S 0255 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO xuu,umc-EEEcrRIGU. PERMH NO
.
BUILDING DIVISION APPLICATION/PERMIT PING ROU-MECIIANIFIC S 0255
I4UILDING 1'NOJ66T'IDENTIt'ICAI'1ON
jNIC
SWIMITTAI.UAIli
BUILDINGADDRLSSI :�— / CONTRAC DRS NAMIi: LIC NO: Y)NTkOI,k
C NO: /V ADDRESS:
O ,PACT: PHONE: BUILDING 11I714MIT INFO
5laeYA?",rr q3-1443 6 Csnsxhaxt Fees Paid by Applicant(Initial) BL G BLE,CTy 11VM CG II
LICCNSED CON'1'RAC I OR'S DECLARN'[ON QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION IrIJY
I hereby mlirm that I in herrosd under prwidon,of Chapter 9(vonanencing
FCZ with SEt¢ea 00)offeffiraDivision Sof the Busines.vnd Pmfe,unit,Cust ndmy licence is RF ID NTIAI
WOO PI 1111 ❑SFDWL ❑KITCHEN REMODE1.
in aUU Liccnse Class Lich APPI.IANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PTPE
rr~ici Doc Comrnaur ❑MULTI-UNIT' ❑STRUC'fURAI.
ARCHI I'ECr'S DECLARATION PANEI S MODIFICATION
~ Z 1undemand my,I....hall be used av public recams UP TO 210 AMPS
ZO C]INTERIOR C3 CHIMNEY REPAIR
OZ-�
F ly Licensed Pmfcssional 201-1000AMPS IMPROVEMENT SWIMMING POROUS
OWNER-BUILDER Up I.ARATIONOVER IfM0 AMP5 E]BAFH RI?MODEIAREPAIR ❑DEMOLITION
W 6 1 hereby,allirea that 1 an exempt front he Commit""'Liccnm I.aw for the Q OTHER
a O a U following reason.(See ..7031.5.Business and I'mil comix Calc:Any city or county SIGNS ELF,CfRICAI.
1+13
LLF` which requires a Permit to construct.alter,improve,demolisb,or repair any clmmure
F"u'OQ
prior to ass Io,requires thppl< t farxpch rNarail to rile a signed statement SPECIAL CIRCUI rIMISC. ry p
��}" lhmM1 I Jp n th p o I'rl C t 1'n 1 w(Ch.mmr9 r'OMMFRCIAL' 1' K 6D
�y'QD (cnnmencing with Section 7000)of Division ltM1 Business dl (::ions Core)nr TEMP'M CI'ER OR POLE INS'1'.
Ea.a c tY that he is exempt therefrom and the basis for the alleged exemption.Any......tion of !❑!--,,A�NEW BLDG/AUDITION DEMOLITION
Xm_a Section 703 by any applicant for o Permit subjects the applicant ma civil pe..try of POWER DEVICES JKENANT �.Sw .a pFWD RVICE
T'' to not more than live hundred dollars lESWI. IMPROVGht a 1
�4QDI.a,owmerml'the property,nr'Oil employees with wages un their vale compev,alom, SWI MMI NO POOL ELCCTRIC ❑OTHER
t• will dumnsix 1'k,and thesuocmreis ma intended nrollered forsale(Sec.9144.timiuOsl OVII.IfrS-SWDCUS-FIX TURES
a3 m amt Pmfesions Code:The Cantmcmrs License Law does not apply to no owner of ,
poll who builds or impowes,hemon.and who does such work himself or mmugh NEW RESIDENTIAL ELECIR SQ 1'r.
his own employees,provided that such improvements are not intended or offered for SQ.FT.1:1,00K AREA EISA.IT.
edea IL however,the building or imprnvemenl Is old within one year of.......letion.the
owner builder will have the burden of proving that be did not build or improve for npur-
pom.1 tale.). TOTAL:
I.as rwact or the property,am exclusively contracting with licensed contractors m j yO
1
construct the pmtjat(Scc F
ns 7614,Business and Profc,doCmi The Contractor,Li- PLUMBING PERMIT O`1( s
censcl.aw docs outpplym nm Is, or propcny who build.or impovc,thereon.and QTY.
who co dmicts for such ymjmtx with a eons actors)licensed p.,.an,to the Conlmemr.,
Licenxe Law. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
AMER-DRAIN&VENT-WATER(EA) VAI.UAr10N
Owns, DateMIq ./ 010
WORKER'S COME DECLARATION HACK ,OW PROTECT,DEVICE
•.I' I hereby alBren under penally of Perjury one of the fullswing declarmonst
I have and will maintdnv C,nmctte or Cmncent 1.self-insure forWmkia,Co.,.. DRAINS-FLOOR.ROOF.AREA.GOND. SRHS TYPH.C}O�N'S�TR/UC7GON
sation,as provided fur by Section 3700 of the Labma
Labor Code,for the performance of the PIX'rURES-PF:R'I'RAP / ' /
ark for which(hispermit is issued.
