27619 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I.lSING-MECH NIC PBHMI'1'NO.
CITY ON CUPERTINO PLUMBING-MECIIANICAI,
APPLICATION/PERMIT
RIJI��.DINC DIVISION � � BUILDING PROJECT HIEN'I'IIgCA'I']ON 27619
Pls!LDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1/10 / D15yZ SC GI#LG- a UNIT# 1.O'f# � f_
WNERSNAME: a PHONE: TRACTOR'S NAME: LIC NO: N/C CONTROL# JJ
Gu# ON
!l =uAn o✓ • / ,sci't.4" Qluji#� Lo40T3
AR(HITECT/FNGINfiLR: LIC NO: ADDRESS:
yZ FIpAM
CONTAC: PHONE: a ` -V%# ' x X BUILDING PERMIT INFO
V QTYF ) M.}PLELTRIPERMIT .; FEE
`x ! 1d `R S3':*.f'r x..Z rod a'b 4 �. BLDG ELECT PLUMB MUCH
PERMIT ISSUANCE � iUM
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL /�-' FOB DESCRIPTION
C304Z I herebyoffinn thin l am licensed underprovisionxof Chapter9(commencingwith
woo SCction7000)OTDivlsloo 3ofine Busincssund professions Code,and my bona¢is in PANELS
F-la)C full force and effect. Jr V
FZWUP TO 200 AMPS
License Cress Lic.0
m<0- Date Contractor 201-1000 AMPS SQ.IT.FLOOR AREA SSQ.<T.
O FONo ARCHITECTS DECLARATION OVER Iqp AMPS
u1 I understand my plans shall be used as public records.
SIGNS ELECTRICAL
9�N Licensed Professional
E: << OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
�x5�'O a V I hereby affirm that 1 am exempt from the Contmewex License law for the
u13 u.y following reason(Section 7031.5,Business and professions Code:Any city or county TEMP.METER OR POLE MST.
which requires a permit int construct,alter,improve,demolish,or repair any atmemre
C�Q� prior to its issuancertko requires mr,plicant for such permitmfle¢signed statement POWER DEVICES
ay<pm that he is licensed pursuant to the Provisions of the Contractors License Law(Chapter SWIMMING POOL ELECTRIC
9(commencing with Section 7")of Division 3 of the Business and Professions Code) VALUATION
Wim onhet he is exempt therefrom and the basic far thealleged exemption.Anyviolationof OUTLETS-SWITCHES-FIXTURES'
Y
Section TOILS by any applicanpemtit
tfor a aubjm¢tlmapplicant to a civil Penalty of
7 not marc(Iran five handed dollars(55110),
Fp NEWRFSIDENTIALBLECTIt S .FT.
tY m ❑ I,asownernfthePmpeny,ormyemploytts with wagesuthciraolecompensauon, Q STORIES 'I'YPF:CONSTRUCTION
Lo
will do the work,and thestmcture isnot intertddorseffered foraale(Sec.71ki Businaa
and Professions Codr.'ILe Contractors License law does not apply to an owner of
poveny who builds or improves thereon.and who does such work himself m though his
own candoyms,provided that such improvemcrosampol imendedoroffered trestle,If,
OCC.CROUPL RES.UNITS
however,the building or improvement is sold within one yearof companion,the owner- TOTAL:
builder will have the burden of proving that he end not build or improve for purpose of
ealo')' QT,Y1 PLUMBING PERMIT FEE FLOOD ZONE APN
❑ 1,
as ownerofthe pnryeny,amexclusively contracting wit licensed commcmrstm
antrum the pint.(See 70W,Business and Professions Code:)The Contmemr's -
LicenseLawdoesnotapplymanownerofPoci who builds or improves thereon,and PERMIT ISSUANCE
whoamtractsforsuchpmjectswithaconhacmr(s)licensd Pursaanttmrhe Convector's
License Law. ALTER-DRAIN&VENT-WATfiR IFA) FI?E SUMMARY
❑ 1 ant exempt under Sec. .B&P C for this reawnTSIDE
BACK FLOW PR .CT:1,)EVIa 1 SANITARY YN
OwnerDate DRAINS-FLOOR,ROOF, REA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ 1hetehy offirm that l have a certificate ofeonsenuo self-insum,or a rendition,of FIXTURES-PER TRAPRECEIPTp
Worken'Compenmtionlnsumcconeenifidcopytenof(Sm.3800,Inb CJwhich PARK FEE Y N
covers all employee's under this pmah. GAS-EA.4SYSTEM-1 INC.4O S RECEIPT#
Policy X BUILDING DIVISION FEES
Company GAS-FA.SYSTE -OVER4(EA) PLANCHECK FEE
❑ CenifiedexyisLertbyfumishd.
