professions Code: Any city or
c° untywhichrequiresapermit[ mmt d,alter,bnprove,demolish,ormpair
anystmcture prior to Its bsuarce,aborequires theappllcant forsuch permit to
file a signed statement that he is licensed pursuant to the provbloru of the
Contrad.e.Lice. Lw(Chapter 9(commencing with Section 7000) of Divi.
sion 3 of the Business and ProfessionaCode) or that he Is e.mpttherefrom and
the bub for the alleged exemption. My violation of Section 70315 by any
Applicant a permit subject.theapplicant too civil penalty ofour more t han
five I, as o nerdelof the p .
I,asownero! theproperty,orhe employees with wage as theirsolefor
b not Intended or kens offered for
mmp.nvti Kflul dotha work and th. Code:
Bu sinessandfprop cam Cale:The Contraones License Law
vie(Sot apply
does whorl tepply rkhian wnerorth pghhis builds veidh th tand
whodvuauch am not intended oroffered
owns , If, ho ea, provided buildingor
Improvements arenotintended earo(co for wle.theo nvegthebuildingve
Improvement bsold wlthinoneyearofcompietlon,theowner-bullderwlll have
thll*rdenof proving that he did not build or Improve for purpose ofuk).
Lf L as on, of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7064, Busmen and Professions Code:
The Contractor's License Lw does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pto)ects with a
coffdor(e) licensed pursuant to the Conten is License Law.
LI I am exempt under Sec B k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESORPTION
PANELS
TO 200AMPS
7014000 AMPS
OVER IOW AMPS
SO. FT. FLOOR AREA
$/SQ. FI.
SIGNSELECTRICAL
SPECIALCIRCUfT/MISC
'[EMP. METEROR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURFS
.VALUATION
/� 4`19
��i
NEW RESIDENTIAL ELECTR SQ Fr
OWES
`/
TYPE CONSTRUCTION
TOTAL;
QTY, PLUMBING PERMIT FEE
OCC.GROUP
RES. UNITS
FLOOD ZDNE
APN
PERMIT ISSUANCE
ALTER -DRAIN & VEM-WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
CUTS I Up FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY RFDEETN
Owrmr �0 Date
WORKMANTPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -insure, or aTURF,S-I'ER
IILabQ orkers'Compewra
tloninsunceora certlfl.d mre
pytheaf(Sec.
38W, Lb CJ
PWiryp e - /0 ,?
TRAP
SCHOOL TAR Y N_
RECF1PTM
GAS EA SYSTEM -1 INC40UTLM
PARKFEE Y N
RECEIPT If
GAS EA. SYSTEM-0VFR d (FA)
Co�mpany� O/OP4
BUILDING DI VISION Fr. ES
u CertiilM copy is hereby fhthe city
j/j('jCertlfed copy b flied with the city W)aectlon dlvlslon.
CERTIFICATE OF EXTMPT1ON FROM WORKERS'
COMPENSATION INSURANCE
(0) .Hadion need not be completed lithe permit b for cam hundred tlollan
(S1Wftifyth
Icenot thatlnthe peooninanftmerner iorstubehbpermlt is Issued,
I shall not employ any person f any manner at u to become ubjM to the
Workmf Compensation Laws of California. Date
ApplicaNOTICE
NOTICE m APPLICANT: If, after m'Co thiosationlpro isions Exemption,abo
Code,shoulbecomesubjectt°the Workers Cuch provisfo pones Peofthe Lab or
dacmrdmu .kr forthwith comply with each provblov orthb perndt shall be
deemed r.voked.
CONSTRUCTION LENDING AGENCY
I hercbyatfirno that there is a construction lending agency for the perform-
ance of the work for which this permit is issued (Sec. 3097, Cle. C.)
Lender's Name
Lndee.Address
1 mrtitythal l have read this application and statematme above Information
bmrrect. Iagree to comply with all cky and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
dty to enter upon the above-mentioned property for Inspection pu rposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
agamstllabllitles, judgmenb,msband expenseswhich may inanywayaccrue
.g.Id City In oneequencey(the `fthla permit..
AJ �otnfnfco.J 7� �D
CRCASE/WDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Rewi til
GREASE TRAP
SEWER-SAMTARY-STORM EA. 700IT.
WATER HFATERW/VENT/ELECTR
ENERGY FEE Y N
PAID
—Date Remi tH
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMS._SQFT.
