30127APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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CITY OF CUPERTINO BUILDING -ELF.CTR[CAI,
PERMITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL.
30127
BUILDING PROJECT IDEN'I'IFICA'FION
BUILDING ADDRESS :1j
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SANI'I'ARYNO.
APPLICATION SUBMITTAL DA'I'S
V
OWNER'S NAME: PHONE:
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LICNO
CONTRACTDR?: -2-1
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N/C
CONTROL#
❑
ARCHITE .NGINEER: LIC NO:
ADDRESS:
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CONTACT:O j
/�W .p. 2PHONE
Lovi; 4hdLg-7Jgoo
❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
El
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nal 1 am licensed under provisions of Chapter 9 (commencing
with Seelua%IgNgn(Call sloa Sol'the If arsinessend Profession, Calc. and my licensees
i n Toll Cmc an emec 7
License Cloys Lia# 2' i(A�
Date - Cnmmanr
QTY ELECTRIC PERMIT 17EE
jC)Z
O
1UV
:�W
JOB DESCRIPTION
RESIDENTIAL:
❑ADWL LUMBINREMODEL
❑gDDITION PLDMBING RE8IPE
PERMIT ISSUANCE.
AI'PLIANCF,S—RRSIDIiNT1A1.
I=0.
CHITS CLARATION
asshnll un• sp::nlic�t:ords,
PANELS
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
::!!
Ll / (/tea
UI'TO laU AMPS
INTERIOR 11 CHIMNEY REPAIR
IMPROVEMENT
L' sat rofessional
201-I000AMPS
7OVER
W Q
4 U
' LL ya
•O.J
y
OWNER UILDER DECLARATION
I hereby affirm that I em exempt from the Cantmcusrs License know for the
following reason. (Section 703 1.5, Business and Professions CnJe: Any city or imery
which requires a permit to eonswct, alcor, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such Permit so file a signed statement
that he is licensed pursuant n the prnvisions al the Cuntnnnrs License Law (Chapter 9
0 BATH REMODELIREPAIR. [IDEMOLITION
❑ OTHER
UXoO AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC. a--
TEMP. METER OR POLE INST.
COMMERCIAL
NEW BLDG/ADDITION ❑DEMOLITION
IM�
(commencing with Seei.. 701) of Division 3 attire Baminessand Prorevionx Cede)...
that he is exempt therefrom and the boost. for the alleged exemption. Any vialatian of
-
1^w
ZZ
IJd
I O
j a
any red doom fora permit subjects the applicant m n civil penally nl'
Semon 7031.5 five
nm more than five h proope y, o r my a 0).
Lasm..,k,owner f the pmpeny,m, is emptended with mfemdwages avatheir (Sesate tem, Business
will J. am work, hard. The Imre is ton intended oro w domsor of apply to an, ncer of
and Professions Code: The Contractor's License Law dos ern apply to an owner of
POWER DEVICES
❑TENANT �1'DGD SERVICE
IMPROVEMENT ,
❑ OTIi ER
SWIMMING POOL Ef.BCTRIC
/ax
OUTLEI$— SWITCHES —FIXTURES V
'
property who builds of Improves Hamm, and who dais such wurk himself m thrnngh
his own employees, provided that such improvements are not intended or offered for
NEW RESIDENTIAL ELECTR SQ PT,
side. If,however, the building or improvement issnld within one year of completion• the
SQ. FT. FLOOR AREA
$/SQ. FT.
owner -builder will have the burden of proving that he did not build or improve for put -
passe of sale.).
❑ 1, as owner f Be pmpvny, um exclusively conducting with licensed Ouravemrn. to
,
TOTAL:
construct the project (Sec. ROD, Business and Professions Carle:) I he Commerce a Li-
,
cense Law does not apply to an owner of propedy who builds or improves lhereoq and
QTY.
PLUMBING PERMIT FEE
who co eracts fm ouch projects with a colnrsanr(s) licensed pornmennn meeumrector's
-
E ❑'ISSUANCE
LicenseLaw.
Inmemann uler Sco. ,B&PCfonhismo,aa
ALT — RAIN & VENT— WATER (EA)
ft
Owner Date
VALUATION
_�
l b Cr U6 , •
WORKER'SCOMPENSATIOND[7c1 RATION
I hereby.ffind under penalty of perjury ane of the fallowing declarations:
BACK FI. TICE DEVICE
'_FLO ryARFA, CONI.
