20621 (2) APPLICANT TO FILCIN INFORMATION WITHIN RED LINES =USE-BALL POINT PEN ONLY '
Building Project Identification '- - - _ I,�/ PEFtbRTNO. '
0ulldyg Address: - - LJ
20621,'
ner9 ams: one:
CITY OF CUPERTINO-6UILDING DIVISION
ye: ue Nn:' APPLICATION /PERMIT . T S 9d
6RE some SSD
.. Brill
CATGRYArcItd . BUGELKUCALPLUMINMCFIAMCALt ' CONTROL X
Lk.N°:
- QT ELECTRIC PERMIT' FEE BUILDING PERMIT INFO '
Address:
PERMIT ISSUANCE". . ❑
LICENSED CONTRACTOR'S DECLARATION -
IherebyaffirmthatI am Banned under provisions of Chapter9(comuson, APPLIANCESRESIDENTIAI.
ingwlth Sedio.70M)of Divisio.3ofthe Buainenand ProfnslonsCode,and my JOB DESCRIPTION
Iicense Is In full7 f° d effect _ PANELS - '
Lice. IassC �7 Llc.X &,sj /
Dare GHITcutbIECr _I�fn011 ata /j//J/711/�
ARCHITECT'S DECLAR TION UP
C./�
0Z I understand my plant shall be used as public mound s. OVER1fl00AMPS_ -. SQ.FT.FLOOR AR FI.
Licensed Profenloral SIGNS ELECTRICAL
OWNER-BUILDER DECLARATIONS SPECIAL CERCUIT/MISC
Z � 'Iherebyaffirmthatlamexemptfromlhe Contradora LicenseLaw far the -
P4o following reason.(Section 70'(1.5,Business and Professions Code:Any city or
• county which requires a permit to construct,aper,Improve,demolish,or repair TEMP.METER OR POLE INST,
yy anystmcture procto It twrance,alsorequireathe appllcentfaoor permit to fpWg(R DEVICES
W fila a signed statement that het horn d pursuant to the provisions of the
3 n,0 Contnnore Lices.e Lew(Chapter 9(cammendng with Becton 7000)of Divi- _
nlon3ofthe BusNna and Prof em lora Cade)orthat hely exempt therefromand 541�Br1MING TOOL ELECTRIC: VALUATION
6 the bash!or the alleged exemption. Any violation of Seniors 7031.5 by any
OUTLETSSW[TCHESHXTfJRFS (Ja'
Bg�{ appBant(ora permit subjecttheapplkant too civil penalty dnd moretha.
pj five hundred dollen Mali). NEW RESIDENTIAL ELECTR -
QQQ ❑I,as owner o(the property,or my employees with wages a their
wk -cam MRLES TYPE CONSTRUCTION
rompensatiorywRl dothe w•ak,andthestmduretnot intended or offered(or
sale(sec.7fR4,Business and prof
Code:The Contradofe Llmods law-
does not apply to an owner of property who W llda or improves therron,and - /
who does a.hwarkhimaelforthreugIt his own employees,provided lhatsuch ! OCC:GROUP REEUNUS
Improvement are not intended or offered for ask.If,however it oilding or - TOTAL:
- Improvementtwld wfthlnoneyearofcompletioo,tbe owner-buBderwillhave57
tEg,ne.a of pmving that he did not build or improve forpurpmeofsakJ. 'QTY, PLUMBING PERMIT FEE FLODD-ZONE APN _
u L cue owner of the property,am exclusively contracting with licensed t PERMIT ISSUANCE
roo Contra to corsWd tbe pro'e.01 ec.7044 Business and Profemlow Code:
The Contadob Lkenae Law don not apply to an owner of property who
builds or improves thereALTER-DRAIN
on, and who contracts for such pkojects with a &VENT-WATER OW
' 0.t{anor(s)licensed pursuant to the Contradoes Llmme Law.
