29875 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM BING-MEWHANICAI,
29 Q V 75
HU I LDING PROJECT IDRNTIFICA'PION
BUILDINGADDRFSS: SANITARY NO. APPLICATION SUBMITTAL DATE
/ /97.5/ . SCA A99Q d � P�fA Go�ItsT C'e 'S'�-Q'6
OWNER'SN II - -PHONE: CONTRACTOR'S NAME: UC NO:
d /• (~ NIC CONTROL#
HCHITECf/F.NGINEER: V LIC NO,, AD RESESS
/ - .� �� i• ❑
cONT'ACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLEG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
DMZ
Thereby affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
with Section]0X))af Division3ofthe Business and FkofcxsionsCdc.and myliccnse is
C0 O PERMIT ISSUANCE RESIDENTIAL:
SF in full finexamdcRar. ❑SFDWL r' ❑KITCHEN REMODEL
aUU License Class Lic.p APPLIANCES-RESIDENTIAL ITION ❑PLUMBING KIi-PIPE
.<c.d Date Contractor
ARCHITECTS DECLARATION PANELS MULTLUNR El STRUCTURAL
z0oz l understand my plats shall be used a.public rano. MODIFICATION
OZ^O - UP IND 200 AMPS ❑INTERIOR '0 CHIMNEY REPAIR
E-4F"u] Licnrscd Profcaional 201-IOW AMPS IMPROVEMENT
ad J
Oat I am BUILOERDECe Contra ON OVER I(XIUAMPS ❑BATHREMODEUREPAIR ❑DEMOLITION
W Q 1 hereby ulBrm thm 1 sun exempt Gam the Convvemr's Liccnsc Lew for the
LL 3 a F following reason(Section 7031.5.Business and Professions CtvU:Any cit,o,countySIGNS Ii1.liC'fRICAL - [IOTHER
y¢ which rrgmrex a Samoa ro comwn,alter,improve,demolish,m repair any strurc
um
F�DJ
prior to itsissuance,also rectums the applicant for such permit o file a.signed statement SPECIAL CIRCUIT/MISC.
mmmat he is licensed pursuant m the provisions of the Contractor's License Law(Chapter M9
_
0 (voenang with Section](XO)nf Divlslun 3oftheni,inesnand 11 la...or,Co is)or TEMP.MET ER OR POLE INST.' - COMMERCIAL:
C Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BI.DG/ADDITION- ❑DEMOLITION
X n LL Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W^a, ❑TENAYT ❑FOOD SERVICE
yOnot more Stuart five hundred dollars($5 W).
❑I,us ownendthe pmpenY,nr mY employees wioM1 wage,wsoheir solecnmpenaoion, SWIMMING POOLELECTRIC Ih1PROVEMENT
F., willdomework,and theamature ismaimended proffered hassle(Sec.JOMI.136eness ❑OTHER
W^m and Professio"x Code:The Commands License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES Q
a 3 his own who builds or improves thereon,and vem dna m n work deed or or through
his own employees,e provided that psuchansam nt is ad nu arc not intended a n offered for NEW RESIDENTIAL F.LECIR SQ
ownef,hosver willhbuildiburdenmvnmentithath did non build rnfcompletionme SQ.Irl'.FLOOR AREA $ISQ.FT.
lir-builder will have the burden o(pmving that he did not build nritnprove for par- _
pose inside.).
❑1, owner of the propeny'm exclusively contracting with ibensedcontractors oo TOTAL.
conVoict the project(Se ](94 Business and Professions Codx:)Thc Contractor s Li-
nsc Laved : oapplyocraft pn pc oy h M1 'Id.n p oh reon nd QTY, PLUMBING PERMIT
ho contracts for such protects with ac contractors)licensed puumnuo She Contractors %l
License Taw' PERMIT ISSUANCE
E] m L,� 6199 1
1 aexam r code,Site Br
c. &P C for this scam V
w'ner Date ALTER-DRAIN A,V17N'T-WATER SEA) VALUATION Vv
WOR ER'S COM - SATION DECLARATION BACK FLOW PROT[CT.DEVICE 'rt'� WT ♦_Nr1-
hueby uffinn under penalry o pc jury one of the following declarations; b
I have and will mainminn Cenificam of Consent mscll insure far Workers Cnmpcn- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
section,as provided for by Section 37M of the Labor Code,for the performance of the ,
work for wb,ch this .it is issues. FIXTURES-PER TRAP ,
s\ I have and will maintain Worker's Compensation Insurance,m required by Sea inn
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP APN
My Workers Compemmlon lnsumnw carter and Policy nmnbentm:
C.amee Policy No.: GAS-EA.SYSTEM-OVER 4(EA) ,
CERTIFICATE.OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS_OINDUSTRI.WASTE.INTERCEPTOR
BUILDING DIVISION FEES
('This sectio"need not he completed if the pae nit is for one hundred dollars IS 1110).
is,less.) GREASETRAP I'LANCHF.CK FEE
I certify thin in the perfnrmaare.f Har work forwhich this permit is issued.lehall SEWER-SANITARY-STORM EA.2nd FT.
not employ any person in any manner so as to become subject in She Workeri Compcn- ENERGY FEE
ZZ scion Lawsnf Cnlifomia.Datc WATER HEATER WNENTIELECB
2 Applicant ., GRADING FEE
h
-NOTICE TOAPPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM(TREATING
a ; hevoin,subject to the Writers,Compensation f me Wbnr Code,you must SOILS FEE
Pram provislaaxa
Eta fanhwith comply with such previsions is, permit shallMdeemW revoked. WATER SERVICE
P.i
Q
CONSTRUCTION LENDING AGENCY NEW RESIDEN'1'[Ali PLMSQ.FT. PAID
=I B. '
r�1'Z� IM1ercby efGrm manMmis aconstrvction lendingaRency(or the performance of ])ate Receiprp
V the work for which suis permit is issued(Sec.3097,Civ.C.)
