6669CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
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BUILDING
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES "i USE -BALL POINT PEN ONLY
BUIL DI NG PROJECT IDENTIFICATION ` .
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APPLICATION & PERMIT
BUILDING - ELECTRICAL -PLUMBING - MECHANICAL
PERMIT NUMBER
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ILDING
ADDRESS
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DTV. EL'ECTRIGPERMIT FEE
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•UTLETS
- PLAN CNECK VALIOA
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029 7
„
DATE OF APPLICATION
CONTRACTORS -
.1• o�A.-' .I'a c uC.No. 2,YOS'15'
-SWITCHES -RECEP 5.00/1.00
JLiGHTING FIXTURES" 5.00/1.00
'CONTHAS y /!7/.ya �rA ///pS /
ADDREACi�j��g/�A /
O /�% C - PHONE �O/ -0 .�D�
APPLIANCES -RESIDENTIAL 4.00
PANELS .5.00
OpcwtECT .. '
ENG( ER
/P��/}Yi'U LIC.NO. '
SIGNS 6.00 -
PLAN CNECK FEE •P.C. NO.
SIGNS TRANS. 3.00
ARC" ORENG.
ADDRESS ///O /�u4/v's/6��r/CF �'.�� -
C15i'' 'ZIP f C/D
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SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
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ISSUANCE DATE
BLDG. ELECT, PLG. MECH.
TEMP. METER OR POLE INS. 15.00
APPLICANT'S -
AD..Ess
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MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSF,D'CON'I'RAC'I'ORS DECLARATION
I hereby ul'finn that'[ an, licensed under Provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Husiness and
Professions Code, and my license is in full force and effect
I License Cl..-- Lic, Number
are Contractor
-
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cnnlmctor's License
Law for tie following reason. (Sec. 7031.5. Busmessand Professions
Code: Anycity orcoonly which requiresa permit mconstruct, alter,
Improve, demolish, or repairing structure, prior to Its Issuance, also
requires the applicant for such permit ID file a signed statement that
he Is licensed pursuant to the provisions of the Contractor's License
Law (Chapwr9(commencing with Section 7000) of Division 3 of the''
Business and Professions Code) or that he Is excolt therefrom end
p
the basis for the alleged exemption Any violation of Section 7031.5
by any applicant lot a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500t): ,-.
❑ L as owner of the property,my employees ract wages as
their sole compensation, will do thee work, and the inW, re is not
intended or offered for Sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law_does not apply to an owner of
properly who builds or improves thereon, and who does such work
himselBor through his own employees, provided that such improve-
ments are not intended orOffered for sale. If, however, the building
or improvement is sold within one year of completion, the owner-
wner
budder
builder will have the burden of proving that he did not build or im-
prove for purpose ofsale.). -'
❑ -I, as owner of the property, vol exclusively contracting with
licensed contractors to Construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License L w."
❑' l ani exempt undo ec. ,ELARC.^for this
rensml /
BUILDING4%ERMIT
�N FURMA_TION
MISC. - REFER TO ORD
PERMIT ISSUANCE'
5.00
VALUATION SIFT. -
ELEC. CONTR. LIC NO,
ELEC.
TO.,LPERMIT
TO
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OTY, Sim. '' `r, b
,„- :'c `PLUMBING P,ERMITt i s t,, FrEE
S v's' . +' ov? x -+' h N '$
ALTER-DRAIN'&VENT - WATER (EA.)4,DD
Q S
p
TYPE CONSTR.
-
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
'
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
FIXTURES - PER TRAP 4.00
GAS-EA.SYSTEM-11NC.40UTLETS 4.00
SG. FT. FLOOR AREA
TOTAVACREAGE
'
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON AS Omer
INDUSTRIAL WASTE INTER. 20.00
-LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
'
ASSESSORS PARCEL NO.:
•' '
LAWN SPRINKLERS - OVER 5 (EAJ 1.00
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO:.
-PARC EL NO.
WATER HEATER W/VENT 4.00
Owner T„ Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a ertiftcalc ol"consent to self -insure,
or a certificate of Workeri Compensation Insurance. or A certified
copy I Immof ( Sec. 3800, L.b C.jL�-� �
I'olicYNo. Company�,.LA-yltrcI
WATER SYSTEM - 4,00
Ace: DATE
ACC FILE NO.
WATER TREATING EQUIP. 4.00 .
-
ZONING
ENG. SITE NO.
-
_
❑ Certified copy is hereby furnished.
❑ Certified copy i h the aspection division.
Applicant �Af�16 //�2L o%l��I
FIRESPRINK
YC3 N�
ENERGY T-24
,v❑ N[
MISC.- .� REFER TO ORD,
CCRTIPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
I Ihrs Section need not be completed If the permit Is for one
tun lr Jdolluro ($100)or less)
1 rids that m the performance of tin work for which this per-
nut Is IssueJ, I shall not employ any person In any manner so as m
become Subject to the Workeri Compensation Laws of CalRomia.
Date - Applicant
PERMIT ISSUANCE - 8.00
FLOOD ZONE
Y ❑ N•❑
A.L.O.C.
1 Y [3 NEI
PLG. CONTR. „LIC. NO.
^-
PLC.
TOTAL
-
STV. ME HANICAL PERMIT J F„EE
.€ ,: �. '! a.
- -
FEE SUMMARY
BUILDING
ALTER OR ADD TO MECH.. 4.00
NOTICE '10'APPLICANT: If, after making this Certificate of Ex-
emptiun, 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.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for
the Performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
Name
APPLIANCE - 4.00
AIR HANDLING UNIT (TO 10;000C.F.M.) 3.00
PLAN CHECK
FEE '
AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00
q
SEISMIC FEE /O
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
-Lender's
LendersAAdrcss
HEATI NG UN IT (OVER 100,000 B.T.U.P.50
ELECTRIC
I certify that 1 have read this application and state (hat the above
information n correct f agree to comply with all oily and county
ordinances and stale laws relating m building l city construction, and
above- authorize representatives of this city to enter upon the
above-mentioned property forinsp ofth i purposes.
(We) agree to save, indemnify and keep harmless the.City of
Cupertino against liabilities, judgments• costs and expenses which
may in any way accrue against said City in consequence of the
gra It.
Zl �Y
VENTILATION FAN (SINGLE) 3.00
BOILER -COMP.(3 H.P. or 100,000 B.T.U.) 4.00 -
'.PLUMBING'Im-by '
BOILER -COMP (Ower 100,000 BTU) SEE FEE SCH.
MECHANICAL
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST: TAX
MECH. CONT. LIC.NO,
MECH.
TOTAL
-
TOTAL
Signature of Applicant/Conlmetor Date'
OFFICE COPY