3209 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
a BUILDING PROJECT IDENTIFICATIONPERMI NU
9UlE ING APPLICATION& PERMIT 09
AD REu
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PHONE
NAmERAcroes UTLETS-SWITCHES-RECEP 5.00/1.00
AA 00' LIC.NO. Q LIGHTING FIXTURES 5.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
A.
GRESS _T
J((XC/L„fir PHONE -y�Lq
7 PANELS 5.00 DATE OF APPLICATION
ARRCHITECT SIGNS - 6.00 PLAN CHECK FEE P.O.NO.
ENGINEER -
LIC.NO SIGNS TRANS. 3.00
ARCH,OR ADDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT s MOTORS SEE FEE SCH. 1/1yAy�
AOOREss
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION
a u 1 hereby affirm Ihm 1 em licensed under provisions of Chapter 9
ISSUANCE DATE
n a a (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H O i Professions Cod j!nd my license is in full force and effect.
Z 0 2 o License Class 1 Lic.Nwnber $9 402
o w H to Date-, Contraztor �j�Llb�'�
a M � - BUILDING PERMIT
a OWNER-BUILDER DL'CLARA'I'[ON -
It
Wo a u - INFORMATION
w3: ,� 1 hereby affirm that I am'exnmpt from the Contractor's License MISC.- REFER TO ORD
u o j Law for the following reason.(Sec.7031.5,Business and Professions TION 5/FT.
H _ PERMIT ISSUANCE B4O0 -l�
l Code:Any city or county which requires' rmil to construct alter, i
a O improve,demolish,or repair any structure,prior W its issuance,also ELEC.CONTR. LIC.NO. ELEC. ��
DLL requires the applicant for such permit to file a signed statement that TOTAL IT TO
w he is licensed pursuant to the provisions of the Contractor's License
rzi Law(Chapter 9(commencing with Sect ion 70000ut Division 3 of the
a Business and Profca'mm Cale)or that he is exempt therefrnln and GTY. PLUMBING PERMIT FE�i �1
IS t $ the basis for the alleged exemption.Any violation of Section 7031.5 salof Ino TYPE CONSTR.
A by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN& VENT-WATER IEA.) q,00
of not more than five hundred dollars(S500).):
❑ I,as owner of the pnrperty,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 not
intended or offered for side (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law dols not apply to an owner o1
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 So,FT.FLOOD AREA TOTAL ACREAGE
hirrselt or thmugb It.,own employees,provide)flat Such improve-
- ments are not intended or offered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- USE
BUILDING
GAS-EA.SYSTEM-OVER 4 (EA.) 1.00
builder will have the burden of proving that he did not build or on. HES -IND CNG PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the properly,am exclusively conte cting 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 Contractor's License Law does not apply
m an owner of property will)builds or improves Ilio eon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts I'orsuch projects with a contractonsl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec...B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner WATER SYSTEM 4,00
i ACC.DATE ACC.FILE N0.
WORKERS'COMPENSyTION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm Ilia( I have a certificate ofconxent Io ulpinsun,
or a cerlilicam of Workers'Compo cation Insurance,or a cerlitted ZONING ENG.SITE NO.
copy thereof(Sec.3800,
L'b.C.).7 OO .OZ•T
M
PoNo. Compan
Oy1iicd copy hereby fumishcJ.
Z Z �crl ifi 'oPY filed Ile Ihu ly Is'pection division. FIRE SPRINK ENERGY T-ZA
F O Applicmlf b�t- MISC. REFER TO ORD. Y [J - NE] Y E] NE]
� N CERTIFICATE OF EXITMPTION FROM WORKERS' - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.D.
DJ > COMPENSATION INSURANCE PLG.CONTR. LIC,NO. PLG.
d O IThis Section need not be completed if the permit is for one TOTAL Y❑ N❑ Y E] IN
Z hundred dollars(S 100)or less.l
U O 1 artily that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
U_ F- mit is issued, 1 shall not employ any Fer am In any manner w as to
Uw hucome,,ihjc,t to the Workc,, .m
CompcntionLawxofCnl,knliu- /
Date Applicant ADD TO MECH. 4.00 BUILDING
} y NOTICE,'f0 APPLICANT: If,after making this Certificate of Ex- ALTER OR
♦- ? cmption,you should become subject to 01c WorkersCompaisation APPLIANCE 4.00 PLAN CHECK
_ Prov sio 'ol' the L:Ibm
or Code, you list forthwith c mply'will, FEE
U
such rmprolisions or this permit shall be deemed revoked.o AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE .!`z
I hereby affirm that there is onxvuaion lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's AddressELECTRIC
I certity that I have read this a0plicmion andstate that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city end county' PLUMBING
ordinanm and state laws relating to building-conslruclion, and BOILER-COMP I3H.P.or 100,000 B.T.U.) 4.00
hcrcby mitilon,c cI)o,Rnnliycs of this city to toter Ilion Ilrc BOILER-COMP IDNlr 100,000 BTU)SEE FEE SCH. MECHANICAL
shove-mentioned properly int inspection purposes.
(we) agree to save, indemnity and keep harmless the City a MISC.- REFER TO ORD.
Cupertino against liabilities,judgments. costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way acme againsl Rid City in c Hoe(lucnce of the
,noting of On,permit' MECH.CONT. LIC.NO. MECH.
Q 3 TOTAL TOTAL a/ SL3
SlRnature a Appllcam/Cl)ntraemr Dale '
•OFFICE COPY
CfTY OF CUPERTINO INSPECTIOI! RECORD (OEfice Copy)
• Pf:PJIIT NO. SANITARY DIST. 140. LOT MO. ADDRHSS
PROJECT 01,1NER JOB SITE PHONE NO.
PERMIT ISSUED Date FLECTRICAL
BuLldinr _ 3 -�3 Date Insp.
Electrical Power Pule
I'Lumhing Under ground _
ilcchanical RouFF;h Ilfrin
Temp. Gas/I'lect. llatIs _
Solar Ceiling_
Fire S rinkler Fixtures int/Ext
Sign 1lotors
Grounding
4lisc. Temp. Power _
Other _
FINAL INSPECTIONS Not Approved
Date Insp.
n•.y - PLUMBING
EI.ectr4.c Date Insp.
I'Inmbin , Back flow
llechanical Underground
Solar Underfloor
Pool Partial Rough
Gradin , Rough Complete
Planning Solar Rough _
Piro De t. I-later & Insulation
Health Dept. Main Drain
Duildin R/of/S Drain
Other Gas _
Other
BUILDING Not Approved
Date Insp.
Pad Certification NECIIANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Ilembrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel _ Grease Duct & hood
Tiedowns One (lour Shaft
Di.aphrains Condensate Drain
Seismic Bracing Equipment Anchoragr-
Ilal..l.s-Panels Flues & Comb. Air
Frame 3-g=� Other
Lath Not Approved
Uallboard In /I?xt . k9 /
Firewalls �,� 0
Other
Not Approved
BUILDING
•
ELECTRICAL
PLUMBING
MECHANICAL
i
MISCELLANEOUS
j