0484 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
I PERMIT NUM
Is - BUILDING PROJECT IDENTIFICATION �AATIO LU PERMIT 8BUILDINGADDREss BUILDINGCAL-PLUMBING-MECHANICAL
Rub
i• ' Ow ER'9 PLAN CHECK VALIDATION
' vAn
y� TV. ELECTRIC PERMIT FEE
D PHONE �O/I�
.NTRACTORS OUTLETS-SWITCHES-RECEP 5.00/1,00, 'p0_
/ME
uc.No. LIGHTING FIXTURES 5.00/1.00 RO
PARK
ORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF APPLICATION
ITE SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER �Z�/•1� 3.00 '
uc.NO. SIGNS TRANS.
ENG. 5.00
PERMIT VALIDATION
ADDRESS G SPECIALCIRCUIT ,
S7o cym,uw0 L ZIP/ 08 EMP.METER R POLE I 15.00
APPLICANT'S MOTORS (T SEE FEE SCH. _
ADDRESS
64,bbSERVICE NGE /I/ 10.00 y� T
Foo LICENSED CONTRALTO SDECLARATION .Ot� d
HISSUANCE DATE
¢ v u I hereby affirm that I am licensed under provisions of Chapter 9
P
'42
¢ °' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
F,w i Profesxions Code,and my license is in full force and affect. (�I
z o - License Class Lie,Number. ILx, s
o z w Date Contractor
P r f W - BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
E:
3 e y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO OR
g - PERMIT ISSUANCE 6.00 B VALUATION $/FT.
u 77
O a Law for the following reason.(Sec.7031.5,Business and Professions O
Code:Any city or county which requires a permit to construct.alter, �O QO-0 .(
¢ au Q 2 improve,demolish,or repair any structure,prior ID its issuance,also ELEC.CONTR. LIQ NO. ELEC. LIS 0
-
0,
requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO Iu,
wm ut he is licensed pursuant to the provisions of the Contractor's License ..
H z r Law I(Chapter 9(commencing with Section 7000)of Division 3 ofthe
a
thus,imol'and Professions Code)or that he is exempt therefrom and GTV. PLUMBING PERMIT FEE
ftpSTORIES TYPE CONSTR.
¢ s- the basis for the alleged exemption.Any violation of Section 7031.5
malty
n ;� by any applicant for aoundresubjects the Oh.): anttoacivilpenalty .ALTER-DRAIN& VENT-WATER (EA.) 4.00
of not morethan five the prop dopes(my em: I
❑ Las owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00 R-00 •Oce.GROuv RES.UNITStheir sole compensation,will e is not.
intended or offered for sale(S the work,and the struct(Sur
(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,CONIC. 4.00
Codec The Contractor's License Law does not apply to an owner of
an
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 1A,00-70-FT.FLOOR AREA TOTAL ACREAGE
i� himself or through his own employees,provided ihatsuch improve- GAS-EA.SVSTEM-11NC.4 OUTLETS 4.00 Q
mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving That Ile did not build or im- RES IND CON PB Clair
pr ve for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
�( Las owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Btrdnexx LAWN SPR IN KLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projectswith a contructons)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACTN0. PARCELN0.
the Contractor's License Law. ,
'❑ lam exempt under Sec. ,B&P C.for this yygTER HEATER W/VENT 4.00
reason
Dam - Owner WATER SYSTEM 4.00 ACC.GATE ACC FILE NO.
WORK F RS'COMPENSATI DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. BONING ENG.SITE NO.
• or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lub.0.).
Policy No. Company -
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. y q❑ y ❑ N❑
F yApplicant
PERMIT ISSUANCE 6.00 ()0 FLOOD ZONE A.L.U.C.
(r CERTIFICATE OF EXEMPTION FROM WORKERS'
lyj> COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. a LDO Y❑ N❑ Y ❑ N❑
CL 0 (This section need not be completed if the permit is for one TOTAL
:) Z hundred dollars($100)or less.)
L) 0 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEELL FEE SUMMARY
F mit is issued,I shall not employ any person in any manner so as to -
0 w become subject to the Workers'Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 4.00
} this NOTICE TO APPLICANT: If,after making this Certificate of Ex.