]Ihnve and w it l maintain a Ceni Sane of Consent to scot -insure for Worker's Compete
satton, as provided far by ScOom 37M of the Labor Cud , fart Ne performance of the
ark for which this permit is issued.
-
STORIES
TYPE CONSTRUCTION
IBX'Np5 ER TRAP
❑ 1 have and will maintain Worker's Campensmiun Insurance as required M1y Sectioniseli
37W of the lsbor Code, for One Performance of the work for which this permit is issued.
M Worka' m teen ecru 'errand Polic gt�la r{ r'
C.rder: zl o nfn policy NreYli�I n` e�
GAS —EA.S -1 INC.4 OUTLETS
OCC. GROUP
APN
GAS — BA. SYS TEM-OVER 4 eL
• CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
Ohis action need nal be nsmplelW if Ne tis for.nehnnJred dollars (SIIlO)
on, lass.) pcmai
GREASCE USTRI. TG INTER CEPTOR
[BUILDING DIVISION FEES
GREASE: TRAP
PLANCHECK PF:F,
SEWER — SANfI'ARY� STORM LA. 2
,�
w raj
whichthisIn thepermitWelsissueglshull
Icenify that in Ore Performaanymrinecdfthe chisfa facture
nm employ any person in any manner so az m become suti act m the Workers' Com _
ndian Laws of Califn..in. Date ) pen
Applicant•
ENERGY FEE
y„
WATER HEATER WIVENT/F;LEGI'R 1 • .
GRADING PE
NOTICE TO APPLICANT IL ager making this Certificate of Exemption, you should
Ivxome subject to the Worker's Compensation provisions of the Labor Cale, yuu must
forthwith comply with such pinsiders ser this permit shall be deemed revoked.
WATER SYSTEMTREA'fING I kV
SOILS FEE
WATER SERVICE
a
]z
O
CONS] isaconRUCTION LENDING AGENCY
I that them issued(mnion lending agency for performance of
PAID Eli
Dnt Receipt of
NEW RPSIDIiNT1A1. I'LMB. SQ. FT
(••d
the work for which this nermil is issued (sea 9097. civ. c.)
lenders Name
'
TOTAL:
Lenders Address
I Oddity that I have read this application and pate that the ahovc infannmion is
TOTAL:
U
y W
fy
BUILDING ;It �/
to
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, aced hereby nmpre
uofor, resentatives ol'ttok,ity the
QTY. MECHANICAL PERMIT FEE
SEISMIC F E
/
glove -mentioned property for Inspection purposes.
(We) agree to suvq indemnify and keep hannlcas the City of Cufaminc against
PERMIT ISSUANCE
f:LECFRI FEE
Hahihlies.judgments.coxts and expenseswhich may many way accrueagmad surd City
in asequence of the granting of this permit.
ALTER OR ADU'I'O MECH.
PLUMBI GFEE
AIR HANDLING UNIT (TO 10,000 CFM)
MGCHA [CAI. PEE
APPLICANT OWDERSTANDS AND ' .GMPLY WITH ALL NON -POINT
SOURY1eEBE IATIONS.
AIR HANDLING, UNIT (OVER 10,(klll CFM)
CONST UCf10N TAX
f
S' Applica...Can icor Date
HA DOUS ATERIALS DISCLOSURE '
UC
EXHAUST HOOD(W/DT)
HOUSIN TLGATI(IN FEF.
HEATING UNI 'I(TO 100,000 BTU)
Will the applicant or future building occupant store or handle hneardous material
as defined by the Cupertino Municipal Code, Chapter 9.L, and the Health and Safety
Code. Seelan 2553200!
HEATING UNIT (OVER 100,000 B'I'U)
❑Yes ON.
Will the air conn or Puts a building occupant ora ea Air Qu or devices which
Amitricil ons air contaminants as defined by the Noy Area Air Quality Management
)tests'!,.
❑Yes ON.
PAID .
