19434 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BufldingAddreys: 19434
WXLC C/
wners ante: Phone: Iq
CITY OF CUPERTINO-BUILDING DIVISION
cenerado aNam: CIeNe: APPLICATION / PERMIT0� _
BUILDINGELECTRICALI'LUMBINGMFCHANIC' L CATEGORY CONTROL t( l
rch /Engineer. k.No: J G..
QTY ELECTRIC PERMIT PL'. l 'FE$ IR ) BUILDING PERMITINFO
Add. PERMITISSUANCE - CL.0 y N KI
❑ ❑
LICENSED CONTRACTOR'S DECLARATION fin
APPLIANCES-RESIDENTIAL r R
I Mrcbyiofirmthat f Division
ofunderprovisionsof Chapter 9de,and c- JOB DESCRIIPIION
Ingwith .full for.
(lhe Business and Professions Code,and my
Livens Is In full force and cited. PANELS
License Claim Clea `n
I Date C ARCHITECT'S
r V
ARCHITECT'S DECLARATION OVER0000AM
0' understand rtryphreahall be used vpublicrecoNa OVER IOW AMS SQ.FT.FLOOR ARG f/SQ.F .
wwO
Licensed Professional SIGNS ELECTRICAL � LAD
• < OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
DH7 Ihembyafl.that l am exempt from the Contractors License Law for the
DOfollowing reason.(Section 7015,Business and Profashms Code:Any city or TEMP METER OR POLE INSr.
F I"' countywhich requires a permit tomretruct,alter,Improve,demolish,orrepair
4M
anystmu mpdortoiUat ancGaisarequimtheapplicantforsuchpermitto POWER DEVICES
6 O file a signed statement that he Is licensed pursuant to the provisions of the
�3
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMNMNGIY)OLELECTRIC UA
sion 3ofthe Business and Professors,Code)or that he b exempt therefmVAC
mand
the basis for the alleged exemption. Any violation of Section 7015 by any OUTLEISSWITCHFSFUOURES O
"�65 appliontforapec tsubimutheapphcanttoadvilpenaltyofnd=mtbn
five hundred dollars(¢500. NEW RES/DEM7ALELECTR
I,as owner of the roe `SQFr.. RIES TYPE CONSTRUCTION
? property,Pry,or he employees with wages r thele sole
compensation,will do the work and the structure b not Intended or offered for
vie(Sec.7004,Rumness and Profeviore Code:The Contndols License Law
�$ does not apply to an ownerof propertywho builds or lmpro,mthermn,and tXCGROUP RFS.UNITS
who doessuch work himself orthrough his own employees,provided that such
improvementsarenotlntendedoroffemTforsak.If,however,the building or TOTAL:
improvement bwld wlthinoneyearofcompldiogtheowner-bu0derwBl have
tryg¢rzdenof provmgthat he did not build or improve forpurposoofsak.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with EcensM PERMITISSUANCE
contractors to construct the project(See.7004 Business and Professions Code:
The Contractor's License Taw docs net apply to an owner of property who ALTER-DRAIN&VENT-WATER OINK
w Idro
s or Impve m
thon,and who contracts for such p(ojeds with a FEE SUMMARY
,[Lt.[actor(s)licensed nd
Funniest to the Contor's License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec. B& P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_�
• Owner Date RPCFlIPf p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI IDOL TAX Y N_
❑1 hereby afllrm that I have a certificate of concent to wlf-Insure,ora RECEIPT If
certflumofWorken'Compensation Wuranre ora renl0ed copy thereof(Sec. GAS G.SYSTEM.1 LNCAOUTLETS PARK FEE Y N
38W,lab C. —
PoliryM G CAS G.SYSTl7.4-0VERd(EA) RECEIPT'#
BDILDING DI VISION FEES
,�;rrl(A copy Is filed with
city
1 1 n. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
faCertifled copy k filed with the city Ir�spectlon division.
