30107APPLICANTYO FILL IN INFORMATION WITHIN RED LINES - USE,BALL POINT PEN ONLY
CI YOF CUPERTINO BUILDING - ELECTRICAL
B LNG DIVISION APPLICATION/PERMIT PLUMBING- MECHANICAL.
BUILDING PROJECT IDENTIFICATION
.PERMIT NO. O O
BUTLDI . DRESS:
SANITARYNO.
APPLICATION SUBMITTAL DATE.
6
)WN.'S NAME : - PHONU: �C /��N
' / '/
CON' CTOR'SJJAME: LICNO:
t / --'I/a
NIC
❑
- cchinb .#
ARCH Cp GINEER: S� LIC NO:
ADDRESS 37— 00nille Dr. S,14,—,
CONTACT PHONE: "
/���/ �� /� {�
`/'Y
%
-
❑ Consultant Fees Paid by Applicant (Initial)
-
BUILDING PERMIT INFO
- ID ELECT, PLUMB M H
_�l~4•' sitiassi
LICENSED CONTRACTOR' ECLARATION
I hereby affirm m.t ant licensed arch, pr s of chapter 9 (emomoming
wife Smion]o00)nfDivi + ionJofthe Business end axed ors Code,and my license is
Lease la and effect.
License Class Contract 3 Da Convucmr
QTY.
ELECTRIC PERMIT
FEE
-JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ gDDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ' ❑STRUCFURAL
MODIFICATION
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT
❑ BATH REMODELIIHPAIR C1 DEMOLITION
❑ Ol'HF.R
PERMIT ISSUANCE
APPLIANC 5- ItESIDI:N TIDE
ARCHITECTS DECLARATION
I understand my orm ah ill he mad as public retards
j Licensed Professional
Oat lam exempt front
E 1 hereby affirm that I am exempt from tM1e Contractors Lic for the
following reawn. (Section 71q 1.5, Business sad Professions Cedr. A county
hich requires a permit to c onstruct, alter, improve, demolish, fir rer came priortoitsissuance, also requires the applicant for such permitto rile mart
hat he is licamedpursmat w the prownionsafthe Contractor's Licenha r9 ode r
that he is exempt therefrom and the basis for the alleged exemptionation o
Sedion7031.5 hy any applicant fmupermit objects the applicant rtacivil peachy of
t more than five hundred dollars (SSW).
0 1, as owner of the propert or my employees wife wagesmthcirsole armpcnsatinn,
and dome wons Code The ... lure
and Professions Cade: The Convector's Licenu Inw dtcs not apply man owner of
Contra nut s License de Lie net -(Sec. ]14{4, owner of
property who builds or impmves feemon, and who does such work himself or femugIt
his own employees, provided that inch impmvemen¢ arc not iotended m offered for
safe. the building or improvement is sold within one your efcompletion ,the
nor "builder will have the burden of proving that he did out build or improve for per-
Kaw sale,.
owner ol'the pmpeny, am exclusively contracting with littnseJ amvadon to
coast t the project (Sec. 7044, Business and Pfofessions Cutlet The Contractors Lik
ecrise Law does not apply to an owner of property who builds or improves thereon, and
who "ohnicAr such projects with. contmemr(s) ioensed pursmmnri the Cnmmctor's
License t
❑I a le ,B &PCfnnhis rtamn
PANELS
UP,TO2W AMPS
201- IINNtAMI•.S
OVER IWOAMPS
SIGNS ELECTRICAL
SPECIAh CIRCUIT/MISC.
TEMP. METER OR POLE INST
DMM.R IA
❑ W BLDG /ADDITION ❑DEMOLITION
ANT El FOOD SERVICE
IM ROVEMENT
❑ OTHPI{
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NIIW RESIDE ELECIR SQ PT.
�1t•
`�'l
." '
-
SQ. FT. I:LOOR AItP.A
JUN 21 1996
r s
ill t Ur IJUf'Cfl'I IIVV
$ISQ, I',
s
,TOTAL:
QTY. UMBING P • 14 PT
FEE,
PERMIT ISSUAN
AUFTIR- DRAIN& !NT-WA"
tun Date
.VALUATION h
'
WORKER'S COMPENSATION DECLARATION
1 hereby uffirm under penalty of perjury one of do following declarations:
❑ I have and will maintain it Certificate of Consent o set l' -insure tin Workers Compon-
Nation, as Provided for by Section 37M of the Labor Cede, for fee perfomtance of the
wart for which this permit is issued.
❑ I have and will maintain Walkers Co ulubt, ice Immume, m squired by Section
37Wof0he Labor Cede,dtrfeeperfonoanceoI thexvrk for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Courier. Policy No.:
BACK FLOW PROTECT. EVICE
DRAINS - FLOOR, ROOF, EA, CON D.