H ? emplion,you should become subject to the Workers'Compensation JAPPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit Shall be deemed revoked. AIR HANDLING UNIT(TO IOD00C.F.M.) 3.00 L
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER I0,000C.RM.) 5.00 SEISMIC FEE a, fld
I 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(See. MICROFILM
3097,Civ.0.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Cender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 7S-b ELECTRIC 442 0_a_
Lender's Address
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 ,3&,o
information is correct.1 agree to comply with all city and county BOILER-COMP l3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
- henna au and state laws relating m building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (OVBr 700,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree,to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities '-it Is, costs and expenses which PERMIT ISSUANCE 3.00 3, DT CONST.TAX
may in any way accrue 'nst said C' y in Consequence of the
gm ingo this pe it. MECH.CONT. LIC.NO. MECH.
p TOTAL /3 TOTAL -d,1,30
Signature o(Ap licant/Contmc Date Y /
OFFICE COPY C I p a,,
ADDITIONAL, P]rl4IT FEES
I ,
BUILDING PROJECT IDENTIFICATION VALUAT40N
• BUILDING
AooxE.
f
xa `
FEE SUMMARY
ervorvE
NMrnwcr BUILDING
NAME
uC.No PLAN CHECK
.T.Aaoxa FEE
ADDREW
SEISMIC FEE
GTV. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS TOTAL O d
' SIGNS TRANS.
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VALIDATION
MOTORS SEE FEE SCH.
0 SERVICE CHANGE
Z z
F- a TOTAL
� Issu
UJ > OTY. PLUMBINGPERMIT FEE attic. WIwxcE DATE
ELE .PLG. E
2 O
Z) 2 ALTER-DRAIN&VENT-WATER(EA.)
LO
L BACK FLOW PROTECT.DEVICE
0w DRAIJJS-FLDOR,ROOF,AREA.COND.
} h FIXTURES-PER TRAP
F 2 GAS-EA.SYSTEM-I1NC-40UTLETS
V GAS-EA.SYSTEM-OVER 4IEAJ
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS OVER 5IEA.)
SEWER-SANITARYSTORM EA.200ft/
WATER HEATER WNENT
WATER SYSTEM
WATER TREATING EQUIP.
TQTAI
OTY MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10,OWCF.K)
AIR HANDLING UNIT(OVER 1GOODCF.K)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000
VENTILATION FAN(SINGLE)
BOILER-COMP 13 H.P.or 100,000 B.T.U.)
BOILERCOMP lo.<�too.00D ElTUI SEE IEE s l
TOTAL
CITY OFI Cull INSPECTIO[! EC
'RORD (Office opy)
pe ti ,� -9) X
0484 _ 11236 Bubb Rd.
PI]Pd1I'r NO. SANITARY DIST. NO. LOT NO. ADDRESS
Addition � ` Richard Dayton 255-6125
PROJECT 014NER JOB' SITE PHONE N/0.
PERMIT ISSUED Date ELECTRICAL /
Buildin - - /-q-rtr �Q/. G �� _ �- -c ate nkp.
Electrical 6-5-81 Power Po_l.e
Plumhin,r, 6-5-81 Under ,r.ound �-
Mechanical 6-5-81 Rou�(,h Wiring _
Temp. Cas/Elect. llalls
Solnr Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Elisc. Temp. Power Uvtec
Other U,y, C /-1 Fc.cc
FINAL. I14SPECTIONS Not ApProved
Date Insp.
r' 's y'�3 PL 1BING
�Flectric
al
ate Insp.
�PL�mbin , Backflow
\-!lechanicUnderground
Solar Underfloor
Pool Partial Rough
Gradin Rough Complete
. Planning Solar Rough
Fire De t. water & Insulation
\ Ilealtli De t. Main Drain
Vluildin R/of/S Drain
Other g(, `10 Gas
.�.r OYo. other
BU
])IG / ?1/ r/p Not Approved
Date Insp. P1V p ,
I'ad Certification ME 11ANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulatic, A
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One Hour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
lialis-l'ancls Flues & Comb. Air p y
Frame i v Other
Lath Not Approved
Wallboardsxti-- L a�
Firewalls
Otheron'�""T 3
• Not Approved Z titl Rte �/
P
47-1 - 1 C. 2 — c F <,
n,eT cam . �.ib-s Z=� S $(��~� 8
W� i.1bc (�- 6= " 20 - 8Ifcr 2 �0, PIasRBC-p /ZO° � �
BUILDING '
of
•
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
l
•
CITY OF CUPERTINO PCOPYE
GAS SERVICE NOTICE
�ijuJ► /Q , 19��
To
You are hereby authorized to connect the GAS service for
Owner or Tenant
At i 3(p x.
New Service
No. of Meters Reconnect
No. of Add. Meters Move Service
May eter_
PLUMBING INSPECTOR ] n.
i
CITY OF CUPERTINO aCOPY
I
' GAS SERVICE NOTICE
To
You are hereby authorized to connect the GAS service for
Owner or Tenant
New Service
No. of Meters / Reconnect
No. of Add. Meters Move Service
Move M/eterr, G L
PLUMBING INSPECTORf LtS.cX f�
I