28612 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY '
••'-'CPI•Y OF CUPERTINO BUILDING-ELECTRICAL - "PERMIT NO., [�
RUILI)ING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL - ..� 2'8.612
- _ BUILDING PROJECT'IDENTIEICATION '
BUILDING ADDRESS: . SANITARY NO. APPLICATION SUBMITTAL OAT(
' O NER' AM� SHOE - � C fR CN 'S NA �( 1. -1.1�$�, O�
C �.sy _g7�0 Ili,,
NIC CONTROL#
iRCH ECT/ENGINEER: l LIC NO: D
Ov6p L/
CONTAC'C PHONE: m +' .BUILDING PERMIT INFO
— [5V0 ❑ COngulteId Fees Paid by Applicant(Initial) FILM ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION GG//EWZ. El ElQTY. .ELECTRIC PERMIT PEE
1 hereby of rat Thal 1 sum licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Seclinn'/1100)afDivision 3uflhe ffionessand lhofessionu Code.ammyliceme is
FSO in!fill foacandetfn' PF:RMI'1'ISSUANCE
Liver' ss Lic,X �• •_•-' ' . 'DWL •• ❑KITCHENREMODE1.'
N6 GW, 0ntc Cent ECI APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F t=za Z I anders®nd of I PANELS
XOy,-, YP erns shall heuuJ os Public rdords MODIFICATION..
UP IT)200
ERICH
O Z.+� OVER I1f0AMPS gpIMPRO BM EWR,L'P 0CHIMNT:Y REPAIR
F<-�. Licensed Professional - 201-1000AMPS IMPROVEMENT
ecs Id - OWNEILBUILUER DECLARATION- - IR.�UEMO.ITI
cGa C4 I hereby affirm that I ran exempi tram the Cnmrncior's License Law for the .��.. y1
Jq5 O y V following reason(Semen 7031.5.Business and Professions Curie:Any city or county - SIGNS ELECTRICAL ❑OTHER �� 4••Q
which"Wres a permit t c .t t Iver improve demolish, rep ray svumum SC
y� print ( ,Ess q r Ih ppliwntibe CoM1pttntn fl Lw(Clue nem SPECIAL CIRCIII'TIMISC.
(hath licensedpursuant Chep i ms of the Contractor l ssamC ore) 9
�50� (commencing 1M1 Section]0110) fD .ion3af(he Business JP f :'ms Core)or TEMP.METER OR POLE INSIl COMMERCIAL: I
a ry,M q that he is exempt(hemGom and the basis for the alleged exen(piun.Any violation of ,a ❑NEW BLDG/ADDITION ❑DEMOLITION.
i� Y. Section]tpl.56y any uppllcani fnr'a perntii subjects On,epplicah m aolvil p arall,of POWER DEVICES EITFNANT- ElFOOD SERVICE
not more Ihhn five hundred dollars S500).
CSO ❑ I,ns owner of the property,nr my employees with wagesm their so le cumpmentun, SWIMMING PO)LELECRIC IMPROVEMENT
will do the work,and the nruaum is net intended or offered for sale(SeeA044.Business ❑OTHER
-' and ProleWons Code The Contractor's License Law does nor apply In an owner of OUTLEIS-SWITCHES-FIXTURES
property who builds or improves(hereon,and who does.verb work himself or through
his own employees,provided that inch improvements an not intended or aft for NEW RESIDENTIAL ELECTR SQ T.
sale.If,however.the building or improvement is sold within one ycor ofcompletidn,rheSQ.FT.ILOORAREA $/SQ.Er
mer-builder will have the burden of proving Oat he didnol build or improve far pur-
rysmcfsale.).
( [] 1,as owner of the property,am exclusively contracting with licensed'indications to _ �� ! M•-- '�
- rnnalNcl the p..jc,t(See.7044;Business and Pndcssions Cadc:)The Cont maim"I., -
aseLaw does not apply toanowner ofproperty who builds orimproves(heram,and QTY. PLUMBING PERMIT I FEE
who reports for such projects with a contractor(%)licensed pursuant the Contractors -- —
License Law. PERMI'1'1SSUANCL
❑lam exempt unlet Sec ,B&P C for this laic) '
- Date ALTER-DRAIN&VENT-
Owner Wq VALUATION
WORKER:SCOMPF.NSATIONDECLARATION - , BACK FLOW PRO'TF.CT.DEVICE— s`
I hereby affirm under penalty of perjury one of The following declarations: y-
❑ I have and will mountain a Certificate of Consent to self-insure for Workers Compete DRAINS-FLOOR,ROOF.AREA,CONTI.
