17947 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE-BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
' ADDRESS ` ' . . 17 9'4 7
- V 1 LDING - ELECTRICAL-PLUMBING-MECHANICAL
MINER'S PLAN CHECK VALIDATION.
NAME
� �7f�� MTV. ELECTRIC PERMIT FEE
1 a\ �1 PRONE �J(J
fH' CONTRACTORS
NAME ObTLETS-SWITCHES-PIECED 10.00/1.00
C1,04-
LIGHTING FIXTURES 10.00/1.00 ( U Q
CONrRACAOE.ESSrors PPLIANCES-RESIDENTIAL 4.00
IJ 5}'PHORE Z` S PANELS 10.00 DATE OF APPLICATION ~�
ORCNITECi PANELS,IOVER 200 AMP) 20.00 PLAN CHECK'FEE P.C.Na.
ENGINEER
LIC..O. SIGNS TRANS. 3.00 '
ARC1A OR ENG. PERMIT VALIDATION
ADD
r5Esa SPECIAL CIRCUIT 5.00
t
IA
' ZIP TEMP.METER OR POLE INS. 20.00 d�A��.j,,((ir-'y
AESS is MOTORS SEE FEE SCH.
APP
10ULICA
5 'L LAJ .1 J11 �, SS SERVICE CHANGE -- 20.00
000P Ilk
.;
Hoo LICENSED CUNT'RACTORS UECLARA'TON
a v W I hereby affirm that I am licensed under provisions of Chapter 9 UANCE DATE _
r
(commencing with Section 7000)of Division 3 of the Busin�ss and n ¢ BLDG. ELECT. PLG. MECH.
H ¢ professions Codc, my Iltt'nse is in full f yry1� - t.
z o - Urrp"Oew��Co`n Nu r CIC
2 Z, r Date _Contac R �{
a m W BUILDING PERMIT
¢ rc ¢ OWNER-BU LDER DEC A'flO
ca ca ur u INFORMATION
wLL v, I hereby affirm that 1 am exempt from the Contractor's License MISC.- c REFER TO ORD
H LLoa Law for the following reason.(Sec.7031.5.Husiness and Professions PERMIT ISSUANCE 1000 VALUATION O S/FT.
m0 Code:Any City or COunty which requiresa permit to construct.alter,
O„
¢ . < 0 improve,demolish.or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. U V
ta
- 0 ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a w m he is licensed pursuant to the provisions of the Conlincmr's License ,
Ha• i Law.(Chapter 9(commencing with Section 7000)of Division 3 ofthe I� D
- ¢ Husiness and Professions Code)or that he is exempt therefrom and MTV. PLUMBING PERMIT FEE tl.
¢t $ the basis for the alleged Cxanption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a ; by any applicant for a pencil subjects the applicant tea civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more than rive hundred dollar,(S5001.):-
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.00 occ.GROUP RES.uNITs
the it sole compeosation,will do the work,and the etn¢no,Is not
intended or offered for sale IS,,. 7044. Business and ProcL ions DRAINS-FLOOR,ROOF,AREA,CORD. 5.00
Code:The Contractor's License law don not apply to an Owner of
property who builds or improves thereon,and who den such work FIXTURES-PER TRAP 5.00 Sri FT.FLOOR AREA TOTAL ACREAGE
himsetlnoultb ,his own oncplo,ca provin
ded that ouch ignove-
men is lf arcm nut intended or offered for SJ E.If,however,the building GAS-EA.SYSTEM-111NC.4OUTLETS 6.00
A (4 or improvement is will within orte year of completion,the owner-
builder will have the burden of proving that he did riot build or im- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
prove for purpose of sale.l. INDUSTRIAL WASTE INTER. 30,00 RES IND CON PB Omer
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044, Husiness LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Profvy,ions Code:Thu Contractor's License Law docs not apply
to an owner of property who builds or improves thcrcon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00contr � ' /Y
the
t for such Licenectswithncontactorls)licenced pursuant to NG SEWER-SANITARY-STORM EA.200tt/10.00 ,. TRACT NO. -lPAJRCEL NO.
the Contractor i License haw.
O cunt exempt under$ec.' ,N.&P.C.Gu this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00
ACC.GATE ACG FILE NO.
WORK ERS'COMPENSAT ION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affnn Dlat I have a cenifsate ofconsent to self-insure,
or a cenifcwte of Workars'Com ullop Insurance,or a cerlifed ZONING ENG.SITE NO.
copy thereof(Sec.380Q Lxb.C.)�
Policy No. Company_wV-
O ❑ Certiliedcopyis hereby funlsheN FIRE SPRINK ENERGY T-24
Z 2 1!1�Cer d oily is IC it the cit inspcnion division. MISC.- REFER TO ORD.
