25058 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO HUH.VINiJ.hLhLr-h A. PERMIT No,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING..MECHANICAL 25058
BUILDING PROJP.CT IDFINITFICA'1'VIN
BUILDING A.PDRESS: SANITARY NO. APPLICATIONSUBMI'ITA^L�DATE.
C /0//0 ' V. ��.A�,z� t✓ UNITN LOT# —(I l
OWNERS NAME: PIIONE: C( C 'SN E: LIC ND: _—_JJ7
fL/ O C�'S`C O F E ZB .B J 39' ,' NIC �/ CONTROL#
\RCIII'DiCI'/ENG BER: erZ (IC NO: 2 A1,10 : n "J4LI� ,..s ^,T�/� /
CONTACT: PHONE: /T G/ONa /F Y S
v� Q �Jz� QTY. ELECTRIC PERMIT FEE BUILDING PI2RMIT INFO
IP-rAAl �UMi/ �Il- 2_U7 0 /J DG - E ECH
PERMIT ISSUANCE
LICENSED CONTRACT'OR'S DECLARATION D APPLIANCES-RESIDENTIAL LOB DESCRIPTION
QWz Ihereby affirm that l am licensed underprovisionsofChapter9(commencing wit s
uU C C Section 7")of Division 3 of to Business and Professions Cade,and my license is in PANELS �/�G, L
[Fy--��t full farce endo UP T0200 AMPS ��ul—
2 License Class l.ic.p
rFir44 Date Contractor 201-IOW AMPS
Z.Oy� ARCHITF.CfSDECLARATION Q OVER Iti00 AMPS _. _ _SQ.FT.FLOOR A :A — $/SQ.FT.
O2_O I understand my plans shall be used se public records. 1n�1I ��aa�p
O SIGNS EIECTRICAI. / 1'� L'+1' ! N
Licensed Professional
gg�O F I hereby offiw that I mor a cra D frrom R DEhe Convenor's License Low for the SPECIAL CIRCUIT/MISC. I T R
'Ia��i Wm following rumor.(Section]031.5,Business and Professions Code:Anyaymeounty TEMP.METER OR POLE.INST. \J I
�sK\
which re prim,a permit to convect shot.improve,demolish,or repair any structure Lis
f'a
i� Frusta its issuance.also requires the applicantforsuchpermittofileasignedsumment POWER DEVICES DDI` l7 ]
<p that he is licensed pursuant to to provisions of the Commemrs License Law(Chapter
p.,QK 9(commencing with Section 7")of Division S of the Business and Professions Code) SWIMMING POOL ELECTRIC — / —VALUATION
m=in nation he is exempt marcftom and the basis forthe alleged exemption.Any violation of UTLEfS-SWITCHES-FIXTURES Uv O O
l_ } Section 7031.5 by any applicant for a permit subjects tm o applicant a civil penalty of
f not more than five hundred dollars($500).
C ❑ I,asownernftepropeny,ormyemployen witwagee astheirsolecampemmion. NP.W RESIDENTIAL ELELTR _SQ.FT. STORIES TYPE CONSTRUCTION
6'3$ will do the work,and the structure is nut intended or offered for side Sm.9004.Business
and Professions Calc The Convector's Lianse Law does not apply to an owner of
lonamy whobaildear improves thercogand whodo iatich workhimselfarthmugh his OCC.CROUP MS.UNITS
nemployec.,pmvidedtatsuchlmprov ent arenotintendedoroffemdforsWe.IL
however,the building orimprovement is sold within one your ofcompletion,themseer.
builder will have the burden of proving that he did not build or improve for purpose of t Lo
sale.).
❑ I,as ownerof thepropeny.um exclusivclyconwning wit iiansed connecmrslo QTY,: PLUMBINOPERMIT FE17 FLOOD ZONE. APN
1 convect to project(Sec.9044,Business and Professions Cobs)The Comma tors PERMIT ISSUANCE
License Law does nm apply man owner of property who bui Ids m improves thereon,and
whacrmctsfurch projeae witc. roman (s)licemostionuam m mu Contractors
wmALTER-DRAIN&VENT-WATER(11A) FEE SUMMARY
License Law.