action,as provided for by Section 3700 of the Labor Code,for the performance of the, - STORIES TYPE CONSTRUCTION
work for which to,peoab is leaned. PINTO R ILS-PI7R TRAP ^x , x,` n
❑1 have and will maintain Worker's Compensation Insurance,m required by Section - -
37l0of the Labor Gude.forthe performance of the work for whichdo,permit is issued. GAS-EA.SYSTP.M-I INC40UTLETS��
My Work, m�sgtisv Insurance carrlerand Policy nm � - - OCC.GROUP AI'N
�s}u T�Y
Carden �IF'�7 PIONFRO OAS-BA.SYSTI3M-OVER 4(EA)
C[RTIFlCATE DE EXEMPTION INS FROM WORKERS COMPI:NSA'I'10N INSURANCE GREASPIINDUSTRL WASTE INTERCF.FT 1,
� ' � (VISION FEES
(Thio%carina need mol be wmplemA i10a paved(is fonmc hunJtal Antlers($I(X)
BUILDING D
to less.) GREAYl1'fRAP =� � • -
IPLANCHECKTHE -
Iccmfythatoninan marmot lh kfor
eimby,lhr:to (': sued. Km- SEWER SANITARY-STORM EA.210 FT.
shall
not employ any person m any manner so as t became wbjea t the Workers'Compen- ENERGY FEE '
O z onion Laws of Cal i furnie Dare WATER 11HATER W/VENTICLELTR
z 2 Appluan( - GRADING FEE
Tr. NOTICE TO APPLICANT.If after making his CeniGcme of Exemption,you should WATER SYSTEM?REAPING
(••' become subject m the Workers Compensation provisions of the[..be,Code,you must SOILS FEE
wforthwith comply with such provisions or this permit shallbe deemed restood. WATER SERVICE ..
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FII PAID
LJ O l hereby affirm that there is u construction lending agency for the performance of - Date Receipt It -
ILIn thewurkfor which this permit is issued(See309],Civ.C.)
0Ixndcra Name TOTAL:
L) Lender's Address - TOTAL:
y . I rnify(fit,l have rend this application and one but the above iiloomdin i is - BUILDING PEE
to cracker.I agreemcomplywnh all city and coumy ordinances and stale mwsbelaengm QTY. MECHANICAL PERMIT FEE - A
I> z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
rs above-mentioned property for inspection pmpores.
(We)agree(osave;indemnify and keep hu less the City of Cupchinm against PERMIT ISSUANCE ELF,C'I'RIC PEE -
liabilitics,pilgments,costs and expencea which any wayaccrueugaion said City ALTER OR ADD TO MECII.
in conxquence of thignringof thispcnnit: y PLUMBING FEE
APPLIANTU iRSTANDS ANUW .. MP;Y WISAI ALL NON-POINT AIR IIANDLING UNIT(TO 10,00,00:07i B1.
SOURCENE ONS rH
SOURCE MECIIANICAL PIiE
Y AIR HANDLING UNIT(O CFM)
J _ CONSTRUCTIONTAX
$' alhm of Apphv n(ICon ns r /Date EXHAUST HOOD(W_IDUCI) v r .HOUSING MITIGATION NL'E '
HA ZAR US MATISRIALS DISCLOSIDIE " '
Willthe applinnt mm building srcupam score or handle hazardous mnrerial HEATING UNIT(TO 100,IMp BTU)(�A,c ,
us der, d by the Cupc o Municipal Cole,Chapter 9.12,and the Health and Safety - -
Code,Section 25532 1 - HEATING UNIT(OVER 1(0,110 BT Of fJJJJ
❑Yes Fl No PAID -
VENTILATION PAN(SINGLE RESID)
Will the u he m or future tiuildln t use equipment or devices which Dim Receipt X
pp gby then 4°P BOILER-COMPLHPOR 110,00011 'U)
til hazallous air amrnminants as defined by the Bay Arca Air Quality Management TOTAL:
teWc(?
Yes (]No BOILER-COMP(OVER If0,M)BTU)
❑
I have real the hazardous materials requiremonu under Chapter ri.95 fthe C#li- AIRCONDITIONER (SSU "
,.;(omit Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
huilding does nor curtc lly hove utenanL thin lite my rceponsibilitymnnftyrheoc upum
ofthem,moment whichmus Banal ixior to issu:mre oft Cenificuie of Occupancy.