Dale Receipt#
VENTILATION FAN (SINGLE BESID)
BOILER—COMP (3HP OR IW.000 BTU)
TOTAL:
BOILER — COMP (OVER IIXn,000 BTU)
AIR CONDITIONER
I have read the hmardau.s materials requirements under Chatter 6.95 of the Cull-
q p
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
Health & Safery Coda eating 25505, is my and 25534th understand Net if the
building doesnot haveale that It is my resat.Coil'nynaramifythe occupant
hthom
re and
of the rryuiremenls which must be men prior m issuance of a Certificmc of Ocsvpancy.
swhich
ISSUED BY: _V+1(•
Ownerorauthnriud agcm - Uma
' TOTAL-:
OFFICE
.:UPERTINO
,,INC DIVISION
27316
ADDRESS:
8:q STE5NA: R PL_ L �1,
SANITARY NO.
ARUUTION SUBMR DATE
G_ 94
�WRS AM tim�, PHONE
•LIC
CONT1iACIOR'S NAMBrUC NO:
N� CONDlOL/
❑ -
.RCMMCIIENGINEER: NO:
ADDRESS:
?,r a
INSPECTIONS ;,�;, �,, , ' DATE. INSPECT
INSPECTION RECORD
NOTE: ALL GRADING AND DRAINAGE
SHALL BE INSTALLED TO COMPLY WITH
THE APPROVED PLAN
CUPERTINO STANDARDSS AND CITY OF
_;. �* BUTIZINGPEIWTFNN �
BLDG ELECT PLUMB MECH,
FOUNDATION/PIERS/H.D.S.
UFER GROUND
JOB DEscg(PT7�N D
KK� lam( D �L
PAD/SET BACK -CERT
GARAGE SLABS/PREGUNITE
POUR NO CONCRETE UNTR. ABOVE HAS BEEN SIGNED"
INSPECTION SPECIAL INSPECTION
REQUIRED ❑
DATE
INSP.
UNDERGROUND/SLAB
PLUMBING
ELECTRICAL
DO NOT POUR FLOOR UNPIL:ABOVE HAS BEEN SIGNED..
PLUMBING
MECHANICAL
ELECTRICAL
FRAMING VENTS
INSULATION
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SHEATH/DIAPHRAM
PLUMBING
t
TUBS & SHOWER PAN
MECHANICAL
iLECTRICAL/POOL BOND
FRAMING/STAIRS/E. EGRESS
I NS ULATIONN ENTI LATION
COVER NO WORK UNTBS'ABOVE HAS BEEN SIG&ED�k
EXTERIOR SHEARMOLD DOWN
INTERIOR SHEARIHOLD DOWN
SHEETROCK/SHEETROCK SHEAR 1-'ff-Yy
EXTERIOR LATH/W-SCREEN
SHOWER LATH
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED:
SCRATCH COAT
SEWER/WATER
TEMPORARY APPROVALS
--------------
BUILDING
ELECTRICAL
GAS
FINALS - -(Z.
/
GAS TEST
GRADE
APP D FOR OCCUPANCY
FIRE
HANDICAP
CA, - '
A.I;" TERNOONS (12:30 PM • 4:00 PM)
252-450-WMONDAY TO FRIDAY 24 HOURS
BEFORE REQUIRED INSPECTION. JOB AD-
DRESS ANDPERMIT # ARE NEEDED WHEN
PHOI_j
ATTENTION CONTRACTORS:
NO PERSONS) SHALL PERFORM WORK ON
THIS JOB SITE WITHOUT WORKER'S
COMPEN S C
ISSUANCE DATE
`
P A D-
NOV 18 1994
CMT Vr vu rnIBrU
_
_ �• • ,
IssuPn BY:
ELECTRICAL/ENERGY
PLUMBING/ENERGY
•MECHANICAL/ENERGY
BUILDING/ENERGY
ELECTRICAL FINAL TEST
OCCUPANCY OF BUILDING. IS NOT PE��T�D
UNTIL BUILDING FINAItIS SIGNED BY BUILDQJG
SPECTOR,+-•°z
IN�,v,:.,.
.n . _ .+t,.'•..•r )
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION!!I
w nnI In w w +.n ......•.�w�i. r..-.nv
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LJ -
CITY OF CUPERTINO
RECMPT ,
No. 04733 j
/i DATE 5 - Z ,1 96f-
RECEIVED
_ FROM
I
^✓ GSH
CNECK
MONEY
ORDER
DOLEARS
'
CEN,
75MN
CROWN BUSINESS SYSTMES, INC.
- (M �SM5
{
Ni
RECEIVED
BY 111 111///
,
1
75MN
CROWN BUSINESS SYSTMES, INC.
- (M �SM5
{
Ni
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