❑ 1 am exempt under Sec. ,B&P C for this r.a.n OUTDE FEES
BACK FLOW PROTECT.DEVICE SI
SANITARY Y N
Owner Dam pRA1Ns-FLOORROOFAREAGONDRECEIPTN
WORKMAN COMPENSATION DECLARAT , , , .ION SCHOOL TAX YN
❑ Iherebyarfirmthatlhaveucenificme of comem to self-insurc.m accrtificate .XTURES-PER TRAP RECEIPT#
i, s!CompensatiM.surence or a codified copy thepmof(Sm.3800,Lab C.)which PARK FEE Y N
r1aw.)
e s or ^y rod /.2J O—Oor GAS-EA.SYSTEM-I INC. OUTLETS BUILDINGRECHIT#FEES
JA DIVISION
GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
py is hereby furnished.
opy is filed with the city inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR GRADING PEE
ERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
n nxA nm becompleted ifthe permit is fimmichimdrW dollars($100) SEWER-SANITARY-STORM EA.2001T. ENE.
Ianifythetinthe performance of the work for which this permit is issued,l shall WATER HEATER W/VF- /ELECTR
not employ any person t any manner so as to become subject to to Workers' PAID
CDmpermiion Lnwsof C.Efomis. Date WATER SYSTEMfFREA'ONG Date Receipt#
Zz Applicant
0 NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL: 3a g
pry become subject to the Workers Compensation provisions of to Labor Code,you must BUILDING FEE
t-' forthwith comply with such provisions m this permit shall be domed smoked.
7
SEISMIC FEE CONSTRUCTION LENDING AGENCY
z Ihereby affirm that hem is a construction lending agency for the performance of ELECTRIC
U2he work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name
u•' F lenders Address QTY. " MECHANICAL PERMIT FEE PLUM G E
U I certify that I have read this application and.taut that to trove information is Lb
ME L FEE
emrect.lisrmmcomplywitholidl,andc...ty oNinarmes and sorra law.ralming to PERMIT ISSUANCE ✓a
buildingconshuaion,and hereby autumns reposentelvesofthiseity Wester upon do C 5 UCTIONT
U z above-mentioned propeny for mspmIhm polarms. ALTER OR ADD TO MF.CH.
(We)agree m save,indemnify and keep lorfless to City of Cupertino against
liabilities,judgments,costs and expenses w ich may in any way acerae against said City AIR HANDLING UNIT GT)I 0k00D CFM)
cone Dfit grantingo n.
AIR HANDLING UNIT(OVER IO,gXI CFM)
rg t rcof Applicent/Cwtrncmr etc EXHAUST HOOD(W/)UCH
PAID
HAZARDOUS MATERIALS DISCLOSURE
- HEATING UNIT(TO 10D,000 BTU) Data Rea, N
Will the applicant or future building occupant store or handle hazardous material I[RATING UNIT(OVER 100'"BTU)
as defined by the Cupor ino Municipal Cale,Chapter 9.12,and the Heart and Safety TO
Cod<,Socr6n 25532(a)? VENTILATION FAN(SINGLE RPSID)
❑Ycs ISSUANCE DATE
Will theaMticammrfumrebuiidingmcupanmweuipmentordevias whichmon BOILER-COMP GHP OR 100,000 BTU)
_ azaH...air conmminanu as defined by the Bay Area Air Quality Management BOILER-COMP(OVER IM."BTU) ^ p
C3 Y. 49<'
I No NEW RESIDENTIAL MCCII. SQ.FT.
1 have read the hazardons maUriala reyuiremcnts under Chapter 6.95 of to JII�
Califomis Health&Safety Code,Sections 25505,25533 and 25534.I understood that Y48 k;9j
ifthebuildingdoesnotments yhaveatenant:tatit is myssuanceiofa tonmifythe ,```�
atho aratbui of to res not c ire which must be ma prim m irsuance of it Ce notify he - N
of
Occupancy. CTI 111v
Owner or autorimd agent Date ISSUED BY:
O
QPOFESSION
IOSEPy
4i� 4J Z
-� Stan Rupiper CONSULTANT ENGINEER y v G =
1033 Vilia Maria Court, San Jose, CA 95125 408/287-8759 a No. 17827 a a
i •
'r Cl N @ter
lrF OF Al\FSP
REce1vE�
March 17, 1994 MAR i v
1994
.CITY of CUPERTIn0
Mr.J.Brager BUILOIBG Am
Building Inspector
City of Cupertino
10300 Torre Avenue
Cupertino, CA 95014
Re: Plan Check - Control No.: 7782 Permit No.: 25058
Interior Remodel, St. Joseph Residence, 10110 De Anza Blvd.,
Cupertino, CA
Dear Mr. Brager;
During the course of the construction of the above referenced project I made
numerous site visits to observe the framing and various structural details.
They are in accordance with my drawings, specifications, recommendations
and Uniform Building Code requirements.
Aely
pipe R 017827 OFES
OSE
MION DEPARTMENT
No. 171= CUPERTMO
E:xp.6-30-
d+�q OIYI1r Q��Q
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