S 2068 (2) APPLICANT TO FILL-IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
;BUB'
TY OF CUPERTINO BUILDING-ELECrRICAL PE IT IN /�
DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 2O68BUILDING PROJECT IDENTIFICATIONVH.DINGADDRESS' � . , S�NO. APPLICATION SU�BBMJITTAL DATE
NER'S NAME: 02403 O pH-,A��o� pCl'ORitA LICNO: _3(^ `�N/C CONTR`OL p
CHITECT/ENGINEER: LIC NO: DRESS: _NTACT. vHONE: BUILDING PERMIT INFO
p J` ❑ Consultant Fees Paid by Applicant(Initial) )(G ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FAaz th Secuan7li(p)uf Divi,ioo3 ohne Business and ProfusionaC de.me mylicense is
s'- Wtmn loreetme Iw PERMIT ISSUANCE RESIDENTIAL
.4UU Livens Inas Lue.of - � _ ❑SFDWI. ❑KITCHEN REMODEL
rFaa Daa Contractor APPLIANCES—RESIDENT'IAL ❑ADDITION Ll PLUMBING RE-PIPE
ARCHITECF'SDECLARATION
z0f,lz PANELS ❑MULTI-UNIT El STRUCTURAL
Iundersmnd ivy plans shall he aced as public records MODIFICATION
524- UP TO 200 AMPS ,�s
F.1"'Iyl L¢enue Prufeasronal - ❑INTERIOR ptCHIMNEY REPAIR
Q .I 201-IfNI(IAMPS IMPROVEMENT
iK Gi OWNER-BUILDER DECLARATION C]SWIMMING POOLS
0. 1 hereby affirm that 1 am exempt from the Contractor's License Low tar the OVER 1000AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION
X 0.0 following reason.(Section 9031,5,Business and Protestants Cade:Any city or county ❑OTHER
W 3 p,F' which re SIGNS ELECTRICAL
F Its,Orn requires a permit to coanmeto.Iter,improve,demolish,or repair ony scours
m Plant.ifs iemance,nlsp requires the applicant for such permit m File a signed statement SPECIAL CIRCUIT/MISC.
y (hat he is l icensed Earaannofha provisions of Ne Contractor',License Law(Chapter 9 - _
N (commencing with Section 7000)of Division 3 of the Business and Professions Cori)., TEMP.METER OR POLE(NST. COMMERCIAL'
IL p,o yr that he is exempt therefrom and the basis for the alleged exemption.Any violation of - [:1 NEW BLDG/ADDITION ❑DEMOLITION
W.a rn Section 7031.5 by any applicant for o permitsubjw¢the applicant m a civil Penalty or POWER DEVICES
F z>f nm more than Five hundred dollars($500). E TENANT ❑FOOD SERVICE
F4 ❑ 1,as owner of Ne Property,or my employees with wages compensation, - IMPROVEMENT
� payceswi gesustleirdoce70m tion, SWIMMING POOL F:LECfRIC ❑OTHER
andwiltip lesions ande he Cure is not s Livens Law does
Is not apply in
Business
and property
who
Code:The Contractors License Low dues not apply s .n owner of OUTLETS-SWITCHES—FIXTURES
propeny who builJs or infpnrves Nercpn,and who eon such work himself or through
his own employees,provide)that such improvements are not intended or offered par NEW RESIDENTIAL ELECTR SQ FT.
