19495 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMIT NO.
BtDdinga ddren: - 19495
e ners ante:cc) Phone: A
� CITY OF CUPERTINO-BUILDING DIVISION
(1 " tmd anx° a} No APPLICATION / PERMIT 1—( z97 d
�'.Archit /FBNLDINGEECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL X
Li
sc.Na:
_ '6TY ELECTRIC PERMIT 'FEE BUILDING PERMIT INFO',
Address: Lys' CA PERMITISSUANCE ❑ ❑ ElNLI-CENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under prevbalonso(Chapter9(commuse APPLIANCES RESIDENTIAL JOB DFSCRE'11ON
ingwlth Sedlon 7000)of Divlslon3ofthe Busimuand PmfeulomC,.ode,and my
license Ie in foil force and effect. PANELS A '
LicenseChm nt
Data _Contractor UP TO 200AMPS "' l 1` 1... ✓�.
ARCHITECT'S DECLARATION 201-IODO AMPS
p7 Iundentand my plane shall he used as public remrdw OVERIOODAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Profasstm al SIGNS ELECTRICAL
I4 OWNER-BUILDER DECLARATION
n SPECIAL CIRCUIT/MISC
Zs, follIhereby affirm that Iam exempt fromthe Contractor's License Law fm the
owing reason.(Section 7031.5,Business and Professions Code:Any city or
TLMP.METIR ORPOLE INST.
� countywhlch requires permit to construct,alter,improve,demolish,orrepilr
Oa anystmc mprlortoihba ance,aborequrestheappUrantfmsuchpert tto POWER DEVICES
V Ole a signed statement that he b licensed pursuant to the provblens of the
Contractor's License Law(Chapter 9(commenting with Section 7000)of Divi-
3 p�n SWIMMING IDOL ELECTRIC
s the bass fo the alleged
Any)violation la exempt 703rd by any VALUATION
the barb for the alleged exemption. Any violation of natty o 7031.5 re any OUTLETSSSWITCHF_.FI%IURES
s,5+ appUcantfor a permit subjects the applkanitoa dull penalty of nor rtnrethan
Ove hundred dollars(5500).
❑I,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
p perry,or my employees with wages r thele dole
7< rompensatlon,wllldothe workand thestmcturc boot intended or offend for
O ole(Sec apply Business and of property
Code:TheC lds or imprewr's Llceue law
�$ don not applyes.uch tarn humero(throng his own employees, es
OCC.GROUP RES.UNITS
who doementsa notintended
ntte dedoroughed own yen,providedthat such
improvementsarcnot Intendedorelfeco forsale.theownvepthebulil have TOTAL:
Improvement b soltl within oneyeam(compltlon,thcowner-bund erwlll have
tlill-Iiurden of proving that he did not bund or Improve for purpose ofwle.). QTY, PLUMBING PERMIT, FEE FLOODZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed
contntore to construct the pmjcet(See 7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License law don net apply to an owner of property who ALTER-DRAW&VENT-WATER(EA)
builds or Improves thereon,and who contracts ntras for such in eject with a
cgll(Tador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE 'FEE SUMMARY:
LI I am exempt under&c. B &P C for this maaan
Owner Data
DRAI NS ROOF,AREA,COND.FLOOR RSANITARY Y N0
KRECEIPT
`Y
WOR
MAN COMPENSATION DECLARATION �.���.�, SCIiQQL TAX Y_ N
❑T hereby affirm that I have a certificate of consent to all-Insure,or a RECEIPT' wni(inteof Worken'Comperuatlon Wunnceoramnifk mpythemof(Sec.
!'a_, 3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Policy N GAS EA.SYSTEM-OVER 4(EA) DINem any BUILDING
p
GDIVISION FEES
Certfied copyis hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city!rope<lon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID .
COMPENSATION INSURANCE SEWER-SANITARYSIURM EA.200PT, Date RCCCI I#
(Thlssectlon need not be completed If the perrtdt ba forons hundred dollars
(SI (Borlcu.) WATER HEATER W/VENT/ELLCTR ENERGY FEE Y N
I certify that in the performance of thewmk forwhlch this permit le basted, —
I shall not employ any person in any manner m as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Lawso(Caltfomb.Date PAID
0 Z NOTApplICE NEW RESIDENTIAL PLMB. SQPT. Date ReceI t#
ZO NouldbeOMPLICttothe ahermakingthbasaller procato o(Ens offi ,Lyou
should bemussubjecttothe Workers'Compenoatlonprovhiorsrefthe Labor TOTAL:
LU N Codyoue, must forthwith comply with such provlelom orthba permit shall be BUILDING`� deertad revoked.