STOIt1Eg
'TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS -PA. SYSTEM-] INC.4OU ETS
OCC. GROUP
,
APN
'
GAS - E "OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSArioN INSURANCE
(This section need not bo compiled ifthe punnit is future hundred dollats ($1007
or less.)
I certify that in the perfortnanecofthe work for which this permit is heated. 11 shall
fiat employ any pe.a in any m finer tat as to hecome whjccno the Worked Compen-
Nation Lows .1 Coffman. DUba
Applicant
Gft[?ASpI1NDU.
BUILDING DIVISION MRS
GREA' a
PLANCHECK PEE
SEW.
II��/aa��t
WAT�e� 7L7 'R aa1T
Wit T lee
C C
a
Y FEE
NOTICE bj APPLICANT. IL after making this Ciijorsaof of FLabor, ind, you should
become subject m the Wnrkar's Compensation pmvisiuns of the Labor Code, you must
fuMwiih comply with so permit M
ch provisions or this permit sfall deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sea 3097. Civ. C.)
Lender's
in
n
EEE ,
Wp tons`
NE 1' �771 Will B sFT.
i
PAID '
Data ItaeiptH
TOTAL:
"
Name
Leader's Address
1 certify that I have read this application and state this the above information is
acct. I agree to comply with all city and county ordinances and state laws relating to
building cansvuclion, and hereby nuthoriz representatives of this city to emcf upon the
above "mention W pmpeny for inspection purposes.
(Wa)agrte to save, indemnify and kmp hamtless the City of Cupertino ogains0
'liabilities,judgmems, costs and execrses which may in anyway uceme against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Prom 'TOTAL:
QTY. MECHANI E
FEE
LDING FEE.
SETS IC FEE
'
PERMIT ISS
HLECTR FEE
ADDT :CH,
G B
-
AIR HANDLIN ,
AIR I IANDLINGUNIT (OVERIII,II(q CPM)
MECHANICAL. •E
UCTIONT
Signature of ApplicanVCharaanr : hate.
HAZARDOUS MATERIALS DISCLOSURE
Will the teCupemmfutuni huralinge. Chan0nore or handle fmalth and Sae
a defined io fee Cuponina Municipal CNe, Chapter 9.12, and the Heahh and Safety
Code, Scotian 25532(0)^
❑Vas L] No
Will the applicant or future building by the Bt use equipment of devices which
'mil huxurdnus air contaminants as JefinW by the Boy Area Air Quality Management
DOSWn^
❑Yard []No
I have read the hazardous materials requirements under Chapter 6.95of the Cali-
forms licalth & Safety Cale, Sections 25505, 25533 and 25514. 1 understand that if the
building does not currently have a tenant, that's is cry responsibility to notify the rccupam of the requio mmes which man he met pabo m iou rote of. Certificate of Occupancy.
EXHAUSTHOODUNMUC )
HOUSINGMrGGATIOh SEE
HEATING UNIT I'IO Ifq,Q10 BTU)
HEATING UNIT (OVER 1001000 BTU)
PAID
VENTILATION FAN (SINGLE RESID)
Date Receipt
BOILER - COMP (JHP OR I00,WB BTU)
TOTAL:
BOILER - COMP (OVER IIX),pg) BTU)
AIR CONDITIONER
ISSUANCE DATE
ISSUED BY
NEW RESIDENTIAL MECH. SQ. FT.
Owner or outhouses] agent e. Dare
TOTAL:
OFFICE
•
•
•
Inspection Query for a Specfic Permit Print 10/23/96
DATEDESIRED
I DateDone
I Inspector
Units
I Pass /Fail
7/11/96
7/11/96
AD
2P
7/11/96
7/11/96
AD
1
P
7/16/96
7/16196
811/96
8/1/96
CC
1
P
8/1/96
8/1/96
CC
2P
8/7196
8/7/96
JB
2
8113/96
8/13/96
CC
3
P
Page 2
•
•
•
Inspection Query for a Specfic Permit Print 10/23/96
PERMIT#
SITUS ST
SITUS STREET
AVE,CT,ST,RD
Lot#
INSDESCRIPT
InsType
30107
19110
STEVENS CREEK
UNDERFLR PLBG
30107
19110
STEVENS CREEK
TOP OUT
30107
19110
STEVENS CREEK
UNDERSLAB
30107
19110
STEVENS CREEK
ELEC
30107
19110
STEVENS CREEK
PLMBG
30107
19110
STEVENS CREEK
FRAMING
30107
19110
STEVENS CREEK
FRAMING
Page 1