O Ap(p�IhlCant Y ❑ N❑ Y ❑ N❑
L6 Clilr I'OF FXJ:MPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
W > C PENSATION INSURANCE PLG.CONTR. LIG NO. PLG. y.[-] N N
❑ Y ❑ ❑
OL _ ('phis section need t be cpleted if the permit is for one TOTAL
hundred dollars 1 S 1001 0
U O 1 certify that in the perks at o tine rk lilt which"Itis per- MTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not empl any pe in any in in so as to
U become subject to the Workers' satimt laws of California.
a we APPlicanl 'BUILDING �•-�/
} Um NOTICE TO APPLICANT' a. If, t' king this Certificate of fix- ALTER OR ADD TO MECH. 5.00
F ? CmptrUir yac ilmuld become subjee o Workers'Comlcrueamn APPLIANCE 5.00 PLAN CHECK
provisions of the labor Code, you m 'orthwith comply with FEE
U such provisions oIhls peonll shall be decree evoked. AIR HANDLING UNIT(TO 10.0DDCF.N7) 4.00
CO RUCTION LENDING ACEI Y AIR HANDLING UNIT(OVER 10=1C.F.M.) 6.00 SEISMIC FEE q, a
I hereby uffem I t there ? consvuclion lend agency for EXHAUST HOOD (WITH DUCT) 5.00
the permrnancc of th mrk/ which this permit is ucd(Sec. MICROFILM
3097.Civ.C.l. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,DOO B.T.U.)9.50
Lenders address, ELECTRIC '
( certify thmlhave read this "cation and state that above VENTILATION FAN (SINGLE) 4.00
' � inl'onnation is mrtect.I agree c nolyrwith all city and county PLUMBING '
ordinances and stale laws r ting building construction, and BOILER-COAT I3 H.P.or 100,000 B.T.U.) 6.00
a� hereby abolentioriee repo ty for
city 1D enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
2a4�. above-meminneJ property for ins looses.
(Wc) agree illsave, indeomlfy a d kc c harmless the City of MISC.- REFER TO ORD. ,
u nino against lie bilines,judgments, costs and expenses which' CONST.TAX
y any way acme agaycst said City in conuqucnce of the PERMIT ISSUANCE 10.00
nti oflhis permit MECH.CONT. LIC.NO. MECH.
SL, TOTAL TOTAL O �1
Sign (
are Applicant/Contractor Urate /
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING PERMIT NO.
19364
CITY OF CUPERTINO APPLICA nON SLJBM=DAa
INSPECTION DIIV19IO�N/- JOB INSPECTION RECORD
lam.-lt
"JOB ADDRESS a.I�'-3,G i ou V kew h�_ UNIT,W / LOT N CATEGORY CONTROL I
OWNER S Il CONTRACTOR 7"L �+ 0 BUILDING PERMIT INFO
INSPECTION DATE INSPECTOR] INPECTION RECORD '� . ❑
FOUNDATION/PIERS NOTE ALL GRADING AND DRAINAGE
UFERGROUND 91 ALL BE INSTALLED TO COMPLY MTH JOB DFSCMI, Oil
PAD/SET BACK-CERT THE APPROVED PLANS ANDCMOF ,
CUPERTINO STANDARDS.
GARAGE SLABS PREGUNITE i
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND/SLAB INSPECTION DATE SPECTOR
PLUMBING
ELECTRICAL
MECHANICAL -
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
WOOD FLOOR - - -
PLUMBING
MECHANICAL
ELECTRICAL •.
FRAMING VENTS CLEAR
INSULATION -
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
ROUGH
PLUMBING ctW 00A, -
TUBS&SHOWER PAN -
MECHANICAL -
ELECTRICAL/JACUZZI BOND
FRAMING STAIRS
INSULATION/VENTILATION
EM ERG.EGRESS `
10 SEWER WATER
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
EXTERIOR SIJEAR HOLD DOWN _
INTERIOR SHEAR/HOLD DOWN
SHEETROCK/SHEETROCKSHEAR
EXTERIOR LATI-I/W-SCREEN
SI 15WEIZ LATH
SCRATCH COAT
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
NOTE:NO FINAL INSPECTION SHALL BE MADE BEFORE
THE CONSTRUCTION TAX IS PAID
FINALS - DATE INSPECTOR,
SAN.# .
