22154APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
[Address:
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LICENSED CONTRACTOR'S
ilicense is in fub and effect.
ice.. Coss lL.•aa d� Lie. M T S C7b
Date Contractor
ARCHITECTS DECLARATION
w0 O 1 understand my plane shall be used as public records.
Licensed Professional
«< OWNER -BUILDER DECLARATION
7 �7a Ihc.byafflrm that l am exempt from the Contractor's License Law for the
O
following reason. (Section 7031.5, Business and Professions Cade: Any city or
09r eau my which requires a permit to corwtmd, altep Improve, demolish, or repair
any structure prior to Its Issuance, also requires the applicant forsuch permit to
ry1 fill a signed statement that he Is licensed pursuant to the provisions of the
Contractola License Law Chapter 9(commencing with Section 7000)ofDivl-
F O the besfo Budnessand Any
violation
of exempt therefrom and
0 the baso for the alleged exemption.theap Any viola civi of Section t 15 by any
appfive huntfonollars $5Msubjects the appllcanttoa dull penalty effort more than
flue hundred dollars ($500).
Q •• �n F� 1, as owner of the property, or my employees with wages as their sole
compensation, wW do the work andthcatmeum Isnot intended or offered for
n sill (Sec. 71366, Business and Professions Code: The Contractor, License Law
� $ does not apply to an owner of property who build& or improves thereon,and
who doessuch work himself a through his own employees, provided that such
improvements are not Intended proffered for sale. If, however, the building ar
Improvement issold within one yearofcompletion, the owner -build erwill have
tfgjrerel en of proving that he did not bit lld or Mpmve for purpose of sale.).
L j I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sac 7066, Business and Profenloru Code:
The Contractors License Law data not apply to an owner of property who
Wilds or Improves thereon, and who contends for such pGoJeds with a
cgR[fador(0 licensed pursuant to the Contactors Limn. Law.
LI I am exempt under Sec. B7 F C for this .neon
I hereby affirm that I have a certificate of consent to self -Insure, or a
irate of Workeri Compensatlonlmurance ora certlfled copy thereof (Sec.
Lab C.)
ertlitM copy 6 hereby famished.
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF E(EM PTION FROM WORK ERS'
COMPENSATION INSURANCE
(Thlssection need net be completed lithe permit is for one hundred dollars
($100) a less.)
I mnily that In the performance of the work for which this permit Is issued,
1 shall not employ any person In any manner so as to become subject to the
Workers' Compensation Laws of California. Date
O Z Appllcant
Z Q NOTICE TO APPLICANT: If, after ma king this Certificate of Exemptlon,you
Fshould bacomesubject to the Workers'Compensatlun provisions ofthe Labor
CCN Code, you =at forthwith oomply with auch pmvWorsorthis permit shall be
LU 9 deemed revoked.
CL o CONSTRUCTION LENDING AGENCY
f hcmbyaffirm that there 6 a comtmetion lending agency for the perform -
7O once of the work!or which this permit 66vred(Sec. 3097, Cl, C.)
(� leader's Name
LL f Lender's Add.
O W ce
I rtifythat l have read this application and statethat theaboveleformaRon
0. 6 mrred. l agree to comply with all city and countyordlnences and gate laws
relating to building reIlly
endhereby authorize.prexntativn of this
)— Z city to enter upon it mien for for Inspection purposes.
— (We) agree to an d keep harmless theCityof Cupertino
agairg'11201 psteand expenses which may In anywayaceme
againstold�l&ha grant Ing of this permit.
I Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I lealth and Safety Coil, �SSection 25537(1)7
n yes,LJ No
Will the applicant er uture building occupant use equipment or devices
Wiff
t hazardous air ro"'t-mm nsasdefined bythe Bay Area Air
ai-6ment District?��a❑❑ No
uead the hazardwa materials requirements underChapter 6.95of
rnia Health k Safety Code, Sections 25505, 25533 and 75536. ]
understandthat iff Ildlng don not co rrently haves tenant, that it6my
re§pbrufbl ton i the oavpant of the requirementswhichmust be met
prior to l• neap Cartiflca ccupancy. —
Q _10 -//
or
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT S
BUILDINC-ELFCTRICAI.PLUMBING-MECFIAMCAL CATEGORY
ELECTRIC PERMIT
POWERDEVICES
OUTLETS$ W ITCHESSFIXIURES
NEW RESIDENIIALELECTR
FEE
El El El
2154
N
A i CL�y��7�U-s>�DL%���0�
IALED
MPUTE
)RAIN A VENT- WATER IEA)
ENERGY FEE Y_ N
PAID
Date Reeei til
OW PROTECT. DEVICE
WATERSYSITM/TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
FLOOR ROOF, AREA, COND.
SANIT,
S-PERTRAP
SD•IIX
,SYSTEM -1 INC40UTLETS
PARKI
,SYSTEM-OVER4(FA)
TOTAL:
IINDUSMLWASIEINTERCEPTOR
PLAT`
TRAP
PAID
FEE SUMMARY
RECEIPT I
FEE
WATER HEATER W/VENT/E-ECTR
ENERGY FEE Y_ N
PAID
Date Reeei til
WATERSYSITM/TREATING
NEW RESIDENTIAL PLMB. SQ.FT.
_.I3U11xQING
TOTAL:
f•
SEISMIC FEE
TOTAL:
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEEMECHANICAL
FEE
PERMIT ISSUANCE ZM
FEES PAID: -
ALTER ORADDED MBCH.
Date RnCeiptq
( AIR HANDLING UNIT (TO 10,000 CFM) `L,a(/
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
E(MUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
,{fir
HEATING UNIT (10 100,000 BTU) �(„ij/
Date Revel til
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
e
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
two
A d
BOILER -COMP (3HP OR 100,0(] BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ,rr,
TOTAL' IZ CUj
(, OFFICE COPY`—_"_--'-' -- i—.�
Frank among 1698 S. Blaney Ave, San Jose, CA 95129 Tel: (408) 406-2213 Fax. (408)253-7559
Building Department I [ l Do D
The City of Cupertino
Saratoga, California
January 7, 2015
Subject: Special Ins ection of Epoxy Holdown Anchors
10240 Yos no Place FULE
Cupertino, alifornia t
Gentlemen:
This is to certify that special inspection was performed for the installation of 5/8"
diameter all -thread rods imbedded through plywood shear walls into existing concrete
foundation as shown on structural foundation plan.
The installation of 5/8" diameter rods were drilled with 3/4" diameter holes, 12" deep.
The holes were wire brushed and cleaned. They were then filled with high strength
Simpson SET -XP adhesives. The all—thread rods were then inserted into the holes. The
contractor was informed on site that a dry time of 24 hours shall be allowed before the
hold-downs are attached to the walls and the rods shall not be loaded within 72 hours
after installation.
Based upon my observations and to the best of my knowledge, the installation satisfies
the procedures recommended in ICC report ESR -2508. This letter shall be used solely as
special inspection report of the installation of epoxy holdown anchors, and the contractor
is not relieved from compliance with the structural documents. This letter shall not -be
used as approval for any construction operations/practices in the field.
Very Truly Yours,
Frank L. Kong, P.E
Project Engineer