C151
RACY FLOW pgOTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B&P C for this reason
Owner Data ' DRAINS'FLOOR,ROOF,AREA,CONDI SANITARY Y N '
WORKMAN COMPENSATION DECLARATION - - - RECEIPT# -
E31 hereby affirm that I have a certificate of consent to self-insure,or FIXTURES PER TRP S -1001,TAX Y - N
adtflcate ofWorkers'Cumpersatlon Insurance ora certified copy thereof(Set,, _ RECEBrTIf
S
GAEA.SYSTEM-I INCA OUTLETS PARK FEE Y N
Poilry# �i 1Q�86-
GAS EA. RECEIPT#
Com ' -.BUILDING DIVISION FEES'
�CeniRed copyt hereby famished. GREASE/INDUSTRL WASTEINTERCEPTOR PLANCHECK FEE
ertified copy t(Ikd with the city Iwpedlon dlWalon. '
CERTIFICATEOMPE SATION INSURANCE FROM WORKERS' GREASE TRAP. PAID
COMPENSATIONheperSEWER-SANITARY-STORM P.A.200PT Dat¢" Recef t#
Rhlssection need not be completed I(tbe permit Iron one hundred dollare
(5100)orfyth ed WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
all not employ
an person
any m w�k for to born eesubt d to the' +
I shall not employ any person In any manner w n to become anbjen to the - -
Workera'Compeneatbn Lawns of Cekfomia.Date WATER SYSTEM/TREATING
Z PAID
Z _ Applicant '
Z NOTICETOAPPLICANT: f,e ermakngthoCertifimteo(Eempbn,you NEEVRE9DENTALPLMe. . np[, Date Recei t#
F
should become subject to the Worker Compensation provisions ofthe Labor TOTAL:
N. Code,you must forthwith comply with such provsima;or this permit shall be CYJ
> domedBUILDING revoked. ^ FEE
CL G CONSTRUCTION LENDING AGENCYSEISMIC FEE -
I hereby affirmthst there t a corstmdlon lendlogapocy for the perform-
OInce ofthe work for which this permit t twed(See 3097,Civ,C.) - TOTAL: ELECTRIC FEE
U _ Lender's Name PLUMBING FEE
IL.F- Lender's Address ' QTY. MECHANICAL PERMIT FEE
O W Iuntifythatl have readthisappboatlonand statethatth'above information MECHANICAL FEE
IL Iscorrect lagreetocomplywlth all dtyand countyordinanms and state laws PERMITISSUANCE FEES PAID:
} W relating to building construction,and hereby authodae representatives ofthis r, -
I— Z city to enter upon the above-mentioned property for Inspection Purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City o(Cupertino. - - Date - Receipt#
agabstliabliltks,judgment,costand mpensnwhlchmayirdywayacnue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in conamuRnrX ofthe soling of this permit.
AIRHANDLING UNIT(OVER I0,0D0CFM). CONSTRUCTION TAX
. .nighdom.f Applicant/Contractor Date DX USTHOOD(W/DUCT) CONSTRUCTION TAX PAID: -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardousHEATING UNIT CI0100,000 BTU) Date R2Ce1 t#
materials.defined by the Cupertino Municipal Code,Chapter 9AZ and the
Hcalthand n SafetyCod Ion25532(a)7 HEATING UNIT(OVER IW,OWBTU) TOTAL: a�Yea [&No - -
1llthe applicant orFuture building mapantuse equipment ordevices VENTILATION FAN(SINGLE RESID) DATE
which emit hazardous air tamina.t as defined by the Bay Area Air
Quality Management Dls d7 i BOILER-COMP OHP OR 100,000 BTU)•, -
Yea No J k�0 5 193iJ-
Thavereadtheb.. ousmateciatmquimmntunderChapter6.95of BOILER-COMP(OVE.R 100,000 BTU) 'the California Health&Safety Code,Sections 25505,25533 and 25534.I - -
understandthatlithe building does not currently have atenanfthatittmy NEWRESIDENTIALMECH. EQ.FT '�I1sa Mj
r+sporsibllity to not the occupant ofthe requirements which must be met
prior to issuance of a Certificate of Occupancy.
