23943 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PCRMITNO.
Bonding Address:10 S S s al RX 23943
wnero ansa: {^
dQ �iJ�l"t��ne. CITY OF CUPERTINO-BUILDING DIVISION "�^$_qZ
Contractors Name: Lie.No: APPLICATION I PERMIT �1,
\� Lie.No: 16 BU[LDINC-ELFLTRICALMUMBING-MECHANICAL CATEGORY C LaY�
Arch d/ glneer.
QTY ELECTRIC PERMIT I� FEEBUILDING PERMIT INFO
Add. PERMITISSUANCE 1�'/1 ❑
LICENSED CONTRACTOR'S DECLARATION IL—
I hereby afflrrnthat l am Bedded under provisions of Chapter 9(mermenc- APPLIANCGSRESIDENTIAL OBDESCRIMION .01
ingwith Sedton7000)of Divislon3ofthe BusinemandpmfesslonsCode,and my a� _
license is in full force and effect. PANELS
License Clam Contr
T
Date ontndor
ARCHITECT'S DECLARATION 201-IOWAMPS
q�q�vvOZ I understand my plans shall be used as public remnls. OVERIBWAMPS SQ.FT.FLOOR
AREA q� $//sBQ.FF�T.
Fib�Q�[k�^j Licensed Professional NS ELECTRICAL 1I , ill �eiQ
I'nTg OWNER-BUILDER DECLARATION —4 it VVV CJ
2t, FA IhercbyafRrmtlutlameaemptfromthe Contradorb Llmnwe .forthe SPECIAL CIRCUIT/M15C
oo following m..(Section 7031 S,Business and Professions Code:Any city or
O Z E- TEMP.METER OR POLE INST.
countywhich requireaa permit tomnstmct,alters Improve,demolish,orrepalr
anyatmu mpr rwitsbwance,alsorequlmstheappllrant(orsuchpermltto POWER DEVICES
(� file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's ILicense Law(Chapter 9(commencing with Section 7000)ofDlvl-
n SWBv1MINC IDOL ELECTRIC
elon3o(the Business end professlonsCode)orthet helaexempt lhercfromand VALUATION
Sn the basisfor the alleged exemption. Any vlolallon of Section 7071.5 by any /�,L
<� appflcantfora permit subjectathe applicant to a civil pemltydnot more than OUTLE7SSWITCI IF_SFIXNRES s0 L
Alive dred dollars(SAO. NEW RESIDENTIAL ELECTR
s owner of the property,or my employees with wages as their sole SQ'FT' STORIES TYPE CONSTRUCTION
ou satI n.flIdothe worband the structure is not intended or offered for
(Sec.7044,Business and Professions Code:The Contractors License Law
oes not apply to an owner of property who builds or Improves thereon,and OCC CROUP RFS.UNITS
who doessuch work himself or through Msown employees,provided that such -
Improvements are net intended oroffered forsele.If,however,thebuileiingor
improvement bwldwithlnon.yearofcompletion,theewner-bullderwlll have
t"rden of proving that he did net bund or Improve for purpose ofsale.). QTY, PLUMBINGPERMIT FEE FLOOD ZONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7654,Business and Professlons Code:
The Contractor's License law does cot apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for ouch plojeda with a
CqI. &or($)licensed pursuant to the Contractors Lleanse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. B k P C (or this rescanOUTSI DF FE
Owner DateDRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
(( WORT AN COMPENSATION DECLARATION _ RECEIPT N
4
01 hereby affirm that I have a certlf cae of consent to self-Insure,or a FIXTURES.PER TRA SMOOL TAX Y N
certificate of Warken'Compensatlan Insunnceora certifledcopy thenrof(Sec. RECEIPT M
3800,Lab C.) GAS EA.SYSfEM4 INC4 OUTLETS PARK FEE Y_ N
Colmryan GAS G.SYSI`EM.OVER d(EA) RFCG DI N
Y .�BUIrL�U�LN.G DIVISION FRCS
Ceriltled copy la herebyth the city GREASE/INDUSTRL WASTE I CEPTOR P I E 3S