0 1 have and will maintain Worker's Cmmpenmtion Insurance,as required by Section GAS-FA.SYS'1'1INC,M..IN4 OUTI,ETS
3710.1'the later Code.far the perfnman
rceofthe work for which IS,pemti'is issued. OCC. OUp APN
My Workers Compensation Insurance carrier and Policy number am: GAS-CA.SYSTFM.OVER 4 HA)
rri
Caer: Policy No.: A
CERTIFICATE OP EXEM19'ION FROM WOR KERS' GRIiASIIINDIJS'I RI,WASTE IN'I'13NCF.PIOR
COMPENSATION INSURANCEBI - G VISION FEES
Tinsmctionneed not be completed LEON Permit is forms,hundred dollars C$100) GREASETRAP PLANCHEC +C 00
or lees.)
I ,minthe performance athe m wuruts rl. SIW1iR-SANITARY-STORM r:A.2W FIINIRGY FI
nucntplo,anpimm In- Y nwnnm nnn,In he,,cnsubjecl In the Workis ers issued.
variant Lows of California.Date WA'I FR HEATER W/V1iN fl1,EC'IR GRADING 1921?
ZO Applicant -
sN., NO-RCE TO APPLICANT:If,Offer making this Certificae of Exemption,you should WA'rFR SYSTF.MiTREATING SOBS Rli
[-� fa cons,subject ht the Worker's Compensation provisions of the Wrxm Code,you most
iimhwirh comply with such Pro'va.,onhhs permit hall he dccmcd revoked. WXI ER SERVICE
PAID
CONSTRUCTION LENUINGAGCNCY NEW RESIDENTIAL PLMB. SR FC Dale < pt
UO Iherchy vfxrm mat mem isecmnaruc,inn lensing agency 1'.r the perfomtavice of
W E-+ the work for which this permit is issued(Sec.3097.civ.C.) OTIC:
O U Landers Name TOTAL:
r lander',Addrexv, RUH-DING FE O ��
6. 1 cenify Ill.,1 have mad this applica,io r and eaa mate above information i..
ielect.I agree,ocmmply with all city and county ordinances and since law,miming to QTY. MECHANICAL PERMIT FE: SEISMIC
N7
V G building eon.aruclion,and hereby authnrim representatives of,hi.c citym enter upon the
uMwe-ntcm edproperty fminspccdnn pnrptos PERMIT'ISSUANCE ELEi RIC 717
(We)agree to save,indemnify and keep hurmle's the City of Cd,mro again.
Imbili,i,e,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FTE
in cmnmquenee.1'the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HI.IXXI CFM) MlIC14ANICAI SCE
SOURCE RrVC UI.ATIONS.
AIR IfAND1.ING UNIT(OVER 111.60 CFM) CONSTRUCTION TA
Signature of Applicant/Contractor Dam EXHAUST HOOD GNMUC) HOUSING MITIGATION FE
HAZARDOUS MATERIALS DISCIASURE
Will the applicant or fnmtre huilding occupant etnm or handle ha soloue matedol 1117ATING UNI"I'110 110.011)8"1'U)
as deined by the Cupemna Municipal Calc,Chapter 9.12 and the Health and Samly DEATING UNIT(OVER IN),000 BTU)
Gde.Section 25532(x)'!
0Yca Cl No VENTILATION PAN(SINGLE RE-SID) PAID
D;vc kmcipt
Will the applicant or t'umm building acupant use equipment or devices which BE ELER-COMP(IIP OR Emma)B'I'U)
h hauavka,air cunaminasts as defined by the Bay Arca Air Quality Management 'I )TA L:
)BtricTl BOILER-COMP(OVER 100.1X0 BTU)
❑Yes ❑N.
AIR CONDITIONER ISSUANCE DATE
1 have read the Code. us ntacrid,mgoi 533 an order Chapter 6.95(if the Culh
fmmia Healthbuilding
&Safety Code.Sections 2that i 255]3 and ns511.1 to indilaml rho if the N1;µRI3IUENTIAI.MECII. SQ.IT.
of thong does mom,which have the.1.that d is my responsibility Ch clfi m aotify me«cupum
of me requirtntents which must be stet prior m iz.uanm of a Cenifi<am of(kcupanry.
Owncr.r uulM1nrimJ.gem
Date '101'AL: ISSUED ItY:
OFFICE
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
Fui in
Fc,-
Plumbing Power Pole
Mecca r oun
emp as ec � ugH irin
Solar Waiis i^
Fire Sprinkler Ceiling
Sign ixtures int/Ext
tors
Misc. mound
'Reower
er
FINAL INSPECTIONS DATE INSP. Not .Approved
Gas
Electric
um in PLUMBING DATE INSP.
anica
oar Backflow
,•'oo r un
r in OPEN
azmin Partial ou
ire pt. 31 ( u ete
Ugt. ar ou
ui��in ater ' Insulation
0er
o a3.n
Gas
Dther
BUILDING DATE INSP of Approved
Pad Certification
Foundation ELECTRICAL DATE INSP.
re- unite
Slab4bubrane Underfloor S.M.
9Yn-d-tFw—n Ducts & Insulation
Under±loor i ersirk e� ers
oorteeFireplace_.
ie ownsreuse 7Duct o0
is rams a our a t
eismec racin 7m—Men—sate Drain
Wal s- ane m ent Anchorage
Frame a Flues 4 Uomo. Air
aL thitt� eTr
�a oar nt xt. of rove
�irewa s
Other
Net rove