Ownero W oozed agent ,Date ISSUED BY J
TOTAL:
OFFICE COPY
p. POST THIS CARDNEAR FRONT OF BUILDING tZs �'�rNO10621'.fn'62 1
IIAL
CITY OF CiJPERTINO.-
INSPECTION DIVISION- JOB INSPECTION RECORD
7 ".
JOB ADDRESSc79O.3"-LO/lOD%J��sI/ !KD '+" °UNIT-#' LOT#- 79.f CATEGORY + '+ CONTROLp ^''
OWNER" D 'CONTRACTOR. :6• c un I BUILDING PERMIT INFO r
INSPECTION I .DATE INSPECTOR _'. -INSPECTION!RECORD -;; �- ` - :-„ -❑, „
FOUNDATION/PIERS1. NOTE ALL GRADING AND DRAINAGE
LIFER GROUND •,. ,- '•SHALL BEINSTALLED TO COMPLYWITHIPTIO
. ^ ; JOB DESCRN -.
PAD/SET BA -CERT - - - •'•'7HE APP.V....N AND CITY OF
'GARAGE SLABS PREGUNITE .. coPElerwo STANDARDS.
POUR'NO CONCRETE•UNTILABOVE HAS BEEN SIGNED '
uNDERCRouND/sLAe INSPECTION' DAA, INSPECTOR
PLUMBING
. . . ELEC'RICAli
MECHANICAL'." ,
- DO' OT POUR FLOOR.UNTIL VE WAS BEEN SIGNEDWOOD FLOOR
PLUMBING �• ,. - h;�'i -
• MECHANICAL- "r
ELECTRICALFRAMING/VENTS/CLEAR - `
_ c INSULATIONS .'_ . . , , . . - ,� •'a
PLACE"NQ-SUBFLOOR UNTTL ABOV HAS"BEEN SIGNED
. . ROUGH
PLUMBING' - - - :• - .• 2' n .
TUBS&SHOWER PAN -
MECHANICAL' •.. .* - ''y + - • ,. '; .. -
ELECTRICAL ACUZZI BOND -
FRAMING STAIRS
INSULATION/VENTILATION _
- EMERG.EGRESS 7
' .SEWER WATER. ., .• r '. ..
GOV R ND WORK:UNTIL ABOVE HAS BEEN SIGNED
'EXTERIOR SHEAR HOLD DOWN
INTE
RIOR SHEAR/HOLD DOWN," -
SHEETROCK/SHEETROCKSHEAR
EX"TERIORLATH/W-SCREEN, :. .l '•
' SHOWER LATH's• -
SCRATCH COAT
77
'NOT .E OR PLASTER UNTIL AB6vE HAS DEEN SIGNED
NOTE:NO FINAL INSPECTION SHALL BE MADE BEFORE
" THE'CONSTRUCTION TAX IS PAID '' 'r -
.: FINALS- y. . ': . DATE . INSPECTOR
. . - . SAN:# - y
_ ELECT.ENERGY' - -
'` +'
PLUMBING ENERGY
_ MECH.ENERGY ' i._. - ' ' r -
.d. BUILDING ENERGY ' _ : . - - - s -_F. - -'• .. '.'. - .
ELECT.FINAL TEST .
PLUMBING. '
GAS TEST
MECHANICAL .9,' • - Y+ '-
HEATING. .. "t..
•� ELECTRICAL RELEASE '
FIREDEPT.. - -
GRADE - - - - -
OCCUPANCY•
TEMPORARY APPROVALS
.ELECTRIC
GASBUILDING
'
f OCCUPANCY OF BUILDING . r u'
• ' '� . 'ISSUANCE DATE'
ISNOT PERMITTED
BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR -
ARRANGE'FOR INSPECTION BY PHONING 252-4505 BETWEEN' a'
12 P
.30 _ M AND�4:30'PM'MONDAY THROUGH FRIDAY,24 HOURS `
BEFORE REQUIRED INSPECTION.'JOB ADDRESS AND Jul U
PERMIT'#•ARE NEEDED WHEN PHONING. " ''
IMPORTANT! i - ! Ps49@ it tw
`PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION LID BY., 41F I C _
OFFICE CORY,' ;, +