❑ CeniGd copy is filed with the city inspection division. GREASEANDUSTR. 1 STE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FRF.
COMPENSATION INSURANCE 712 09f
(This section need not he completed Athepermit is foronehundml dollars($100) SEWER-SANITARY-STORMF ENERGY FEE
or less.)
I cmify tat in the performance of the work for which this permit is issued,l shallWATER HEATER W/VENT
not employ any person in any manner so as to become subject to the Worker' PAID
Compensation Lawsof Cslifomia. Date WAw7$YSTEM/
z Applimmt I'RI+ATI Dom ReceiPtp
Q
Z 0 NOTICE TO APPLICANT:If,after making this Commerce of Exemption,you should NEW RESIDENTIAL PLMB. Q. TOTAL:
f•-' City become subject to the Workers Compensation previsiom of the labor Code,you must
ai fortwith comply with such provisions or this permit shall be dcemd revoked. BUILDING PER
FT7A CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm thin fere is a construction lending agency for the performance of
U O TOTAL: ELECTRIC PEE
the work for which this cement s tuned(S«Jig],Cis.CJ
Lenders Nome PLUMBING� Leaders Add.. MECHANICAL ;FEE.
U I econy tat I have read this application and state that to above information ` MSCI{ANI .FE
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
buildingeonswction,and hereby autherizemptesematives ofthis city to enter upon the CONSTRUC ION TAX
U Z above-mentioned property for impection purposes. ALTER OR ADD TO MUCH.
(We)agree to save,indemnify and keep harmless the City of CuMnino against
ladilitics,judgerean,ctsts and expenses which may irony wayacerueugainst said City AIR HANDLING UNIT(TO 10."CFM7
in tomo,tithe,mon,of tl' Pe it.
AIR HANDLING UNIT(OVER 10,OW CFM)
�mmctel e
Signumrc of p nt/Commctm Date EXTIAUST HOOD(W/DUCq P n
IIA2.ARDOUS MATERIALS DISCLOSURE HE6'1'ING UNIT(TO 100,000 BTU) Date Receipt#
Will the auditors nr future building commitment handle hazardous material HEATING UNIT(OVER 100.000 BTU)
TOTAL:
u defined by the Cu,xmino Municipal Cede,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'1 VENTILATION PAN(SINGLE RE.SID)
❑Yes ❑No
BOILER-COMP UUP OR I(V,O(X)13 ED ISSUANCE DATE
Will the applicant orimure building«cupant usecquipmem ordeviceswhich emit A
zardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER I00,000 BTU) D
ismm'!
❑Yea ❑No NEW RESIDENTIAL MECH.-SQ.FT.
I have read the homrdous materials requirements under Chapter 6.95 of the JAN 121995
California Health&Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a tenant tat it is my responsibility to notify the h^
cupant of the regm aximems which man be met prior no issuance of a Certificate of I1 Y ur VurtH 1Y
Occupancy.
