02020070 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLYI(�O��
CITY OF CUPERTINO B1111.)ING-HLPCI'RICAI, PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIfINC MI?CIIANICAI' :�CAJ,S . 2813
BUILDING PROJIXF IDI:N'I'1 FICA'1'IUN
allHANNOADDRLSS: SANITARY NO, APPLICATION SUBMITTAL DA'I'I.
JWNHR'SSNNA IH I'H(3 Ii: CON'IRACIORS NAME: LIC NO:
NIC ^ CON'TH(ll.#
RCI 111 FC11/4 CINHHR: LIC NO I ADD ESS. - ❑ a�r1 /"1
._CONTACT _ " PDONE BUILDING PERM IT INFO -
517 5 jJ ❑ Consultant Fees Paid by Applicant(Initial) BLDG PLUMB MI-C-IH�
Q� Ia_V ❑(/ L�
LICENSED CON'TRACTOR'S DECLARATION Q'I'Y BLBCTRIC PERMIT' FEE
I mmhy affirm that I am licensed under toort inna of Chimax 9(.......limiting JOB DESCRIPTION
qaZ with Section 9(N0)of Divisiun3mfthc9minesn and PmfensionsCmte.and my llansu in
OO in full force and effect I'ERMI'I'ISSl1ANCli TIAL
ml^ .IT)WI. ❑KITCHEN RHMODEL
<-U License Class LicX r APPLIANCES-REST DFN'IIAL ❑ADDITION ❑PLUMBING RE PIPE
y< ale—I(1 tOO Cnnu'Jr it
ARCHITECT'S DECLARATION ❑MUI.TI-UNIT El STRUCTURAL
PANNI.
I unJemanJ my plans shall be used us Public records MODIFICATION
Z80O IT TU 2W AMPS ❑INTHRIOR ❑CHIMNEY REPAIR
F4F"W Lu,u,,d Prnlbssion.] 2111-11NN1 Ahll'S IMPROVEMENT (]SWIMMING POOLS
OWNER-RUILDER DECLARATION
tYY J OVIut IINOAMPS ❑BATH REMODHUREPAIR ❑DEMOLITION
C Q I hereby M.that 1 oro exempt from the Cuntme¢ns I icemc law for Ne
pKj B lay U following reason.(Seldom 9031.5,Business and Professions Ctda:Any city..,nmmtY SIGNS ELI!CfItICAL ❑OTHER
y which require n permit m emm�ad ahe,,improve,demolish,or repair any menu. _ _
f"iOS pnono its issuance,aLo requires the.pplieem Imombpenin,,filcasigned statement SPECIAL CIRCUITIMISC.
} that he is licensed pursuant to the previsions ofthe Commenor's License law(Chapmr9
Ic3�00 mminmecingxi.h Section]W(hof Division 3 offs,ltusinesx and Professions Ca,c)or 'I'HMR MCTIiR OR NTLI:INST. '
Q.EL e C that he is cxmnpt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DHMOLITION
Section 703 L5 byany...hemu fora proratsubjems unc ooTema ma civil pe.any,,] POWER IIIWICES ❑TENANT ❑FOOD SERVICE
nm marc Nan fee hundred dollars(8501).
F Z P IMI'ROVIiAIFNT
p6 -1 Las omework,the pension,wine, onnyemntendedwith wagesos faIsSee. 044.]bsinOuraporroates, SWIMMING POOL HLECfRIC
E me will Jothewon,aide:The Cmuaure innot tra,License
conferral rsole(,1111,tho nvoin,eof J1 ❑OTHER
W 3 m and Profession,who
Code:The Contthereo License law s such
nm apply s un r Prot of OUT'LITS-S\VITCIiP_S-PIX'T11RE5 L
pmpeny who huilJs or improves therm..,and who does such work himself or Nmugh
his..it employees,provided that sock improvements are out intended or nffmcd for NEW RESIDEM'IAL HLI=R SQ Pf.
sale.If,howeve%the building or improvement is sold within one year of comptetion.Ne 1 , SQ.FT.IlOORARG LSp.II'.
mer builder will have the buNcn of proving that be did not build our in.prove for par- -L
low of sale.).