y^' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID _ r
COMPENSATION INSURANCESEWER-SANITARY-STORM EA pBF-I. Date Recei tH
(rhlssection need not be completed if the permit b forone hundred dollars
(f1(0)or less.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y_ N
ce _
I nlly that In the performance of the work for which this permit is leaned,
I shall not employ any person in any manner an as to become subject to the WATER SYSTGM/TREATING
Wmkord Comprrmgxm awsof Cahlomk. Date PAID
OZ Applicant NEW RESIDENTIAL I'LMB. SQFT. Date Remi tq
Z O NOTICETOAPPLICA -.1f,.her. Wngthb CenBiateof Exemptbnyou
Hshould becomesubjM to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provkiov or this permit shall be BUILDING FE d�
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d O Iherebyaffirmthm there ba construction kndingagenry forthe Perform TOTAL: ELECTRIC FEE 2�.DD
7 Z area ofthe work forwhkh this permit b Issued(Sec.3099,CIv.C.)
O O Iendece Name PLUMBING FEE
Lendreanddreas QTY. MECHANICAL PERMIT FEE
OW Icertlfylhatl havereacithkappBcationand date thatthe above Information MECHANICAL FEE
S Iscorred.Iagreelo complywlth all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned property far Inspection purposes. ALTER ORADDTOMECH.
_ Remi t
(We)agree to save,indemnity and keep harmless the City of Cu accrue Date
AIR HANDLING UNIT(TO 10,OD0 CFM)
against liabilities,judgment, e sand expenses which may in any SUBTOTAL: stir
against said City In monryuence of the greming of this permit. AICONSTRUCTION TAX
R HANDING UNIT(OVER 10,000 CFM)
Signatu to of Applicant/Controcior Data IXHAUS r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand in hazardous HEATING UNIT(TO I W,WD BM Date Recel til
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the -
Health and Safety Cod Stolon 25532(a)t HEATING UNIT(OVER 100,00 BM TOTAL:
❑Ye M No
Will the a pplicant or Tutu re building occu pant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air 10 A R!V
Quality Management District? BOILER-COMP(311POR 100,B00 BTU) CALM
Yes No
have mad the hazy ous Rutenals requirements under Chapter 6.95 of BOILER-COMP(OVER IW,000BTU) a�
the California Health&Safety CWe,Sections 25505,75533 and 25530. I
understand that if thebullding does not currently have a tenant,tNrt it b my NEWRFSIDENTIAL MECH. SQ.FT.
nsponsibllitymnatifytheoccvps dthereqrc
ulrernt -must bemet .f,
pr, r m ksuanm of a Certificated ) City Qf etriq
Owner or
red!agent 2/e ISSUED BY:
TOTAL:
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING PTRMITN . 34
CITY OF CUPERTINO "y A.
INSPECTION DIVISION- JOB INSPE?IOI�RECORD
'JOB ADDRESS 9 I Z3 UNIT# LOT# CA By IoNrROL a N
OWNER Su 4E � ONTRACTOR 4e s BUILDING PERMIT INFO
INSPECTION DATE INSPECTOR INSPECTION RECORD
FOUNDATION/PIERS NOTE ALL GRADING AND DRAINAGE 1:1 11
UFERGROUND SHALL BE INSTALLED TO COMPLY WITH JOB DESCRIPTION
PAD/SETBACK-CERT THE APPROVED PLANS AND CITY OF
CUPP.RTINO STANDARDS.
GARAGE SLABS PREGUNITE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND/SLAB TE INSPECTION DAINSPECTOR
PLUMBING
ELECTRICAL
MECHANICAL
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR
PLUMBING
MECHANICAL
ELECTRICAL
FRAMING VENTS CLEAR
INSULATION
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROUGH
PLUMBING
TUBS&SHOWER PAN
MECHANICAL All I
ELECTRICAL ACUZZI BOND
FRAMING/STAIRS
INSULATION/VENTILATION elm
EMERG.EGRESS
. SEWER WATER
• COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
EXTERIOR SHEAR HOLD DOWN
INTERIOR SHEAR/HOLD DOWN
SHEETROCK/SHEETROCK SHEAR
EXTERIOR LATI-I/W-SCREEN
SHOWER LATH
SCRATCH COAT
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
NOTE:NO FINAL INSPECTION SHALL BE MADE BEFORE
THE CONSTRUCTION TAX IS PAID
FINALS DATE JNSPECTOR
SAN.#
ELECT.ENERGY
PLUMBING ENERGY
MECH.ENERGY
13UILDING ENERGY
ELECT.FINAL TEST
PLUMBING
GAS TEST
MECHANICAL
HEATING
ELECTRICAL RELEASE
FIRE DEPT.
GRADE
OCCUPANCY
TEMPORARY APPROVALS
ELECTRIC
GAS ,
13UILDINC ISSUANCE DATE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL
BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR Pma
ARRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN
12:30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS u. LE i $�
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND
PERMIT # ARE NEEDED WHEN PHONING. City, of(:!1 ert-00
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION lSSUEDBv?�
OFFICE COPY v