LU
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is.construction lendingagenry for the perform ELECTRIC FEE
Z anm ofthework(or whichthb permit is issued(See 3097,Civ.CJ TOTAL:
o O Lander'.Name PLUMBING FEE
LL ~ Lenders Addm QTY I MECHANICAL PERMIT -FEE MECHANICAL FEE O,
O W Imdlfythatl have readthb applicationand state that the aboveinformaif..
1 Iscomect.I agree to comply with all city and county mdlnanmsand stalelaws PERMIT ISSUANCE ,OP FEES. I'Al .
} W relating to building construction,and hereby authertaercpresentativesofthbU —S3�3D
Z my to enter upon the abovcmentionM property for Wpetion purposes. ALTERORADDTOMFCIL ��rDA L.. V
(We)agree to save,Indemnify an If keep harmless the City of Cu pert Ino Date Reeej t#
V against liabilities,pdgmems,costs and expenses which may In anyway accrue AIR HANDLING UNIT(170 IO,ODO GEM) SUBTOTAL: 1
a Id City loco ryas nee o(thc granting fthle permit
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of Applicant/Conte r � EXHAUST EIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA SDISCLOSURE
Will the applicant or haum building occupant atom or handle hanrdous HEATING UNIT(TO IOD,000 BM Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9d2,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 17�0,00
❑ Yea MN.
Will the applicant orfuturebuildingoccepanl useequlpmentordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous,air contaminants as defined by the Bay Area Air /�
Quality Management District? BOILER-COMP D11P OR 100,000 BTU) PAID
Yes No ry
Ihavemadthen gousnaterlabrequiremenbunderChapter6.95of BORER-COMPepVPR100,0008 n JAN 1 U IJcJJ
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr.
rspoaslbillty to notify the occupant of the mquimments whichmmust be met a, .a
prior to Issuance of a Certificate ofblpanry. Citi P>' rl)arf din0
Owner or autholmd agent Data TOTAL: .3 .of ISSUEDBY._%I
OFFICE COPY
L�• POST THIS CARD NEAR FRONT OF BUILDING PERMIT NO.
95
CITY OF CUPERTINO 194
INSPECTION DIVISION- JOB INSPECTION RECORD /
(JJOB ADDRESS .L D 6 (/ V�J �) C lr�l UNIT# LOT # CATEGORY CONTROL#
OWNER—,-N UT_Ce--f✓' Y' �tJS CONTRACTOR 0 e� BUILDING PERMIT INFO
`INSPECTION -DATE JINSPECTOR INSPECTION RECORD El ElFOUNDATION/PIERS NOTE ALL GRADING AND DRAINAGE
El UFERGROUND SHALL RE INSTALLED TO COMPLY WITH JOU DESCRIPIION
PAD/SET BACK-CERT THE APPROVED PLANS AND CITY OF
GARAGE SLABS PRGGUN[TE � CUPERTINO STANDARDS. „oma '
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED C_D3-A--T—E INSPECTOR
UNDERGROUND/SLAB INSPECTION
PLUMBING
ELECTRICAL -
MECHANICAL
DO NOT POUR FLOOR LINTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR
PLUMBING
MECHANICAL
ELECTRICAL FRAMING/VENTS/CLEAR
INSULATION
PLACE NO SUBFLOOR.UNTIL.ABO VEf AS BEEN'SIGNED, '
ROUGH
PLUMBING
TUBS&SHOWER PAN
MECHANICAL '
ELECFRICAL ACUZZI BOND
FRAMING STAIRS - -
r ` INSULATION/VENTILATION
. -' EMERG.EGRESS
SEWER WATER.
(GO.VERINO WORK.UNTIL'RBOVE HAS'BEEN SIGNED..'si
1 EXTERIOR SHEAR HOLD DOWN
INTERIOR SHEAR/HOLD DOWN
SHEETROCK/SHEETROCKSFJEAR
EXTERIOR LATFI/W-SCREEN
SHOWER LATH -
SCRATCH COAT
NO TAPE OR PLASTEWUIVTIUABOVEe'HAS-BEEN SIGNED
NOTE:NO FINAL INSPECTION SHALL BE MADE BEFORE
THE CONSTRUCTION TAX IS PAID
FINALS DATE INSPECTOR
SAN.#
ELECT.ENERGY
PLUM RING ENERGY
MECH.ENERGY - - -
-BUILDING ENERGY
ELECT.FINAL TEST
PLUMBING
GAS TEST
MECHANICAL
HEATING
ELECTRICAL RELEASE
HRE DEPT.
GRADE
OCCUPANCY
TEMPORARY APPROVALS
ELECTRIC
GAS
BUILDING - IS6LJ,L�L�ILE DATE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTILP`I'llL7
BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR '
�1 I ARRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN )AN
12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND Gj}x pf Crin°FtJRo
PERMIT# ARE NEEDED WHEN PHONING.
IMPORTANT! !
PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION SSD oer. .�. rR w 1 U
OFFICE COPY