99080106 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 11 !�QnT,0 10J0
CITY OF CUPERTINO BUILDING.ELECTRICAL E O.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL.
ItUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT
C �( fi✓� all �3 4
NIiRSW, PHONE: CO,VAM&%CNAME: LIC NO: t�6
,,HHIIl /- �C N/C CONTROLp
IiRCHITECf/ENGIR: LIC NO ADDRESS: 1.�y ❑
C/O�N'LAC L PHONE: BUILDING PERMIT INFO
/�S/L �AtYA.Is.,' QT_y 8.�2 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLEECTT PLUMB MUCH
/ f I SNS DCO � ❑
LICENSED CONTRACT'OR'S DBCons of hap QTY ELECTRIC PERMIT FEE
1 Ferenc aloft Onn 1 not facies Business
ndProuna ofChapterCode, 9(.almmea.ing JOB DESCRIPTION
WoZ with Semina Al00)of Division3of the Business and Professions Cale,and no'hernsers RESIDENTIAL'
f -= in full force and .. PERMIT ISSUANCE � //ss
OF License Clas hies 681706 ❑SFDWL uiercHEN REMODEL
vFaizW DumuCCP! Contmnu APPLIANCES-RESIDENTIAL ❑ADDITION EJ PLUMBING RE-PIPE
]T
F- ARCHECTSDECLARAT ION P11i PANELS ❑MULTIUNIT [I STRUCTURAL
Z c)y.Z. in 1 understand my plashall be used as public recari. MODIFICATION
OZ-+0 UP TO 208 AMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Profc.sional 201-1000AMY5 IMPROVEMENT'
OWNER-BU1LDI?R DECLARATION ❑SWIMMING POOLS
C Q I hereby'df o that i um exempt from the Contractor's License Law for the OVER 1000 AMPS El BATH REMO F. /R IR ❑Di 'ION
a 6 U fallowing reason.(Section 0031.5.Business and Pffessionx Code:Any city or county SIGNS ELECTRICAL ❑OTHER
d a y which mquimn a pv ndit m comoui other,improve,demolish or repair any saucture
.F+q�� privaits itmmnee,alkno, fres the applicant forsuch permit m File asignedxant
eent SPECIAL CIRCUFUMISC.
.EW�� private that he is licenxd Pursuant to the provisions of the Contractors License Law(Chapter 9
W CpO (cummencingwith Section locaof Division 3 ofthe Busineuand Prufessinns Code)or TEMP.METER OR POLE INS'T COMMERCIAL'
tY Xe❑a. That he is exempt therefrom:aid the basis for the alleged courtroom,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
H Scer an 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
F Z P not more than five hundred dollars(5500). ❑TENANT El FOOD SERVICE
E]1,as owner of the property.or my employees with wages as their sale ammpensair... SWIMMING POOL ELECTRIC IMPROVEMENT
p.� will do the work,and the structure is not intended or offered for sale(Sec.9044,Business ❑OTHEE
'ro and Professions Code:The Commmo/s License Law docs not apply m an owner of OUTLETS-SWITCHES-FIXTURES
propene who builds or Improves thereon,and who does such work himselfor through
his awn employees,provided that such Improve,tentn are not intended or offered far NEW RESIDENTIAL ELECTR
sale.If.however,the building or improvement is sold within one year incompletion.the SQ.IT.MOOR AREA 5/SQ.IT
owner-Wilder will have the burden of proving that he did not build or improve for par,
pose of sole.).
❑ I,as owner of the pmpeny,am exclusively contacting with licensed contractors to IOTA.14 .