sail.If.however,the building or improvementisNld within one year atcompl,fon,the _ SQ.Ur.FLUOR AREA S/SQ.Fir
wner4 uilder will have the burden of proving that he did not huild or improve for put-
few l f eldca)
❑ I,as owner of the property,am exclu.ively contracting with licensed contractors no TOTAL
tmtruet the project(Sec.7044,Business and Professions Code:)The Gmlmetor's LI-
se Law does not apply to an owner of propeny who builds or improves thereLU
on,and QTY, ,PLUMBING PERMIT FEE
who contracts for such prolwfs with a centraclnr(s)licensed pursaantto the Contractors
License Law. PER
MIT ISSUANCG
❑ I.mexemptunder Sec. nis
,B&PC(nhrosam
,neALTER—DRAIN&VIII TE
r Dale VAIAA'I'ION
W.under
WORKER'S COMPENSATION DE CLARATION BACK PLOW PROTECT�IP LCB 9/OOCOQ
Iherebyalarmunder penallyof e,p fC.c oneofthe following Jalker, o OLIO
(have add will maintain aCenifcate ofConscnt to self-amore far Worker's Compen- DRAINS—FLOOR,ROOF. ,(RLN STORIES TYPE CONSTRUCTION
I
ion,as provided for by Section 37(n of the Labor Code.for the pedorromm,of the /
rk for which this permit is iswed. FIXTURES—PER TRAP
1 have and will maintain Workers Compensn(mn Inst once,as required by Sectionm of the Labor Code,for the performance probe work far which Nis Permit is issued, GAS—EA.SYSTEM-I INC.4 Oil FLETSOCC.GROUP APN
Worke'a Compen tion) ter and Policy pnyu��t,ee�r��r�rom A� rn Policy NarOei'NnG9C3D-6 GAS—EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GReASEANDUSTRL WASTE INTERCEPTOR
(This section need not be completed litho permit is for one hundred dollars IS I M) BUILDING DIVISION FEES
offers) GREASE.TRAP PLANCHECKF E
lay any ohminthe any mannerof as he
for Which to
the Wopermit kersuCoppe -hot I SEWER—SANITARY—STORM EA.200 IT.
not employ any person is any manner to ac Ip become subject m the Workers'Copper- ENERGY HE
sabot laws of Caiil'ornia.Date
z O Applicant ' WATER HEATER W/VUNT/F.LF.CTR GRADING FEE
tti y
NOTICE 10 APPLICANT:If,alter making this Cenlfcate of Exemption,you should WATER SYSTEM/TREATING
E Imo'" become-subject to the Worker's Coatpenmoion provision,of the labor Code,you must SOILS P
W �y forthwith rnmply with such provisions nr(his permit shall he deemed revoked. WATER SERVICE
6 n
CONSTRUCTION LENDING AGENCY
D ,Z NEW RESIDENTIAL PLMH. SQ.FT PAID
A) O kfor,huchrm lheainisa .it(Sb,,30lending agency tonne per6rmrroe of Re"Th#
U. he work fnr which the permit Is issue)(Ser.3097.Civ.CJ
ULender's Name
Larders Address TOTAL' JIOTAL
1 certify that 1 travelers]this application end Into that he above iafozmmid.is l BUILDING Q
o-.. h convect I agree to comply with all city and county ordinances and state laws relating I(, QTY. MECHANICAL PERMIT FEE
U building consumption,and hereby authorize representatives oflhisciy to echatmorthe SEISMIC FEE.
drove-mono and provincial Ibr inspectionpurposes.
(We)agree to save,intim reify and keep hnnnless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
babilities,judgmena,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in mequence of the guarantor this permit. _ PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T(110.0(p CFM) MECHANICAL FEE
SO�URRCC�E�REGUULNUONS.
SrL4 0,104 AIR HANDLING UNIT(OVER 10,000)CPM) CONSTRUCTION'TAX
Signature of Appinen nmoshor Dole EXHAUST HOOD(W/DUCI'f HOUSING MITIGATION FEE
AZARDOUS MA'T'ERIALS DISCLOSURE
Will the applicant.1 future building Mcupant store or handle hazallous material HEATING ON]'1'(T0100,000 B'1'U)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Hanhh and Safety
Code,Section 25532(x)^ HEATING UNIT(OVER I(gAW BTU)
❑Yes ❑Np
VENTILATION PAN(SINGLE,RESID) PAID
Will the applicant nr future building occupant use equipment or devices which Date Receipt M
.it limitations air aomamimma as defined by the Buy Arco Air Quality Management BOILER—COMP(3HP OR 100,000 BTU)
7Distriod' TO❑Yes LJNo BOILER—COMP(OVER I00,00GBTU)
I have cad the haz�rd.-materials reyuiorari under Chapterfi95of the Cali- AIR CONDITIONEkISSUANCE DATE
mia gdoes&Safety Gude,Swoons 25505,25533 and 25334)undemumd ohm if Ne NEWRESIDENTIALMECH. SQ.FTilding Noes not cutrcn0y have a tenant,Nm 0 is my responsibility oo notify theoxwpnnt the requirement,whlch must ba mct poor to krranceof a Catificme of Occupancy. (� 1wner or authorized agent Date TOTAL: ISSUED BY ` k A
OFFICE
FROM ' LU PHONE NO. Oct. 31 1999 09:30AM P3
POSTTHIS CARD I i R FRONT OF BU
CITY OW CUPERTINO
BUILDING DIV—ISIONBUILDING PRojEcrinwiseNrioN
)ANI(ARYNCI. APP)iCxrloN SUTIMIMAI.Mil
DING ADDRF.vS
r 3 c
A11111.1 .1
NA
-liv.S(AN�ER:
("Hilix 7A�
UUILDINO PERMIT INFO
INSPECTIONS DATE INSPEC. ED Cmisulljint I nr Paid by ApplivoliL jfililid4 mx("l PLUMB 11LC'H
0
IjOUNUxrlQNlPII3RS/H.0.5. INSPECTION RECORD
ION DESCRIPTION
UFER GROUND NOTE: ALI, GRADINU, AND DRAINAGE. RESIIMNIJ�Aj;
SHALL BE INSTALLED 1'0 COMPLY WITH 1_1 SFI)WI, K I I(.HUN RU M01k.l.