El L as nwaerof ro
the ppeny,attmmr
m exclusively .mnir,with licensed emimas a, 'IYJI'AL: O/
onatmm ec. Rilimes
the project(SJ( , ins and Profession.Cede:)TI a Comocmrs Li-
ceaseLowdessnotapplytoanownerofpropeny who builds or improves thereon,and QTY. PLl 1131NG PFRMIT FEE
whocotnracts forxoch pmjeas with a vmdmemus)licensed pursuant in he Contmewrs q��
License Law. PERMITIS .ANCH C//�/p'
' ❑I am exemptuMe,See. - ,It d P C mot rcmnn
: )edam, Dae ALTUR-DRA ViiNT-WA'I'1: lliAl VALUATION
'O KHRl4 COMPENSATION IARATION BACK FLOW TROT[T.DP 'B
I hereby affirm under penalty of Perjury one of the following Jcclamtinns: (�
]I have and will maintain a Cenificae of Conxenunselsinsum for Warker'n Compcn- DRAINS-FLOOR.140017 A (IND. STOMPS TY PE CONSTRUCTION
ation,as provided for by Section 37M of the Labor Cotte,room performance of the
!,3 work for which this Permit is issued. FIXTURES-PPR TRAP �Ftl
❑1 have and will maintain Workers Compens000n Insurance.as required by Section .
37M ofine Labor Code.funu,performance of the work four which this permit is issued. GAS-HA.SYSTBW I INC.4 OUT LFIS OCC.GROUT' APN
My Workers Compensation Insurance comer and Policy number are.
Cartier. Policy No: GAS-EA.SYSTHNI OVER 4(11M /J/ es-ly oto
CEk'I'IFICATE OF EXEMPTION FROM WORKIikS' K.
COMPENSATION INSURANCE BUILDING WAS'.li IN'IERCfa'TOH
BUIIAING DIVISION FIGS
.This section need not be completed if the fiction ix fume hundred dollars($100) GREASHTRAP --_ --
or
less)(This
FF.I.
I cenify that in the perfommnce of.he work for which this permit is issued,I shall SHWER-SANITARY-STORM EA.218119'.
nun employ any Person in any manner so as to beconm subject o the Workers ComPon. IiNERGY PEIi
Oz sation Laws of California.Date WRIER it EATER WNEN'I/ELECI'k _�,... GRAVING FIiE
Z 2 Applicant - I
r aoI NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should Wool IEIt SVS' :M/BEATING
become subject m the Workers Compensation pmvisinns of the Labor G.le,yuu must _ SOILS ITE
fonhwuh comply with such provisions or this Permit shall be deemed invoked. WAI I7RS17R TA L-�III V
7 z CONSTRUCf10N LIiNDING AGENCY NGW RT:SIPIi FI N.I'I M1 PAID O
L)C) Ihereby affirm that is a construction lending agency for pecomoneernDate Receipt#
the work for which Nis permit is Issued(Sec.3097,Civ,CJ T�
{L11"t lender's Name AL. CJ
V Lender'..,Address
H1 I minify that I have read this application and state thin the above nomination enation is p „_µ t BI111,UIN0 FEE O Q
N correct.l agree m comply with all city and county ordinances and suite laws rclming w QTV MG IIA�IGAI-PEItMIT,-= " FFE' -/
V Z building cnnstmninn,and hereby amhorim represenmtivm of this city wearer upun.he SEISMICFFH 1I
above-(We) nedpmpeny Bar nderanly ad umpthei I'IIRMITISSUANCH
(We)agree to save,InJenuJly unJ keep hunnlesx rho City of G.pedino against f:LIiCCRIC PHP.
Ilabilities,judgmems,costsand eslasseswhich.nay in any way acemc against suit City AUIRR OR ADDTO MHCIL PLUMPING FEEL
4-1
inconsequeaccofthegootingol'thie permit.
APPLICANT UNDHRS'1'ANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(FU Foodd CFM)
'OU 7REGULAfIONS. MECHANICAL 17EE 10 Lf
_ AIR HANDLING LN1'I'(OVER 10000 CFM) CONSTRUCHON'I'AX410-
Signater dApplicant/Comowlar Umc EXIIAUSTHOOD t W/DUCT) HOUSING MI'I[CATION FF.E �n`�
HAZARDOUS MATHRIALS DISCLOSURE V V
WiIIthe applicmu our furore huildingoceosmt xtnreorhnnJle baannlousneacH.1 I IHAHNGI SETITO IQo( 011'1'HE
C 0Y.defced by the Cupertino Municipal G
xle,Chapter 9.12,and the Health an:f Salbry
_
Codi.SecJnn^5592(x)'7 IIEA'TINO UNI'I'(OVBH 100,000 II'I'U) �/
VEN'IILAI30NIoAN(SINGIHRL'SIDI PAID q-6-Od 72-'81 -
D:me Receipt#
Will the upplicanYor future building mca.pann use equipment or(levies which IBIILI?It-COMP19111'OH 110,gXI IITID
emit low,naoms air ormuniums us JuGned by lie tiny Are.Air(saucily Managen.em IOTA:
j Dix.,Irim'7 : HR Iog000 it FU)
Ye's
n x I1O11.Glt-COMP fUV yy/
E
u
`_bheve reed Ow LdlurJnus n.acrial.,mtpiiretmm�,s under ChapmrG95 ul.hc Cull AIR C(INUI'I'IONI!R � ISSUANCIi DATE
fern,HI In Safety Cale.Seen,,,,,255th,25539 ad 25534.1 undurxtund dot eta the
nNEW I HSIDHN'I'IA.MSCII, SQ,Fir
d ' ..t�t�.my nnva6m.DaL Hon ins mire.,pumddli.ymarnu'y Jre oa.mum '
eacm. cocatawhith must hentG p��rinicx.mcN n Cerlil' m:'fkm Esmay.
