6253 - CofO APPLICANT TO FILL IN INF OR ION WITHIN RED LINES - USE BA OINT PEN ONLY
i,) BUILDING PROJECT IDENTI FICATIO PERMIT NUMBER BUILDING APPLICATION & PERMIT
v noones:
�. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 6253
O rvl as'. • I „ ', �,d _ PLAN CHECK VALIDATION
NAME `JN- T co QTY. " ELECTRIC•PERMIT ' f,f»'1T7' F E~• �(f-c� i�
PHONE
CONTR TOGS /J
aMe) ffq UTLETS-SWITCHES-RECEP 5.00/1.00 ��J�
(�� uc,.OZ /( � LIGHTING FIXTURES 5.00/1.00
.ONTRACTOWS .. �A PPLIANCES-RESIDENTIAL - 4.00
o 4. 1^7
� rl' PHONPANELS 5.06 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
GR
LIc.No. SIGNS TRANS. 3.00
AA9PDp C.ENc.' / 1 SPECIAL CIRCUIT 55.00 PERMIT VALIDATION
EMP.METER OR POLE INS. 15.00 ,
APPLICANTS MOTORS SEE FEE SCH.
p
5 ( f/�✓ 4✓7If L SERVICE CHANGE 10.00 1
F¢o 90 LICENSED CONTRACTORS DECLARATION EC 11 19$4
¢u uI hereby affirm that I am licensed under provisions of Chupler 9 ISSUANCE DATE
uQ vWai (commencing with Section 7000)of Division 3 of the Businessand BLDG xELECT• PLG. MECH.
4 'e,
N Professions ,algd se is in full for ef�c. �fyylf Oj}gTl ❑ ❑
License Class ,�•pd�1�/ Lie.Number +�-/ 1� [J
o
Contractor
',O BUILDING PERMIT
¢ ¢w OW ER-BUILDERDECLARATION INFeORMA?ION
oa. MISC.- AEFER TO ORD
X 3 LL w 1 hereby affirm That I am exempt from Die Contractors License VALUATION SIFT.
ruoj Lew for the following rcasm.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6,00
eq
Code:Any city or county which ruircsa permit to construct.alter, EP(0
¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. - LIC.NO. ELEC.
O¢ requires the applicant for such permit to Ole a signed statement that TOTAL PERMIT TO ,
A w Is" he is licensed pursuant to the provisions of the Contractor's License
HiQ
Law.(Chapler9(commencing with Section 7000).(Diesion3ofthe4a u" „ptp T ds x t":d+".`. Thi(/,¢^/' /'-y,z`XJ /9-A4 '
i o Business and Professmns Code)or that he isexcmpt therefrom and OTpY � o fQPLUMBING;PE RMI•T 1, • FEE *
¢ $ the basis for the alleged exemption.Any violation of Section 7031.5by any - STORIES TYPE CO/NSTR.
.four applicant fore undyed dollars
S500).he hcant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 4 ✓A/
.four more than five hundred dollars(E500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
Their sole compensation,will do the work,and the structure is too y
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Codc:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 4:00 SQ FT.FLODR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems are not intended or uttered for sale If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
g builder will have the burden of proving that he did not build or am-
provefonpurposeofsale.). INDUSTRIAL"WASTE INTER. 20.00 RES IND CON PB Orh.,
❑ Las owner of the property,am exclusively.contracting with ❑ E] ❑ ❑ ❑
licensed contmctom.to construct the project(Sec.7044,Business LAWN,SPRINKLERS-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 property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 J a 6 7jZ
contracts forsu License
Lwitharontradorlsl licensed pursualB to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's s Liccnm Law.
O Lam exempt under See,.,BAP.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. -4.00
hhereby affirm that l have a Certificate ofconsent to selGinsure, ZONING ENG.SITE NO.
or a certificate of Workers'CompeSsati n Insu a�rfcopy thereof ISee.38011,Lab.C.f Policy,N.. Co❑ Certified cher umished. FIRE SPRINK ENERGY T 24
❑ Cctificd Is wit I C y o
y�l Applicant - MISC. REFER TO ORD. Y❑ N[3y ❑ N❑
CC LO CFRrl FICA'I'Ii OF BXEMI"TION FROM WORKERS' PERMIT ISSUANCE6.00 FLOOD ZONE A.L.U.C. -
' LJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLC. -
CL O IThls section need not he completed if the permit is I'or one TOTAL Y❑ N❑ Y❑ N❑
Z hundreddol1are(E100).1IcsI.) + -
U O I certify that in the performance of the'work for which this per,r
'•MECHANICAL PERMIT - FEE,' FEE SUMMARY C +%
LL F mit is issued,I shall not employ any person in any manner so as I. 't
OL) become subject to the Workers'Compensation Laws of California! - BUILDING �yy
Dale Applicant ALTER OR ADD TO MECH. 4.00 `�/.d 9
} ran NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emplion,you should become subject to the Workers'CompensationAPPLIANCE 4.00 PLAN CH CK
provisions of the Labor Code, you must fooluvitb comply with FEE
U such provisions or this permit shall be deemed revoked AIR HANDLING UNIT(TO 100MC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 5.00 SEISMIC FLEE
I hereby affirm that there is a construction lending agency forEXHAUST HOOD (WITH DUCT) 2.00
the performance of.the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.1 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UN IT(OV ER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
ordinances n correct. I agree to comply with all city and county PLUMBING
ordinances end stale laws relating c to building construction, and BOILER-COIx'8(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)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,judgments, costs and expenses which �El CONST.TAX
may in any way accrue against Via Cit in consequence of the - .PERMIT.ISSUANCE 3.00
grantin his penniL /� / MECH.CONT. LIC;NO. MECH. g
TOTAL TOTAL • /S% f'K
Si�ure of Applicant/Contractor Date '', /
- OFFICE COPY C
v,
:� ,/ ,
/ .idre T•+Y'Yi. a 1��)r.-.'r`YNH �<1QSkn1../!i,••/� �x - 7H/1•,. VAI fg14;y. \�l\ ,�.i P�tU :I,.. 1 �' r, // q
'�4Q / + r ��
:�•.' n S\� y/r"\C� Fp�f a- Iva
No. 649
_s I,rtf V.Wrtiftratr of Orrupaury
, i
. � Titg of Tuprrtina �
/,y7,
Builbing Division \
This certificate issued pursuant to the requirements of Section 307 of the
Uniform Building Code certifying that at the time of issuance this structure 4M
in compliance with the various ordinances of,the city regulating building
F construction or use. For the following:
(SHELL & 2nd & �y
Use Classification Office Building 3rd Floor only) Bldg. Permit No. 6253
4 Group B-2 Type Constructiony N Hr. Use Zone Planned Development Ke /
«r 4 Owner of Building Hare, Brewer & Kelly, Inc. Address 305 Lytton Ave. Palo Alto ysl -••,�+
�\ Building Address 10101 N. De Anza Blvd. Locality Cupertino, Calif. 95014
Bv.- Joe Antonucci '
-
n August 14, 1985 t
y PUDate: Au
-r \nl•` Building Official r
'
<.y
is
POST IN A CONSPICUOUS PLACE
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