PADISET nAC CERT THE APPROVED PLANS AND CITY OF IJADDIIION LIPLUMBING RU.PIPC
GARAGE SLABS/PREOUNI'l 1, CUPERTINO STANDARDS. rr f-l.StNL["UWM
NIOD[HrAIION
POUR NO CONCRETE UNTILABOVE HAS BEEN SIGNED TO ARRANGE INSPECTION X HNMNEY kEPVR
1Mf-k0VFNlFNT
UNDERGROUND/SLAB CALL AFTERNOONS (1:0U PNI - 4:.AO I'M) 1-1 ,,,kj;M(,j)FJjKj;PAHR 7 LIFNfOUTION
71�ljm
BING
777-3228NIONDAY,10 FRIDAY24 HOURS BE- Dom:*
ELECTRICALFORE REQUIRED INSPECTION. JOB ADDRESS
DO NOT POUR FLOOR UNTIL-ABOVE H A S BEEN SIGNED-
AND PERMIT#ARE NEEDED WHEN PHONING. CQMMEXCIAL
PLUMBING ATTENTION CONTRA(71'ORS: IDNEW111.00AN)MON UPILMOLITION
NO PERSON(S)SHALL.PERFORM WORK ON 1 1 KNANT
MECHANICALTHIS J013 SITE WITHOUT BFINQ IN COM-
PLIANCE WITH W(,)RKERS'COMPFNS/Vl"i(.)N
FRA 1-11 N(�V INSURANCE REQUIRFMI--NTS.
lit-ATIONwsprtc'ru1NSPECIAL I N S P bC I !ON R FQ)U I R IED ❑ imn INSP.
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
R0017 sHEA:rR/DIAPHRAM
PLUMBING
N
S&S5T)%—VERPAN--
'FIANICAL
E3,ECTRtCAI.JK)OL BOND
FRAM INGP STAIRS/E.E(.',Rf-;SS
INSULNI'TONIVENTILATION
COVER NO WORK UWTILABOVE HAS BEEN SIGNED
EXTHRIAL SHLAR/HOLD DOWN
INTERIOR SHE AR/1-IOLD DOWN
SHIEFTWROCKYSHEETROCK SI LEAR
EXTERIOR LA 111 7W'•S C R I��E 1)
SHOWER LATH
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
SCRATCH COAT
SEWER/WATER
TEMPORARY APPROVALS
OCCUPANCY
FLEC I R I CAL
,
GAS HOUSE UNTIL
WNALS
GAS TEST DO NOT REMOVE PF- TROTPLF-L-1
,�Spf-,C,TION IS COM
GRADE CII-IIN14NEY 11
THANK You!
HANDICAP
FCTRTT M.
IM BINO
ItE. 'HANICAL
-RG.Y CERTIFICATE OF ()(.-'.CljlANCY
VISUAI.'FINAL ONIN ISM. .1.1.
LDING IMPORTANT:
FOR H'
lhT
:UCCLfFANCF&P-bunt—mc� 6T PLEASE READ KLVERSF. SIDE BE
CALLING FOR FINAL INSPECTION!!
6w