.rower he projem(Sec.9014,Bosinexs and Professions Cor c)fine Contractors Li
ase Law does not apply to an owner ofpropeny who builds or improves.hernm,an. QTY. PLUMBING PER I
who contracts for such projects with a connotations)licensed pursuant to the Commemis
License law. PERMIT ISSUANCE
I am exempt under Sec ,B&PChathere...n
OwwDate ALTER-DRAIN&VENT-WATER(EA)
VAI IlAT10N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
l- I hereby offnn undo penahyofperjo,one of the following Jer:lan one
I have and will maintain a Cenificate of Consent to self-insurt for Worker's Coupon. DRAINS-FLOOR,ROOF,AREA.CONU.
se.i.n,as Oon,ided for by Semina 3900 of the labor Cade,far are performance of the STORIES TYPE CONSTRUCI'10.
work for which this permit i.Issued. FIXTURES-PCR TRAP
❑ 1 have and will mnimtin Worker's Compensation Insuranceas require.by Section
3700ofthe labra Come,forte perfomtance ofthe work for which.hispermit is issued. GAS-Fist SYSTEM-I INC.40UTLETS OCC GROUP ,r-y�1PN
My W.rke' Cmnp nsasinn mnep d Policy number are: J `IY �Q
Carrier: Te Policy No../I�.-�{.���('/�'/� GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF L(EMP ION FROMWOR'EA R. G REASFJINDUSTRI.WASTE INTERCEPTOR O
COMPENSATION INSURANCE
(This section need not be tam IUed' BUILUINO DI VISION FEES
p dthc term;.is fnnme M1undred Aollnrs tllIXp is.) GREASETRAP
pcff
Toa certify,that,,.he anyommor, a,1work mewhich this the W rker,Crupper; ELANCHEHE—PER
Amon Law of pavan inane manner,saaclo become subset 1.the Workers'Cont em SEWUR-SANITARY-STORM EA.200 FT.
1 P F,NGtGKFEE`-- {{
2 scion Lawn of Cnlilbmiu.Date
O N'ATI;R IIEATLR W/VEM/I:LECfR
z O NOI I,m GBnnNG FEJ - ` `13
rNi became;TUAPPLICANT:ILafter making thisvoimm%of the
Exemption,you should WATER SYSTEM(fREATIM1'G I t1
became stomp Io 0e,Wndcro Compensation or this apard hal of the Labor Crile,you must SOIL FFY
forthwith sample with such o'.�•t n 4 L ��
10 provisions or this permit.M1allhdeemcd rerokeJ. WATER SERVICE it J
7 z CONSTRUCTION LENDING AGENCY NEW RESIDE.YTIAL PI.MB. SQ.FT PAIR i� W
U O I hereby affirm that here is a conxwnion lending agency for the pcermence of !u Date Receipt#
F the work for which this permit is issued(Sec.3009.Co.C.)
Q U LenJcr's Name,
W7 Lender's Address TOTAL:
F a I cenify that 1 have read this application and state that the.brine i... ..na.....is BUILDING FEE
A correct.I agree to comply with all city and county ordinances and state laws mlating to QTY. MECHANICAL PERMIT FEE
Uz huiletugconstruction,anal hereby au.horivc represenmtivcs offlik city to enter act'.'he SEISMIC FEE
above-mentioned property for inspection purprms. PERMIT ISSUANCE ELECTRIC FEF.
(Wrm
e)agree.o save,indemnify and keep harmless file o a
e City of Cupertingainst
Iiabilitics.judgiorma,costs and expenses which may In any way acerae against snit City ALTER OR ADU TO MIiCH.