ELECT.ENERGY
PLUM13ING ENERGY
MECH.ENERGY • _ _ '
BUILDING ENERGY
ELECT.FINAL TEST
- PLUMBING r
GAS TEST .
MECHANICAL
HEATING
` ELECTRICAL RELEASE -
FIREDEPT.
GRADE
OCCUPANCY -
TEMPORARYAPPROVALS -
ELECTRIC -
GAS '
BUILDING �Y.1
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL _ PVU CE DATE
BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR
ARRANGE FOR INSPECTION BY PHONING 252-4505 BETWEEN d E C Ob I3Cj ,
12.•30 PM AND 4:30 PM MONDAY THROUGH FRIDAY,24 HOURS
BEFORE REQUIRED INSPECTION. JOB ADDRESS AND cit! P` 0grort10p
PERMIT # ARE NEEDED WHEN PHONING.
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION VIM BY:
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prue,,Identification PER.WTNO.
BuMing 19364
A A
,?r'_j OLv CITY OFCUPERTINO-BUILDING DIVISION
Contranore Name: Lm.Nn APPLICATION / PERMIT
'•� ��� i ^2CATEGORY CONTROL.
A mhXect/Fi�glver. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. :a c .� PFJthBTISSUANCE
LICENSED CONTRARO SDECLARATION
Ih,ehyaff4 tktlamlkma d.Mde pmvblov.fChaper9(mmmm APPLIANCESRESIDENDAL JOBN
Ingwlth Sectbn7000)of Dl m3ofthe Budvssand P�mfeW�Code,and P 9
Ilnnse b N full d ileo----=y`�� ��Y'Gf PAM75 • 1'+a A / .i W/
I.kevc Clare `a Lk.I a V "-1 /R_l .
Date Contncimr wQ.JN�
ARCHITECTS DECLARATION 1-1000 AMT'S
µIK'L IuMeretaM my plan aheBkuaed spubBc reorder. OVFRIWDAMPS SQ.FT.FLOOR AREA 5/SQ.IT.
00
L 5Llmnsed larafembvi SIGNS EISERICAI. -
OWNER-BUILDER DECLARATION SI'E{IALCB2CUIT/h4.5C
7F' 7 Ihembyafflmthatlamexemptfr NeCemranor:Llm Uwf«the
pp foWwingreason.(Svefon7m15,Busi ..nd Pmfesbn,Cod,..Mycityor
O Z" TEMP.METER OR POLE INST.
r" anysma�ntykh nequMa permXto cvtnuctireath apmvgdernnlbh,or repair
��� any atronune ratemelt,Wu he o a Ore Wrenthalltto rot(«ruchpemJte ppW.pJ(DEVICES
foe a elgned rtatement that he b Brenn d panuant to the pmWlom of the
wwr Contractor:Lkeme Law(Chapter 9(oomenendngwith Setlbn70(igdDM-
1..,�01 ,bn3 ofthe Business and Prdrmbm Cade)orthat he b eaernpt therdmmand SWIMMING IDOL F].ECIRIC VALUATION
Xi..]ll the kala far the alleged e.emptbn. Any Wolation d Section 70715 by an
�� app0ont(ora perrtdt ubjecta theapplfcanttoa tldl pevhy otnot monetkn OUTLEISSW[TCFiFSFOCEURFS
ItOmdrodddlan(k.500j.
