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APPL)CANT TO FILL IN INFOP '1TION WITHIN RED LINES- USE B, - POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
6255
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AD09
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7 1 "3 - t X' JF{t,h;'3Fy"�� Y .()•C}•
O"�, ELECTRIC PERMIT x FEE'
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PLAN CHEL ALIDA N
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(C) /
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DATE OF APPLICATION
CONTRACTORS
N E �// .s,.T /^+�- 7�f {1
l.f5 a1. L•-� LIC.ND�[rzI
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
rONTRAc]oR's5�
0 PORE A`j
IVa -:�, PHONE L
PPLIANCES-RESIDENTIAL 4.00
PANELS 5,00
ARCHITECT
OR
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
LIc.No.
:noAE°sIt
SPECIAL CIRCUIT 5 -UG
PERMIT VALIDATION
i /
EMP. METER OR POLE INS. 15.00
APPLICANT'S
A[DOC _
gff
MOTORS SEE.FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9
ISSUANCE DATE
I Commencing with Section 7000) of Division 3 of The Business and
Professions Codit ((1mnnny license is in full for of eLy
Lm`7 Cl ss Lia Number
BLDG. ELECT. PLG. MECH.
Fj t ❑ ❑ ❑
LJ'
Date rsllwa' Contnctar
OWNER -BUILDER DECLARATION
I hereby affirm That I am exempt from the COnI2tlOrs License
Law for the following reason. (Sec. 703 1.5, Businessand Professions
Code: Any Cityorceunty which mquiresa permit toeonstrucl,alter,
improve, demolish, or repair any structure, prior to its issuance. also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to The provisions of the Contractor's License
Law (Chapter 9lcommencin ilh Section ]000)o(Division3 o(lhe
P gw'
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of5eelion 7031.5
In ...'10-
MIST.. - REFER TO ORD -
VALUATION
\ r�
Y /
Is/FT.
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIQ NO. ELEC.
TOTAL
- - -
.u4'-'-`='`'^�"}` "^u•` i•ylt 1 'T`
{' x'
OTY1 PLUMBING PERMIT �• F E
s'.�'s'&gi« • L`�:�P+�ks'�iF. .'.it+''.Y%e s< :•«f^_ ..
PERMIT TO
TE�s/PBN% /a�i>•3ea (/�
STORIES
TYPE COrySTR.
by any applicant for a permit subjects the applicant to a civil Penalty
of not more than five hundred dollars(SSOOO:
3
V'
ALTER-DRAIN&VENT-WATER (EA.14.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
-
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Code: The Contractor's License Law does not apply to an owner Of
property who builds or improves thereon, and who does such work
FIXTURES - PER TRAP 4.00
SQ FT. FLOOR AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
enanot intended Or offered for sale. If, however, the building
mta re
GAS - EA. SYSTEM -1INC. 4OUTLETS 4.00
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-
prove for purpose of sale.).
0 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑ ❑ ❑
INDUSTRIALWASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
And Professions Codi The Contractor's License law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contraetodsl licensed pursuant to
the Contmetm's License Law.
SEWER -SANITARY -STORM EA. 200f1/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
'u lam exempt under Sec. ,e.&P.C. (nr miss
reason
Owner Dale
WATER SYSTEM 4.00
ACC. DATE
ACC FILE NO.
WORK ERS'COMPENSATION DECLARATION
WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance. or - certified
$DNING
ENG. SITE NO.
copy thereof (Se 0. L. .H
Policy No. oin
❑ Certified if' he, QS -
❑ Cent ..< y is I y m Tion division.
r Applicant
FIRE BPRINK
Y N
❑ ❑
ENERGY TN
Y N
❑ ❑
MIST.. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L. U.C.
PLG. CONTR.LIC.N0.
PLO.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y❑ N❑
Y❑ No
I�
sg°1L. 'S'"�?"Y'`x�'-5� p Msf¢,.7r a�T"kNt "{x 4%% }
Y J s'Y ��TYS'^r f' FEE r5'
QTY' yt"A' blr,v„IMECHANYCAL' PERMITY i1 -'L c
LI'A x' :Ybwrr f^5 :. w.,•:. L«i T"LatrF ?}s-.•4^ ,C• .?a.*2 •.?
Y.;;S,r.-
La sero FEE $UMMARV}"
-
hundred dollars IS 100) or less.)
I certify that in the performance of the work for which Ihrs per
mit Is issued, 1 shall not employ any person in any manner so as to
becomesubjecttotheWorkers' Compensation Laws of Califomta.
Dale Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers' Compensation
BUILDING
/e}70 ai
ALTER OR ADD TO MECH. 4.00
APPLIANCE - 4.00
PLAN CHECK
ps"isions of the Ubor Code, you must forthwith comply with
Such provisions or this permit shali he deemed revoked.
FEE
AIR HANDLING UNIT (TO 10,0MC.F.M.) 3.00
AIR HANDLING UNIT (OVER 10MC.RM.) 5.00
SEISMIC FEE
30
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.).
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.17.50
ELECTRIC
Lender's Name
Lender's Address
VENTILATION FAN (SINGLE) 3.00
PLUMBING
I certify that I have read this application and stale that the above
intormatlon is correct. I agree to comply with all city and county
ordinances and slate laws relating to building construction, and
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives 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, )uit menta, costs and expenses which
may in any -way accrue gain said ity in onsequ ce of the
gran' This Permit.
(/ {
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIQ NO. MECH.
TOTAL
TOT,
ysmr.-%tom ''
3 00 9
lure Ap hcant/ Contraetor Dat
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
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PERMIT ISSUED _ DATE ELECTRICAL DATE JINSP.'
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Meed
Re—pm
g'ire
FINAL INSPECTIONS DATE I INSP.
Gas
BUILDING DATE I INSP.
Pad Certification
Power