o l� DO
Ownerm t .zed.gem Dim TOTAL', IssuBD 1{Y:
OFFICE
.L'�'Le�-�iT
Inspection Query for a Specfic Permit 5/28/02
PERMIT#SITUS ST SITUS STREET Uot# `-ANSDESCRIPT= : InsT ' DATEDESIRE D'ateDorie Ins ecto Units PasslFail-'Code
52813 10191 ILE13ANON IFOUNDATION 6/26/00 6/26/00 DS 51F
S2813 - 10191 ILEBANON FOUNDATION 6/27/00 6/27/00 DS 2 P
92813 10191 ILEBANON UNDERFLOOR INSPE 7/19/00 7/19/00 DS 1 P
52813 10191 ILEBANON 202/PLB UNDFLR 7119/00 7/19/00 DS 113
S2813 10191 LEBANON 203/MECH/UNDFLR 7/19/00 7/19/00 DS 1 P
S2813 10191 LEBANON FRAME/UNDFLR 7/19/00 7/19/00 DS 1 P
S2813 10191 LEBANON JINSUIJUNDFLR 7/19100 7/19/00 DS 1 P
S2813 10191 LEBANON SHEAR/ROOF SHEAT 10/5/00 10/5/00 CC 3P
S2813 10191 LEBANON ROOF SHEAT 10/6/00 10/6/00 CC 2P
S2813 10191 LEBANON SHEARNAIL 11/13/00 11/13/00 JS 1 N
S2813 ;10191 LEBANON SHERNAIL 11/21/00 11/21/00 DS 3P
§2813 10191 LEBANON IEXT LATH (309) 1/4/01 1/4/01 CC 2P
S2813 110191 LEBANON IROUGH MECHANICA 7/3/01 7/3/01 AD 1 O
S2813 110191 LEBANON ROUGH ELECTRIC 713/01 7/3/01 AD 1 O
S2813 110191 LEBANON ROUGH PLUMBING 7/3/01 7/3101 AD 1 O
S2813 110191 LEBANON IROUGH MECHANICA 7/3/01 7/3101 AD 1 O
S2813 110191 LEBANON ROUGH ELECTRICAL 7/3101 7/3/01 JAD 11 O
S2813 110191 LEBANON ROUGH PLUMBING 7/3/01 7/3/01 AD 11 O
S2813 10191 LEBANON ROUGH MECHANICA 7/5/01 7/5/01 JJS 2F
S2813 10191 LEBANON (ROUGH ELECTRIC 7/5/01, 7/5/01 JS 2F
S2813 10191 LEBANON iROUGHT PLUMBING 7/5/011 7/5/01 JS 2F
S2813 10191 LEBANON ROUGH BUILDING 7/5/01 j 7/5/01 JS 2F
S2813 10191 LEBANON R PLUMB 301 8/14/01 8/14/01 JB IF N
S2813 10191 LEBANON TROUGH MECH 303 8/14/01 8/14/01 JB IF N
S2813 10191 LEBANON ROUGH ELECT 304 8/14/01 8/14/01 JB 1F N
S2813 10191 LEBANON IFRAME 305 8/14/01 8/14/01 JB 1F N
S2813 10191 ILEBANON I IFRAME 305 8/15/01 8/15/01 JB 6F
S2813 10191 ILEBANON IROUGH ELECT 304 8/15/011 8/15/01 JB 2P
S2813_ 1_0191 __ LEBANON ROUGH MECH 303 _ 8/15/01 8/15/01 JB _ 2P
S2813 !10191 LEBANON T TROUGH PLUMB 301 8/15/01 8/15/01 JB 2F
S2813 110191 LEBANON FRAME 305(483-5800 9/11/01 9/11/01 AD 4P
52813 10191 LEBANON . jR PLUMB 301 9/11/01' 9/11/01 AD 4,P
S2813 10191 LEBANON ;INT SHEAR 316 9/11/01 9/11/01 AD 4P
S2813 10191 LEBANON 1307 INSULATION 9/26/01 9/26/01 D 2 P
52813 10191 LEBANON IDRYWALL NAIL 10/5/011 10/5/01 ILS 3P
P e1