Owner m authorized agent Dote TOTAL: ISSUED BY:
POSTTHIS CARD NEAR FRONT OF BUILDING 6`
CITY OF CUPERTINO PERMTT NO. 1
,.. LDIAG DIVISION y.,. Sa RU14DWO ID CATJ N:n7iLi:'dbb•tiifri'.s�
+ BUILDWOADDRB^SS�:,� SANITARYNO. A1PPLICATIONSUBMCITIW ia'I
w OWNER' PHONE. CONTRACTOR'S NAME: LIC NO:
v N/C CONTROLY
CHI CDBNOW _ . UC NO: ADDRESS:; ❑
+
'i; •. r f9 i' r" I y Sd:"�r.`;i?'fiii"J81.11LDINOPBRMIT INFO
^' IDIS ON$ D= ❑ Consultant Feu Paid by Applicant(Initial) BLDG. ELECT PLUMB MR
FOUNDATION/PIERS/H.D.S. INSPECTION RECORD
UFER GROUND JOB DESCRIPTION
NOTE: ALL 'GRADING AND DRAINAGE RESIDBNTIAI-
PAD/SETBACK-CERT SHALL BE INSTALLED TO COMPLY WITH PDWL ❑KITCHEN REAo•111
GARAGE SLABS/PREGUNITE THE APPROVED PLANS AND -CITY OF ADDITION ❑PLUMBING RP.•'Ir1
CUPERTINO STANDARDS. ❑Muvrwwr ❑STRUCTURAL.
PQTJqNO CQNCR(iTB UN�1G`AQpVB,HpS PPBN_glGtq TO ARRANGE INSPECTION ❑INTERIOR ❑CHIMNEY REr•I;.
. UNDERGROUND/SLAB CALL AFTERNOONS (12:30 PM - 4:00 PM) IMPROVEMENT
❑BATH REMODEUREPAIR ❑DEMOLITION
PLUMBING 777.3226 MONDAY TO FRIDAY 24 HOURS BE- ❑OTHER
ELECTRICAL FORE REQUIRED INSPECTION.JOB ADDRESS
`DO'NOTPOUR. R ABOVE HASIONEA ANDPERMIT NARE NEEDED WHEN PHONING.
_ COMMERCIAL
PLUMBING - ATTENTION CONTRACTORS: ❑NEW BLDG/ADDITION ❑DEMOLITION
MECHANICAL NO PERSON(S)SHALL PERFORM WORK ON. ❑TENANT ❑FOODSERVICI
THIS JOB SITE WITHOUT BEING IN COM- IMPROVEMENT
ELECTRICAL PLIANCE WITH WORKERS'COMPENSATION 0OTHER
FRAMING VENTS INSURANCE REQUIREMENTS.
INSULATION
Pf ACE NOS INSPECTION SPECIAL INSPECTION REQUIRED ❑ DATE 11
r...................UBFLOOR'uN'C,ICAHOVBH(�S•}i$FN,YyI. . ._,
ROOF SHEATH/DIAPHRAM '
PLUMBING
TUBS&SHOWER PAN --
MECHANICAL ,
-'' SLECTRICALIPOOL BOND '
IRAMWG/STAIRS/E.EGRESS
INSULATIONNENTILATION -
'_'OQVg NO,WOR&UNTB:ABOVEHAS- SEN_PION
ED y�• _
EXTERIAL SHEARMOLD DOWN
INTERIOR SHEARMOLD DOWN
SHEEIWROCK/SHEETROCK SHEAR
EXTERIOR LATH/W-SCREED ,
SHOWER LATH -
;NO,IAPB,ORPLpR1'ER;UfiTILABOVE,HAS BE6_NSIONED_
SCRATCH COAT
SEWER/WATER
OCCUPANCY -
ELECTRICAL '
GAS
rNil�, Xqwwl
GAS TEST
GRADE
FIRE WF5
HANDICAP
ELECTRICAL
PLUMBING / YacTP-
MECHANICAL oA�
ENERGY, ---
VISUAL FINAL ONLY' CERTIFICATE O� O UPANCY ❑
BUILDING IMPORTANT: - ISSUANCEDATE
tic;,Uf,ANCY,OI!,pU1LQINd4SNbTPERMI77 PLEASE READ REVERSE SIDE BEFORE
SIG 4 CALLING FOR FINAL INSPECTIONI!
" v ,TQ '' ISSUED BY: _
APPLICANT'S POSTING COPY