in n.,ucarr of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
R.iU
SOURCE LATIONS. MECHANICAL FEE
9 AIR HANDLING UNIT(OVER 10,0001 CFM)
CONSTRUCTION TAX
SVgalore st'Ap a mmetor Dmc 17XIIAUST HOOD fW/IIUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Willntc.,dreamof future buildingoecupantxmrem handle haarJou..aerial HEATING ON]P(TO 110.000 BTU)
as defined by the Crimmins Municipal Code.Chapter so]2.and the Health and Safely
,iftody,Sectinn 25532(,)? HEATING UNIT(OVER 1(10,000 BTU)
❑Yet F7 No
41 r VENTILATION FAN(SINGLE RESIU) PAID
Will the air contaminants
m fumes building occupant use equipment or Mara which BOILER- Date' R eipt
emit District'
six art comaminantx ax defined by the Bay Arca Air Qnahry Management -COMP(3HP OR 1 W.f100 BT'U)
Distrin? T nL: s
❑Yes F1 No BOILER-COST(OVER ItX1,fX)O BTU)
I have mad the hmardoro materials re,eircmea¢omMr Chapter 6.95 of the Cali- AIR CONDI'I IONER Oyu I$$LIANCE DATE
front Health&Safety C.rk.Sections 255(15,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FL `1` l ''JJ11 �Z7
building dor not currently have a heart.that h is my res,p�,,or]ip,1.thIlimy m nn.ilyJJJJ,,tthe occupum PV
of. �tn which muN he ares Pdgfyt +f /nifjc af� gp ticywhich must he stet prigµ +f /nifc:p�nf�pny.
Ow the Date 'TOT'AL: ISSUED BY:
OFFICE
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
• 90 7607 Erin V .
PEPM7NO. ADDSS
Shower Repair M. Maurace Lamb
OWNER
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
Fui in
ectn ca
Plumbing Power 'Pole
e�ianical Underund
Temp as ec ulWICo T
Solar Wails
Fire Sprinkler Ceiling
Sign fixtures Int[Ext
otors
Misc. Grounding
Power
er 0- 2=7 /
y ,
FINAL INSPECTIONS DATE INSP. ot: rove /
Gas
Electric
um ui PLUMBING DATE INSP.
anicz
� o ar Backflow
'oo Gradinuar Moor
uu0n
7Planning Partial
Fire Dept. u
uin g
,Zd2:� -�A Water '4 Insulation
Other Main Fin
o ain
Gas
BUILDINGer
DATE INSP. of mve
Pad Certification
oun ation ELECTRICAL
re- ite DATE INSP.
crane Underfloor S:M.
Bond Beam HE & Insuiation
Underfloor Girders ire Da ers
Floor teel ire ace
ie owns Grease Duct & Ho—or�
a 1h rams a Hour Shart
eismec Bracing Condensate 5Fain
U Ts--T ane I s ui ment Ano ra e
Frame _ - ues om r
.at Other
allboar nt xt. of rove
—tirewalls
7p
Net
eE rove
e
ro - a4
1PPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
fir` ,r PERMIT NUMBER
lee. NG PROJECT IDENTIFICATION APPLICATION & PERMIT
N
'Come'Sno +
7667
7 O R`y. ZL14V BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
OANLRPLAN CHECK VALIDATION
NAME
/yJ_ w /nY) �O QTY. ELECTRIC PERMIT FEE
/ f.M"/O PRorvE 7
CONTRACTORS
NAMEOUTLETS-SWITCHES-RECEP 5.00/1.00
�,G�o,NTRm• NO
y70S LIGHTING FIXTURES 5.00/1.00
CONTRACTOR PPLIANCES-RESIDENTIAL 4.00
AODREss
CQ;o=Z 1*4,At PHONE IEQ�I PANELS 5.00 DATE OF APPLICATION
ARRP.
CHITECT SIGNS 6.00 PLAN CHECK FEE C.NO.
ENGINEER
LIC.ND.. SIGNS TRANS. 3.00
ARCH.OR ADDRESS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION///•••
zip TEMP.METER OR POLE INS. 15.00^,
ASMOTORS SEE FEE SCH.
� ADDREDDRESSS '
SERVICE CHANGE 10.00
o
Fo0o2LICENSED CONTRACTORS DECLARATION
U 1 hereby aflirm that I am licensed under provisions of Chapter 9 1 I LANCE DATE
y a (cononencing with Section 7000)of Division 3 of the Business and B D ELECT. PLG. MECH.