C) Fm Leaders Name T
V Isnd,,,AJdrehx TOTAL:
y1 certify that I have read this application and slam that the above information is MILDING FEE.
y comet,l agree to comply with all city and county ordinances and state laws relating in QTYMECHANICAL PERMIT FEE
U Z building construction,and hereby amhorim representatives of this city to enter upon m .e SEISMIC PEE
imove-mentioned property titr inepemlpn purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of CopeAno against ELECTRIC PE
liabilities.judgmcnos,ensu and expenses which may in any way sector against said City ALTER OR ADD TO MECH.
in onsceuence of me granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,010 CFM) MECHANICAL FEE
SOURCE RXULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM)- CONSTRUC 'AX
jiga rcof ApPlic.n ContmctorDille "STATIST HOLD(WIDUCT) HOUSING MITIGATION FEE
HAZARDOUS(IATERIALS DISCLOSURE
Will the applicant or l inure buildingoecupent store orhandle hamrdousanterial BEATING UNIT(10 M.000 H'I'll)
m detinW by the Cupcninn Municipal Cde.Chapter 9.12,and the fieWth and Safety
Cdr.Sectio"25532(x)+ HEATING UNIT(OVER IW.O�BTU)
0Yes ON.
VENTILATION FAN(SINGLE RESID) PAID .
Uae Receipt p
Will the applicant or future buildingfindl by the B use ea Air Qu of devicrs which
mit harardous air contaminants asddnes by the Ray Arca AirQmlity Aianagcmem BOILER-COMP(IHPOR IW.gXI BTU) TOTAL.
Duract, BOIL17R-CONIP(OVER I00,000 BTU)
0Yes ON.
AIRCONDITIONER
I have read the hamNous=[costs requirennuouv under Chapter 6.95 of the Cul,- ISSUANCE DATE
(aria Health&Safety Code,Sections 25505,25533 and 25534.1 uWcrstand that if On NEW RESIDENTIAL MECH. SQ.IT.
building docs not currently have a mnwt,that to is my mspo"sd ility to runty try the tMcupant
it the requimmenr,which nm,t be m t post.Me...se of Crniliaatc of Occupancy.
Owoeror amhaneW agent Dae TOTAL] ISSUEDB .
OFFICE .
�•r
NO. STREET LOT NO.
DATE 17 FILE NO, t
y >F CUPERTINO "
OWNER RE6.lRD OF INSPECTION APPROVA:B '
�. ST u RSG-eft JOB COPY 1
PROJECT -�r�/7/CS
J;v TELEPHONE:252-4505 T
i
BUILDING '
BUILDING INSPECTION RECORD
DATE1 INSPECTOR. DATE INSPECTOR
FOUNDATION. FLOOR STEEL t
i
. PRE-GUNITE • FRAME (Z 4
OND BEAMS TH f
(02 ALLBOARD ']NTa EXT Z
FIREWALLS] $.
MEMBRANE LANDSCAPING
F.M.O.INSPECTION s
Z FINAL BLDG. `
UNDER-FLOOR '
TIEDOWNS -M SIC,
DIAPHRAMS
ELECTRICAL INSPECTION RECORD
- RESIDENTIAL DATE LINSPECTORI COMMERCIAL DATE INSPECTOR `'
UNDERGROUND ROUGH, ZZ UNDERGROUND ROUGH 3
ROUGH WIRING. -(Z ROUGH WIRING
FINISH WIRING FINISH WIRING
FIXTURES INTERIOR FIXTURES
' MOTORS EXTERIOR FIXTURES
FINAL _ i T. . .... ; :". I -f:'117 MOTORS
SIM.t;
_.S SIM . "%' :'• `'.. :.FINAL nI -
ti;� MBING INSPECTION RECORD HEATING 8 A/C INSPECTION RECORD I
DATE INSPECTOR -.a •• DATE INSPECTOR
?BACK FLOW REQUIRED UNDERFLOOR S.M. ,R
BACK FLOW INSTALLED, DUCTS&INSULATION Z,
I;A
a�[h €UNDERGROUND ROUGH FLUES 8 COMB.AIR
app?PARTIAL ROUGH CONDENSATE DRAINS
T i.ROUGH COMPLETE - I FINAL-APP EN
�ku+,.
1 ROOF DRAIN 8 LEADERS nY
Vr:r.
MAIN DRAIN -.
FINAL GAS
-. L
FINAL PLUMBINGV
i
Y"RE IU11M[]]FORMS IMC.,L] L
_ NOTE: INSPECTOR MUST BE GIVEN 24 HOURS NOTICE FOR INSPECTION. /J
' CHIEF BUILDING INSPE 'f
3