-
TOTAL:
-BUILDING
SEISMIC FEE
TOTAL;
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE .
PLUMBING FEE
MECHANICAL FEE
FEES PAID:
ALTER OR ADDTO MECH.
Date ReCCi tN
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER I DODOCFM)
CONSTRUCTION TAX
Sig tore of ApplHAZARontractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future C.perto. ngoccv. I Coca, hhand9. hazardous
material a defined by the Cupertino Municipal Cade, Chapter 9.1Z and the
Eiealthand Safety Cod a Semon 75537(a)7
Yes No
Willtheapplicant turebuilding
na..doccupant fined by tequipnnArt he Bay Area device
which emit hazardous air mntamiwnte as defined by the Ory Arca Air
a�Ilty Management Dia�t ctl
4 Yrs he f76No
havercad ealth&lrirSafet mode, Sections 255nbunder Chapter S95 of
the Californiadtat if the
ASafety Code, Sections75505,ve a tenant,
note currentlyhavewhicht, that bbmy
understand that notify the occupant
rnpr to ossitylo of a Ceheompantccupa requirements which moat be met
prior to issuance of a CertlBcate of Occupancy.
IXF1Al1ST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMT(TO 1W,W0 BEV)
Date Recei tp
HEATING UNIT (OVER IW,ODO BTI!)
TOTAL:
L
VENTILATION PAN (SINGLE RFS[D)
ISSUANCE DATE
/i g
�'I lL 0,3
V r�J qGj
ISSUED BY:
BOILER -COMP OFP'OR IW,IXU BTU)
BOILER-COMP(OVFR IW,(1W BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner oroffthorlacd agent Data
TOTAL:
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO
INSPECTION DIVISION - JOB INSPECTION RECORD
JOB ADDRESS UNIT # LOT,#
OWNER_0 /W 'TA -S kO lV� CONTRACFOR,[a170 �G/7/�0�
PERMITNO. ccqqqq
.20 U G G
.7
CATEGORY
CONTROLN
BUILDING PERMIT INFO
INSPECTION DATE IINSPECTOR
INSPECTION RECORD
NOM' ALL GRADING AND DRAINAGE
SHALL BE INSTALLED TO COMPLY WITH
THE APPROVED PLANS AND CITY OF
CUI'FRTINO STANDARDS.j�I14"944CC:
FOUNDATION/PIERS
UFER GROUND
JOB DESCRIPTION
PAD/SETBACK-CERT
GARAGE SLABS PREGUNITE
POUR NO CONCRETE.UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND SLAB
INSPECTION
DATE
INSPECTOR
PLUMBING
-
ELECTRICAL
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR
PLUMBING
MECHANICAL
ELECTRICAL
FRAMING/VENTS/CLEAR
INSULATION
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROUGH
PLUMBING
TUBS & SHOWER PAN
MECHANICAL
-
.ELECTRICAL/JACUZZI BOND
FRAMING STAIRS
INSULATION/VENTILATION
,
EM ERG. EGRESS
SEWER WATER
'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
EXTERIOR SHEAR HOLD DOWN
-,
INTERIOR SHEAR/HOLD DOWN
SHEETROCK/SHEETROCK SHEAR
EXTERIOR LATFI/ W -SCREEN
SHOWER LATH
-
SCRATCH COAT
O TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
NOTE: NO FINAL INSPECTION SHALL BE MADE BEFORE
THE CONSTRUCTION TAX IS PAID
FINALS DATE INSPECTOR
SANK
ELECT. ENERGY
PLUMBING ENERGY
MECH.ENERGY
-
BUILDING ENERGY
ELECT. FINAL TEST -
PLUMBING
GAS TEST
MECHANICAL
HEATING
ELECTRICAL RELEASE
FI RE DEPT. -
GRADE
OCCUPANCY '
TEMPORARY APPROVALS -
ELECTRIC
GAS
BUILDING -
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL I CE DATE
BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR tR'
ARRANGE FOR INSPECTION BY PHONING 252.4505 BETWEEN
12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY, 24 HOURS %_ I U5 I -q -r- u
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND city Of cumrtI O
PERMIT N ARE NEEDED WHEN PHONING. �_ 1L,
IMPORTANTI
PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION ISSUER By'
OFFICE COPY