Hz w
Profession's ,�I
Coden my license is in full forc�epJ d eff}yr.[ ❑ ❑ ❑
o m u, LiccnClaa- �skk•.. D` Lic.Number._.ylll
/yI Uam.y Contractor
Q re re S;<
S;a OWNER-BUILDER DECLARATION BUILDING PERMIT
MISC.- REFER TO ORD INFORMATION
w ;e w I hereby alfirm that I am exempt from the Contractor's License VALUATION
se W o CodLaw for the following reason.(Sec. uiresa,perBusmit
to construct,nd Professions 6.00 '�,s,sl I $7FT.
Code:Any city or county which regmrese permit to isiuancalter, PERMIT ISSUANCE `///V/
u 2 a O improve,demolish,or repair any structure,prior 10 its issuance,also ELEC.CONTR. LIC.NO. ELEC.
o u requires the applicant for such permit to file a signed statement that TOTAL
d w m he is licensed pursuant to the provisions of the Contractor's License PERMIT,
� z
Law 9(commencingwith Section 7000)of Division 3 of the
a
I i o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
I o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYP CONSTR.
aim by any applicant fir a permit subjects the applicant luacivil penalty
of not more than five hundred dollars(5500).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their Sale compensation„will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.Er.vLooR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
or nts improvement not is sold or within offered
une y Sale.o IL however,thebuildingow ing GAS-EA.SYSTEM-1 INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove tot1,as owner
of sale.). INDUSTRIAL WASTE INTER. 20.00 E IND C❑ON ❑ D❑r
❑ I,as owner of the property,am exclusively contracting with
PS
licensed contractors 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 docs not apply
to an owner of property who holds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such Project,with n emumnoRs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
)am cxcnmt under$cc. ,B.&I'.C.I'or this
reasonWATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
1 /1 WORK ERS'COMPGNSATION DECLARATION WATER TREATING EQUIP. 4.00
//VAI I he sy aflinn that I have a certificate of consent to scl Ginsurc, ZONING
r
a ificatr 1sf orkeri Compensator Insurase,or a certified ' ENG.SITE NO.
".plu
r I' tic N mpany LL(�✓ A
7L C iJ copy is hereby furnished.
z Z ❑ rtifi' yry, is�Iled with the cit inspection division. FIRE SPR INK ENERGY T]4
Apphcwrt_ MISC.- REFER TO ORD- Y ❑ N❑ Y ❑ N❑
~ Oy PERMIT ISSUANCE
Lu CIiRT'IF'ICAT 01:PENEATION ION FROM WORKERS' 6.00 FLOOD ZONE A.Lu.C.
W COMPIiN$ATION INSURANCI! PLG.CONTR. LIC.NO. PLG.
4' O (This %eclion need not be compLted if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
2 hundred dollars IS 100)or less,)
U O 1 certify that in the performance of me work Har which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
H not is issued,I shall not employ any person in any manner so as to
O W become%object to the Workers'Compensation Laws of California. �I
IS. Date nppllrem ALTER OR ADD TO MECH. 4,00 BUILDING /
} 0 NO'I'IC17 'I'O APPLICANT: If,after making this Certificate of Ex- 1
? eprovisions "f the Labor Code, you must forthwith comply with mption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
U Such provisions or this permit shall be deemed revoked FEE AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 r
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE ,
I hereby affirm Hut there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
mance of the work for which this permit is issued(See.
the petlbrMICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) - 3.00
information n correct I agree to comply with all city ucti county PLUMBING
herebymez and store laws relating m building construction, and BOILER-CORM I3 H.P.or 100,0006.T.U.1 4.00
hereby tlmdm representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH.
abo
ovmenentioned property for inspection purposes. MECHANICAL
(We) agree to savc, indemnity and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments,costs and expenses which PERMIT ISSUANCE CONST.TAX
may in any way accrue against said City in consequence of the 3.00
gra gof I' Pcr tit. MECH.CONT. LIC.NO. MECH.
q�� 8r TOTAL
sign n e of p�n v TOTAL /✓/l///
• OFFICE COPY