Owrer or anthoduA agent Dam TOTAL: 'r
15SULD RY: -�
OFFICE' .
POST THIS CARD NEAR FRONT OF BUILDING
CITY OF CUPERTINO PERMITNO. 9 a 61.2
BUILDING.DIVISION /(7
IUpDMG PROJRCT RIRNTVICATTON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI
fl J*T
OWN 1. 'S VAN IF.: HON' -I CONTRACTOR S NAME: LICNO: _
1 NS. oZS,�N--- "4 •/ �c./. , i�. :J NIC CONTROL.
' CHITLCIYENGINEER: LIC NO: DURESS: ❑
BUILDING PERMIT INFO
INSPECTIONS DATE BJ$PEC. ❑ ConSBllant FmPaid by Applicant(Initial) RLDG ELECT PLUMB MECH
�.
FOUNDATION/PIERSM.D.S. INSPECTION RECORD ❑ El
UFER GROUND NOTE: ALL GRADING AND DRAINAGE
JOB DESCRIPTION
PAD/SETBACK-CERT SHALL BE INSTALLED TO COMPLY WITH FOWL ❑KITCHEN REMODEL
THE APPROVED PLANS AND CITY OF ❑ADDmON ❑PLUMBING RE-PIPE
GARAGE SLABS/PREGUNITE CUPERTINO STANDARDS. ❑MULTI-UNFF ❑STRUCTURAL
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED MODIFICATION
TO ARRANGE INSPECTION WNTERIoR ❑CHIMNEY REPAIR
UNDERGROUND/SCAR CALL AFTERNOONS (12:30 PM - 4:00 PM) IMPROVEMENT
�9
[I BATH REMODEDREPAIRR ❑DEMOLITBIN
PLUMBING 777-3__S MONDAY TO FRIDAY 24 HOURS BE- ❑OTHEa
ELECTRICAL FORE REQUIRED INSPECTION. JOB ADDRESS r vola' –TC« c
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED AND PERMIT N ARE NEEDED WHEN PHONING.
`r'GMMFRGIERC AI .'
PLUMBING ATTENTION CONTRACTORS: ❑NEW BLDCIADOrr1oN C3 DEMOLITION
MECHANICAL NO PERSON(S)SHALL PERFORM WORK ON ❑TENANT ❑FOOD SERVICE
THIS JOB SITE WITHOUT BEING IN COM- IMPROVEMENT
ELECTRICAL PLIANCE WITH WORKERS'COMPENSATION COTHER
FRAMING VENTS INSURANCE REQUIREMENTS. E
INSULATION
INSPECTION SPECIAL INSPECTION REQUIRED,❑ DATE INSP.
PLACE NO SUBFLOOR UNTII.ABOVE HAS BEEN SIGNED
ROOF SHEATHMDOWN
PLUMBING
TUBS&SHOW
MECHANICAL
ELECTRICALI
FRAMING/STASS
INSULATIONIN _
COVER NO WABOVE HAS BEEN SIGNED
EXTERIAL SHDOWN
INTERIOR SHEAR/HOLD DOWN
SHEETWROCK/SHEETROCK SHEAR
i 1�
EXTERIOR LATH/W-SCREED
SHOWER LATH
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
SCRATCH COAT
SEWERIWATER
TEMPORARY APPROVALS
OCCUPANCY —
ELECTRICAL
GAS
-PB4AL5","Nu+f'..2SN".'• ';�. .`k�:�'hi �»�'
µGAS TEST
GRADE
FIRE
HANDICAP1995
ELECTRICAL JJJ
PLUMBING II / `-i V " I. •,,
.MECHANICAL
ENERGY
VISUAL FINAL ONLY CERTIFICATE OF OCCUPANCY ❑
BUILDING IMPORTANT: ISSUANCE DATE
'jO
VCUPANCY,OFB ILDINO�iSNOTrPERMIITBD'(;I';`j PLEASE READ REVERSE SIDE BEFORE i !
UNTiLBUIIiDINGiNAL L4 SIGNED BY BUILDING,! CALLING FOR FINAL INSPECTION!!
�INSPBCTOR!" ,�r+3.c '3° la�s,rr 'p'•, >.`v -.r7 " 711 y'
- • ISSUfiD BY'` �
APPLICANT'S POSTING COPY