L,as owner of the pmperty,or my myloym wkh wager an theb wie NEW RESIDENTIAL EIEC R SAFE. STORIES TYPECONSIRUCHON
C mmw
petim,will do b do the work and the cture not imerdea or offered for -
y »le 5ec.7DI4,B.Ineaa and Prdeslev Cade:The Comraciors IJoerue law
�s$ don not apply to an owner d property who build,or Imp.t hereon,and
c. who dm such work himseB or through Ms own employees,provided that,uch OCC.GROUP RES UNITS
Improvementa are not Intended oroffened f«aale.If,however,theb d1ding onTOTAL:
Improvement
is within oneyearolcompletbn,the ownerbullder wfll have
tryt-Laraen of proving that he aid not nrud or Improve for wrp�ofaaae.). QT'y. PLUMBING PERMIT FEE
Ll L as owner of the property,am a hnovely eentracuhem
ng with Ted FLOOD ZONE APN
w
PERMIT ISSUANCE
The Contractor's
mrutuct the w do (Sec 7014,Buainese and Pmlmbv Code: ]�.00
The Coor Improves
Lices nsethen Lw dm not apply b t f owner d property who ALTER-DRAIN k VENT.WATER(EA) a V
build, or Improve thereon, and who trm»cta f«ouch p5o}•cte with a
LjIaor e mrue under Sot to thecmt»e«:Lken,e Taw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt order Sec B 4 P C for this renin
Owner Date%3 DRAINS[laoR ROOP,ARCA,GOND. SANITARY RECmrE a
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a rerdBcate d corwra to rB-Iwre,or a SFlXPJRFPERTRr -0� `Ai00L TAA mettilcate RECEIPT a
3800,labc Workrn'Cornpevatimivuran¢«a certified copy Nerrof(Sec. GAS EA.SYSIT•M-1 WG4 OUTLET aDp PARK FEE Y N
Ibltey I GAS EA.SYSEFM-0V FR 4(FA) RFKEIPI'a
Ce ny BUILDING DIVISION FT.ES
Cc ed copyb led!wereby th the city
rtNed epybflled with the city Wpectbn divWm. CREASE/CJDUSHtL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARYFA 1llOFT Date Rewi t#
(I'hla,e Tlonn inn PENS TI NINEifthe�iLANCE one hundred dalWs
(9100)0,le'') WATER HEATER W/VENT/E].ECTR ENERGYFEE Y N
I¢mfy Nat In the performame of the work for which thio permit o tined,
I,hall not employ any person N any manner m ere to become subject to the WATER SYSTEM NG
/TREATI
Wmkeriom
Cpevatbniawsof Ca fomh.Date ado PAID
Z O NOTICE TO APPLICANT:If,after making thio Certtflvte of Exemption,youNEW RESIDENTIAL PLMB. SO.FI'. Date Reeei t#
P N should kmme subject to the Worker;Compewtlm b
provbbv ofthe laor L
TOTA
Cade,you t[forthwith mmp)y with such provbbv or thio permit shallk
Q > deemed revoked MLDING FEE
aC CONSTRUCOON LENDING AGENCY ` - EISMIC FE
Z Ihercbyaffirmthat there b a mnatmctlm tending agency for the perform - 7Y)'EAI.: ELECTRIC FEE
ams,of the workfon which this permit oM(Sec.3097,CW.CJ aZaOU _
02 1<nder:Name - PLUMBING FEE .OD
LL I— IrMer,Addres QTY. MECHANICAL PERMIT- FEE MECHANICAL FEE
O W I« i"tlkv madthlaapplvUonardtlatethattheW elnfor w
bmrmV.Iagreemcomply whhaBdtyand oountyordlnanmand,fate lawn PERMIT ISSUANCE FEES PAID:
} N relating to Wilding mvtuctlm,aril hereby autharbe representatives of this
= dty to enter u Pon the abovcmenlloned property for lvpedon purpose. ALTER OR ADD TO MECH. Date Recel t#
(Wil ages to»nae,bdemedfy an d keep hamQes the CXy of Cupertlro
against kbWtin,)l me coward expenm whkh may In any way.. AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: 3A.00
agawt said C' kgvmXigd WapamJt
AIR HANDLING UNIT(OVER 1GOOD CFM) CONSTRUCTION TAX
gri
�^ Si �a o Ap r T `« Date E)(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA]A R DO US MATER IA LS DISCLOSU RE -
Willtheappilvm«Future Wilding«spam uort or herdk havrdoua HFATINGUMT(Mlffl, TORTU) Date RCeei t#
material as dellned by tM Cupertino Municipal Cade,Chapter 9.1i,and the
Health and Safety Code Section 2553I(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: x2.00
qYe No
JE the applinnt or u m Wilding moupant use equ ipmeN«devim VENTILATION FAN(SINGLE RFSID) DATE
whkh emit k]amlou,air cola mina ms as dell ned by the Bay Area Air
QO.1ity Management District? BOILER-COMP OFB'OR I04IXD B71A ;
n ❑❑� x ) On 1983
havemadIrement,W3aChe Chapter BO LER CVMProVR100,000BU REE
unmtand that
ifth4c Salary Coda Stolon2550$,ve.tand,that 1
urdenstand tktifthe building doo not umcntly have atevnt,tktlt Is cry NEW RESIDENTIAL MECH. SQFE.
respovBrWty to notify the aavpart d the regaimmems which crust bemet f A r•n�lnp
citprior to lsunee of a Comf o to of Omupamy.
Owner«authmiaed.gent Date �^
TOTAL: ISSUED BY:
OFFICE COPY
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Ca f ¢ w w 0 O 2 w w ¢ - O w N N h O U O o ~
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