6381APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
+
APPLICATION & PERMIT
BUILDING — ELECTRICAL— PLUMBING — MECHANICAL
PERMIT NUMBER
6381!
m,ILGING.
ADORES
S
NAME
�/OTY.
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- m ' ^
E 'EC)TRIC�P.ERMIT FEE
r
PLAN CHECK VALIDATION
'
DATE OF APPLICATION
CONTRACTOR'S
qM / s q/
t—/
/7 'sec. No.43p
UTLETS-SWITCHES-RECEP. ,5.00/1.00
LIGHTI NO FIXTURES 5.00/1.00
CON
CTRACTOR'S ^
ADDRESSAPPLIANCES-RESIDENTIAL
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/•fd40�-'' C - PHONE —
4.00
PANELS 5.00
ARCHITECT
DR
ENGINEER
LIC. NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARC. Ess ENG'
.
ZIP
SPECIALCIRCUIT 5.00
PERMIT VALI DATION
ISSUANCE DATE
TEMP. METER OR POLE INS. 15.00
APPLICANT'E -MOTORS
ADDR Ess - ,'•
..
SEE FEE SCH.
SERVICE CHANGE .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 Code, adinny license is it full for • /'
Licensy�Cluss,�—ii�—�t,� Lic. Nnmbei !�
arc=-�L—SIC_v�Contractor
^OW `N'ER-BUILDER I)G ARATION
affirmT
I hereby that I am exempt from the Contractor's License
Law for the following reason. (Sea 7031.5, Business and Professions
Code: Any city or county which requiresa permit toconstracl,atler,
improve, denmlish, or mpair any structure, prior to its issuance, also
requires the applicant for such permit to File a signed statement Ih.l
he Is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencimg with Section 7000) of Division 3 oflhea'
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 fora permit subjects ($500applicant toacivil penally
of not more than five hundred dollars (my amp
❑ ,Las owner of the willproperty,t or my employees rack wages as
their sole compensation, will do the work, and the structure is not
intended or..Ifered for sole (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
I himself or through his own employees, provided that such improve -
mcotsarenot intended oroffered for sale. If, however, the building
or improvement'is sold within one year of completion, the Owner.
builder will have the burden of proving that he did not build or im-
prgve for purpose o'saleJ.
N I, as owner of the property, an. exclusively contracting with
licensed contractors In 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
contracts (or such projects with a contr,et.r(s) licensed pursuant to
the Contractor's License Law.
O 1am exempt under Sec. B.&P.C. f�rr
re.lon }his
Ownerate
WORKERS'COMPENSATION DECLARATIOIV /
I'horeby affirm that I have a certiticate of consen Llo self -insure,
or a certificate of Workers' Compensation Insurance, or - certified
• copy there c 3 00, Lab.C-. 15(—?m
Policy No J .ompany_ RJ �C
❑ Chili • co yrs htj y f 'i lit
&Cert if -d opy 1, Ilea I the it action division.
am'hcant
AUG 2
ELECT.
❑ ❑
PLG. MEC..
❑ ❑
YOCOfiBLDG.
perm
BUILDING�PERMI
INFORMATION
MISC. — REFER TO ORD
PERMIT ISSUANCE _
• 6.00
VALUATION SOFT.
./�—l��D
'7`•
ELEC. GONER. LIC, NO. -
ELEC.
TOTAL
PERMIT TO
�7� 4
'+ as y•?,
DTrV( ` b e''' 'PLUMBINGyP.ERMIT ads+ N -1v �1 FE
ALTER-DRAIN&VENT-WATER IEA.) 4.00/
� �
STORIES
q
Vit of
y
TYPE CONSTR.
uVV `// TS
�
BACK FLOW. PROTECT. DEVICE 2.0D
OCC. GROUP
REB. UNITS ,
,
DRAINS -FLOOR, HOOF, AREA,COND. 4.00
-
FIXTURES -PER TRAP 4.DD IP 'J
GAS - EA. SYSTEM -1INC. 40UTLETS 4.00
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
50. FT. FLOOR AREq
TOTALACREAGE
BUILDING USE
RES IND CON PB Other
1:1 ❑, ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
'
A ESSORS PARCEL NO.
LAWN SPRINKLERS - O &.) 1.00
SEWER -SANITARY -STORM EA. 200ft/8:00
TRACT NO.
PARCEL NO.
1 WgTEfl HEATVER W T .00
WATER SYSTEM 4.00
ACC. DATE
'
ACC. FILE NO.
WATER TREATING I.00
ZONING
ENG. SITE NO. ^
Misc.- REFER TO ORD.
FIRE SPRINK
Y F N
ENERGY T-24 r
Y 0 NE)
"I IIICA'rE OF EXEMPTION FROM WORKERS'
'COMPENSATION INSURANCE
(This section need not he completed if the permit is for one
hundred dollars IS 100) or less)�,
' 1 certify that in the performance of the work for which this ter
mit Is Issue) 1 shall not employ any person In any manner so as to
become subject to the Workers' Compensation Laws of California.
Dan. ApplicaICANT:m
NOT ICE TO APPLICANT: 1(, after making this rs' Co pe sa Ex-
emptioq you HIO Labor bme Code, youect rouse forthwith comply with'
provisions io Ihet Mise Code, you muss forthwith comply with
such provisions or this permit shall bedeemed revoked.
CONS'T'RUCTION. LENDING AGENCY
I hereby affirm that there is a construction lending agency for
(he performance of the work for which this permit is issued (See.
3097,Civ.C.).'
Lender's Name
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y ❑ NE]
A.L'.U.C. I
Y ❑ NE]
PLG.CONTR.LIC. NO.
PLG.
TOTAL OnnV—
GT 6 k jF�3(„
i v g e-MECHANICAL'9PERMI7 'n k
FEE SUMMARY
s ��� •�
BUILDING
'
ALTER O R ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE'
AIR HANDLING UNIT (TO 10=C.F.M-) 3.0
AIR HANDLING UNIT (OV F. Mi
SEISMICFEE
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 10 B per
Lender's Address -
I certify that 1 have read this application and stale that the above
mmouoUon is Correct 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
hereby_ authorize repiesenmtives of this city to enter upon the
above-mentioned property' for inspection purposes,.
(We) agree to save, indemnify and keep harmless .the City of
Cupertino against liabilities, judgments, costs and expenses which
ITS in any •way accrue 'nst said City in conseq ence,o( the
ITS of his tit.
'Signature of Applicant/Contractorat
HEATING UNIT 100,000B.T.U.17.50,
ELECTRIC-�'
VENTILATION FAN (SINGLE) 3.00 -
-
.BOILER- COMP (3 H.P. Or 100,000 B.T.U.) 4.00
PLUMBING
'• 6a -
BOILER -COMP (Over 100,000 BTU) SEE FEE'SCH.
MECHANICAL
MECHANICAL
MISC. - REFERD.
PERMIT ISSUANCE 3.00
CONST. TAX
MECH. CONT. LIQ NO. MECH,.
TOTAL//
„ TOTAL^.
OFFICE COPY - - -
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
k/ � 3
�22 Sfik� p� �. .
PEICUTNJ L V1 lyV.
ApD�no�
ER
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
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ctrikcal
Plumbing „ Power Pole
FINAL INSPECTIONS DATEINSP.
Gas
BUILDING DATE I INSP.
Pad Certification
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Sti edc `4di
sl�-IRD��t
rorsa;�r�
DATE INSP.
Underfloor S.M. 2,