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APPI ICANIT T(1 PH I IN INIFfYRMATInKI WITHIN RFf1 I INIFS — I ISF RAI I Pr)IKIT PFNI 01\11r"A
---- --- ...--._..__..- ..- ._...... ____.___...
- - -___ --- _..- .._.
-_.-
.
BU I LDI NG PROJECT I DENTI FICATION
APPLICATION &PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
EMIT NUMBER
0 p
(J
PLAN CHECK VALIDATION
aOILGIN
agoRES
NAME Fn "— pj'• %�'
PHONE
OTV.
•, ELECTRIC PERMIT. ,
k�• "f
FEE,,,
NAME °R3 g.A
370ws
UTLETS - SWITCHES - RECEP 5.00/1.00
f�
r�l ETS UMyuc.NO.
DATE OF APPLICATION
LIGHTING FIXTURES 5.0OI1.00
C.ONTRACTOR's
ADDRESS
L PHONE
PPLIANCES- RESIDENTIAL 4.00
PANELS 5.00
ARCHITECT
OR
ENGINEER
sec. NO.
SIGNS g,QQ
PLAN CHECK FEE C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL CIR T 5.00
sS.
PERMIT VALIDATION
EMP. METE R P E 15.00
ZIP
APPLICANTS
ADDRESS
MOTORS Z �E SCH.���/
SERVICE CH NGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Co y license is in full f n fe
License C Lic. Numbe
ISSUANCE DATE
BLDG. ELECT.
❑ ❑
PLG. MECH.
Dale Contracts
q,,,4it�ff^BUIL'DING.PERMITTTTTT 4-'A*
d <?�';.fL
— '•f- �INFORMATION;a. Sj_a'.
OWNER - BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the metro d P License
Code: Any city ounty which m 7iresa ermitt sand Profession
Code: e, den y sh county any structure, uie p oor (o construct, alter,
improve, the or repair h p rmit trile e a si n its ate issuance, that
requires the applicant for such permit to isle a signed actor's i that
he is (Chapter pursuant to the provisions of the Contractor's License
Law (ess andr9 renion, Code) or Section is exemft Division heoo and
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (S500).):
MISC.— REFER TO ORD
VALUATION
a00
S /FT..
PERMIT ISSUANCE 6.00
ELEL, CONTR. UC. NO. ELEC.
TOTAL
�� f�y� 5R MIT
`/v yll�`' '
C "
QTY:
ii r'
-' '•v''F`- ,'PLUM`''ING PERMIT;' MIT;':s';'.':r'a'-
:') ,'PLUMBING PERMITd h ; y
. r = j 10„x/: • _v{ td' 'p_
'';,y; -rvE,
IFEE.is
.i „f.
STORIES
TYPE CONSTR.
-
'
ALTER-DRAIN -WATER (EA.)
❑ I, as owner of the property, or my employees with wages as
their Aide compensation, will d° the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
oCC. GROUP
RES. UNITS
DRAINS - FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments am not intended oroffered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
GAS•EA.SYSTEM-11NC.4OUTLETS 4,00
SO, FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did nor build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS - EA SYSTEM -OVER 4 MA.) 100
. 1.00
BUILDING USE
[NO ,CON PB Omer
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 2000
.
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORSPARCEL NO
'
the projects La., acontnetorts) licensed pursuant (o
the Contractor's ors, License Law.
SEWER- SANITARY -STORM EA. 200ft /8.00
TRACT NO.
PARCEL NO.
❑ lam exempt under Sec. , B.&P.C. for this
mason
WATER HEATER W /VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby a(0rm That I have a certificate of consent to self - insure.
or a ��ert11'jjI�j a�p[ orkeri Compensation Insurance, or a certified
copl�slf�q
Policy No. Company -I:. M'S Q )xa'i�
ZONING
ENG. SITE NO.
-
FIRE SPRINK
y ❑ N❑
ENERGY T -24
v ❑ N❑
❑ Certified copy is hereby furnished.
❑ Applicant- ,po yk fsled_wiW 111. (yvsapse'c' division.
APDlicCer �+- -rS Ir`
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
PLG. CONTR. LIC. NO.
PLG.
TOTAL
v❑ N❑
Y❑ N❑
sir
DTY
'� ^• '
x+ �.y:.f•Ay' +;H Sa,swtys- .u'3inF> .T•
s h MECHANICAL' PERMIT +" %' g
F^ I t'� 'L L lr &%T'vTi ". A'i -.J ;nr, xx�.i t.'d'+
NV",
a'FEE�sti..Et,
-1 �1;
r,�., zw y. .act
i+I: ',FEE SUMMAH_Y �'
r �
BUILDING
e�6
hundred dollars(SI00) or less.)
1 certify that in the performance of the work for which this per
become subject to the Workers' Compensation Laws of California. o
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. q,QQ
APPLIANCE 4.00
PLAN CHECK
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=CF.FAI 3.00
FEE
_
AIR HANDLING UNIT (OVER 10=CRM .)5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.). --
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender, Name - III C ha
Lender,Address
HEATI NG UNIT(OV ER 100,000 B.T.U.17.50
ELECTRIC
I certify that 1 have read this application and stare that the above
VENTILATION FAN (SINGLE) 3A0
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
E hereby authorize representatives of this city to enter upon the
a bove - mentioned property for inspection purposes.
PLUMBING
—�
BOILER H.P. or 100,000 B.T.U.) 4.00
BOILER-COMP (Over 100,000 BTU) SEE FEE BCN.
MECHANICAL
�+
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilili jud a ts, costs and expenses which
may in e y ace ai Ciry m consequence of the
grants f permit
�..
PERMIT ISSUANCE 3.00
3
MECH. CONT. LIC. NO.
MECH.
TOTAL
^.tty.
"•'' „rnT01AL:-
,E'
OD
SignawmofApplican
OFFICE COPY
CITY OF CUPf,RTINO INSPECTIOV RECORD (Office Copy)
p3gg _ 12601 Amine Dr"_._
PER11IT N0. SANITARY DIST. 110. LOT NO. ADDRESS
�w Ara
a •
P Rich Phillips 378 -0334
OJECT O1•DIER JOB SITE P110I4E NO.
'0
PERMIT ISSUED
Date
Buildinr,,
Insp.
Electrical
aeti
P tumh inr
5 -22 -81
Mechanical
5 -22 -81
Temp. Cis /Elect.
Solar
Tire Sprinkler
Sign
Ilisc.
_
FINAL INSPECTIONS
Date
Insp.
Electric -/ff /
aeti
Plumbing
!!"^-
Mechanical
Solar
Pool
Grading
Planning
Fire Dept.
_
Health Dept.
Buildin
_
Other
BUILDING
Date
Pad Certification
Insp.
Foundation
_
Pre - Gunite
!!"^-
Slab - Membrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
_
Seismic Bracing;
halls- I'ancls
_
Frame
Ln th
Uallboards Int /Ext.
Firewalls
Other
Not Approved
ELECTRICAL
Date
Power Pole
Insp.
Underground SY
_
Rou ,h Wiring
!!"^-
ITal s
Ceiling
Fixtures Int /Ext
Motors
Grounding
Temp. Power
_
Other
Not Approved
_
PLUMBING
Date
Backflow
Insp.
Underground
_
Underfloor
_
Partial Rough
Rough Complete
Solar Rough
(dater & Insulation
'lain Drain
R /of /S Drain
Gas
Other
Not Approved
HECl IAN I CAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
_
Fireplace
Grease Duct & hood
One (lour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved