1147 . APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' U I LD ING PROJECT I DENTIFICATI ON PER IT R
ADILDIBooREssNG APPLICATION & PERMIT_ _ _ _ 114 7
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNED
NAME PLAN CHECK VALIDATION
DTV. ELECTRIC PERMIT FEE
� CONTRACTORS (�
N ME q ®� / pOUTLETS-SWITCHES-RECEP 5.00/1.00
G K 1-61/L, LAC.N.36.7p LIGHTING FIXTURES 5.00/1.00
Aooaeu TORS �/) / PPLIANCES-RESIDENTIAL - 4.00
'd (//C �� S PRONEgM b PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS - 5pp PLAN CHECK FEE P.C.NO,
ENGINEER
Llc.no. SIGNS TRANS. 3.00
ADDRESS END' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 /f
ASMOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
w o O LICENSED COKCRACTORS DECLARATION
u I hereby affirm but 1 am licensed under provisions of Cheptcr 9 ISSUANCE GATE
h a n (commencing with Section 7000)of Division 3 of the Business and - BLDG. ELECT. PLG. MECH.
H N z Profession C e a d my license is in full for oil f ¢ �� ❑ ❑ ❑ioLicenu '.la - Lic.Number to�� �t��'4 P, H w Datc Contract _ari l BUILDING PERMIT
a: ¢ 6 OWNER-BUILDER[) RA INFORMATION
I hemby affirm that I am exempt from theactor's Lic nu MISC.— ER TO ORD
.. o y Law for the followingreason.(Sec.7031.5,Businassand Professions ALUATION S/FT.
PERMIT ISSUANCE 5,00
Code Any my or county which sequiture permit tomnsua c alter. �Lne/1
QQ¢ Q
improve, or repair any slntctum.prior its issuance, ELEC.CONTR. LIC.NO. ELEC. � ✓��
- o u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w $w he is licensed pursuant to the provisions of the Co n,,,,Ioi s License
Fzr
Law(Chapter 9(commencingw ith Section 7000)of Division 3 ofthe
i x o Business and Professions Code)or that he isexentpt therefrom and QTY. PLUMBING PERMIT FEE .,F
w H the basis for the alleged exemption.Any violation of Section 7031.5 TORIES YPE CONSTR.
n 3 - by any applicant fur a permit subjects the applicant ton civil lmnalty
ofoot more than Ove hundred dollars(SS00).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ L as owner of the property,or my employees with wages,,, BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
then sole compensation,will do the work,and the structure IS not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owns,of
Property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 I:Q FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees, le.if,ed that such improve building
_
mems are not intended or offered for vile.If,however,me building GAS-EA.SYSTEM-11SIC.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 huild or int- GAS-EA.SYSTEM OVER 4 (EA.) 1,00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 200p RES IND -CON PR Ome,
❑ 1,as owner of the property,and CxClusivCly contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See.7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code The Contractors License Law docs 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 u conlmctor(s)licetnved pursuant to
the Contractors License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ I am exempt under Sec.—,B.&P,C.tier this -
reason WATER HEATER W/VENT 4,00
Date Owner WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
WORK ERS'CO.NPF N'SATION DECLARATION WATER TREATING EQUIP. 4.00
• I hereby affirm that I have a«rtificale ro consent to selbinsum.
or a ucrtiticate of Workers'Compensation Insurance.or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab C.)
I'pllgy No. Company�/�_
Q }1 Cert flied copyi D�yfrrnlilled. FIRE SPR INK ENERGY T 24
z Z ❑ Cert,t iedd..,,aay�ss ly !1y}�'ith t��s�uity I n d'
F O
Applicant ( MISC.- REFER TO ORD. v ❑ -01 Y ❑ N❑
�TT17// 1.41/1/ PERMIT ISSUANCE
LU to GIiR PIG\'B OE I A . TION PRO,\(W'ORRIiRS' 8,00 FLOOD ZONE A.L.U.C.
ION
NCE
W > !This Section eeJ not beTcom co
mpleted
fthe permit is for one PLO.CONTR- LIC.NO. TOTAL v❑ N❑ V ❑ ry❑
a ❑
0 Z hundred dollars OI00)or It..)
U O I certify that in the performance of me work for which this per- TY.OMECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued, I shall not employ any person in any manner so as to
Ow become subject to the Workers Compensalion Laws of California.
a Date—Applicant BUILDING coo
} W NOTICE TO APPLICANT: If,a0er ntnking this Certificate of Ex- ALTER OR ADD TO MECH. 4.00
� Z cloption,you should become subject to the W'orken'Compeasation APPLIANCE 4.00 PLAN CHECK
prosisions of the labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 3.00 FEE
CONS]RUCFION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE '
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the pe rharmance of the work for which this permit is issued(Svc MICROFILM
3097,CivC.) HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATI NG UN IT(OVER 100,000 B.T.U.P.50 ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
S .n.firomeiss n estate 11 s oc to comely with WI sip-and county BOILER-COfvP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state Taws 9vling to building construe upon, and
hereby entiored representatives for ins of this city to enter ufbn the BOI LER-COMP (Over 100,000 BTUl SEE FEE SCH.
above-mem ioneJ property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harm)ss the City of MISC.- REFER TO ORD.
Cupertino against 'ehilitics,judgments, costs and Expenses Much PERMIT ISSUANCE 3.00 CONST.TAX
may in any ssc e against said City in ecosept tee f the
gofthis MECH.CONT. LIG NO. MECH.
.4 � /o ATA` TOTAL Q o0
igtwturc f pVlimnt/'
for
at 3-/, --
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD (Office Copy)
1147 7455 Dumas Dr. V
PERMIT NO. SANITARY DIST. 110. LOT NO. ADDRESS
i
Reroof D. Whitaker 988-4666
PROJECT OWNER JOB SITE PHONE NO.
Date ELECTRICAL
B11ildine 10-5-81 Date Insp.
Electrical Power Pole
Plumbing Underground
Mechanical Rough Miring
Temp. Gas/Elect. Mal s
Solar Ceiling
Fire Snrinkler Fixtures Int Ext
Sign Motors
Grounding
7-Usc. Temp. Power
Other
FINAL INSPECTIONS Not Approved
Date Insp.
Gas
Electric PLUMBING
Plumbing Backflow Date Insp.
ilechanical Underground
Solar Underfloor
Pool Partial Rouph
Grading Rough Complete
Planning Solar Rough
Fire Dept. Water & Insulation
Health Dept. Iain Drain
Building R/of/S Drain
Other Gas
Other
STRUCTURAL Not Approved
Date Insp.
Pad Certification MECHANICAL
ECHANICAL
Pre-Gunite Date Insp.
Underfloor S.M.
Slab-Membrane
Bond Beam Ducts & Insulation Underfloor Girders Fire Dampers
Fireplace
Floor Steel Grease Duct & Hood
edowns
Diaphram
Tiphrams One Hour Shaft
Condensate Drain-
Seismic Bracing Equipment Anchorage
halls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Wallboards Int Ext.
Firewalls
� Other
, Not Approved