❑Ccrtlfled copy 1,filed with the city inspection division, � SV(
CERTIFICATEMOF SATIONEXEMPTIONIN FROM WORKERS'
GREASE TRA a
COMPENSATION INSURANCE SEWERSANITARYSTO G 200F7 Date Recel t# s
(This section need not be completed If he permit V farone hundred dollars
00
(810 unify that
WATER HEATER W/ /ELFCTR E Y
(certify thato the performance of ny work for which bthis permit ubj Is Issued, �•
I shall not employ any Laws In any manner w ns to became subject to the WATER SYSTIN EATING (�1
Workers Compensation laws of GlBornla.Dale PA
0 Z Applicant NEW RE9D AL PCMB._SQFT. - D
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you A t-
Fshould become subject to the Workers'Compensation provislonsofthe Labor
N Code,you moat forthwith comply with such provisions or this permit shall be
j deemed revoked. B
aG chat the is a coNLENDINGAcgncY SEISMIC FEE
I hereby aorkfo hat there i a mnstmctlon lending agency(or the perform ELECTRIC FE,
� Z ante of the workfor which this permit is cooed(Sec.3097,Civ,CJ TOTAL: '
V O Lander.No PL BIN
U. i— Lander.Add.. MECHANICAL PERMIT FEE MECI-IA L 'E
O W 1certifythatl have readthis applicationand statethattheabove Information _re
Is emmet.I agree to comply with all city and countym inanms and nate laws PERMIT ISSUANCE FEES
T C relating to building romtrudion,and herebyauthmium representatives ofthls
N city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. ��. -
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino ate Receipt#
V
Against liabilities,Odgments,costand expenses which may lnanywayacvue AIR HANDLING UNIT(to ill000 CFM) S TOTAL: -
against said City In conseque of the grant ng of this permits.
ellS 9s �RrunrouNc UNIT(OVER 16,0000cFM) CONSTRUCTION X
Signature of App'mant/Contractor IDate' EXHAUSTHOOD(W/DUCT) CONSTRUCTION TA PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant or fulurebullding occupant store orhandle hazardous HEATING UNIT(TO 100,0D0 BTU) Date Revel
materlal as dell ned by the Cupertino Municipal Code,Chapter 9.1 7,and the -
Heahh and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1Y. M No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILFR-COMP OHP OR 100,000 BTU) p�
n Yes 9 No R� A � D
`(have readthehaea ou.materials requirements under Chapter 6.95 of BOILFR-COMP(OVER 100,000 BTU)
the Cxllfarnia Health k SafetyCode,Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that it is my I NEW RESIDENTIAL MECH. SQFf
esponsibility to notify the occupant ofthe mqulremcnts which must be met AUGU
d
prior to issuance of a Cerllficate of Ompan% bII Y
ur L C
Owner orawharized agent Dme ISSUED BY:
OFFICE COPY
6 , 40710EEUIDN_fiC.T1lL1.1 FAR 4RkI,7,.i.:.,- A7 Paae. 1 .
1108 STELLING,SO.
� 3
•, 4
' DATE DONE TYPE OF INSPECTION Inspector Code PASS/FAIL COMMENT
• ' INSPECTION,CATEGORY
193
° 2/37 ' FRAME 3d F.
9 :
° INSPECTION CATEGORY 101
• 11 9/09/92 FOUNDATION t0 P
to
• 13 INSPECTION CATEGORY 205
41013/92INSULATION dB " P
OXA9�2 illF FRAME 1BP
16 '
• t' INSPECTION CATEGORY 206
19 .. ., _.
• a0 INSPECTION CATEGORY' 301 °
at 1998fi R O P
as
•
21 INSPECTION CATEGORY 304
24 ]177
INSP,ECTION CATEGORY 306
v .ClX1-04 JJ P
a3
• ,9 INSPECTION CATEGORY 311
r "INSPECTION CATEGORY, 312
m T IATO r
34
•.3s
36
37
• 38
9
41 EXPIRED
42
45
"
• 47 -