3230APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
BU I LD ING PROJECT IDENTIFICATION
TION &PERMIT
=BUILDING—AL— PLUMBING —MECHANICAL
PER TN
O
aGILOINc
D��/ FrAti��L &14_
OWNER'A -
NAME
.`
&A) A),'7Ck PHONE
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
DATE OF APPLICATION
CONTRACTORS
FM=r/qA uc, No.
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
cONTTRASrGRs
ADDRESS
435-C) r%N)
PPLIANCES- RESIDENTIAL 4.00
PANELS 5 -DO
RCHITECT
AOR
ENGINEER
_JC. No.
SIGNS 6.00
PLAN CHECK FEE P.C. N .
-
SIGNS TRANS. 3.00
ARCR'E ss ENG.
ZIP
SPECIAL CIRCUIT S,OG
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15-00
ANTS
APPLI ESS
ADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
�^
LICENSED CONTRACTORS DECLIRATION -
PAFD�_
I hereby affirm that I am licensed under provisions of Chapter 9
I (commencing with Section 70001 of Division 3 of the Business and
Professions Co my Nonlifeicense is in lull force and, 1
, sn
License Class Lic. Nonlife
ISSUANCE DATE
83
BLDG.
❑
ELECT.
❑
PLG. MECH.
❑
Date Contractor
'J 'OWNER -BUILDER DECLARATION
I hereby affirthat 1 am exempt from the Contractors License
m
Law for the following reason. (Sec. 7031,5. Businessarul Professions
Code: Any city or county which mquiresa permit toconstmcl, alter,
p L /� �p
LI O` Cu IDno
BUILDING PERMIT
INFORMATION
MISC. — REFER TO OR
MISC.
PERMIT ISSUANCE 6.00
SIFT.
ELEC. CONTE. LIC. NO.
ELEC.
TOTAL
improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit us file d signed statement Ihat
he is licensed pursuant to the provisions of the Contractor's License
PERMIT TO
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Cale) or (hal he is exchipt therefrom and
OTY. PLUMBING PERMIT FEE
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects the applicant lua civil,rafty
ofnot more than f, undned dollars 155001.1:
STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wags as
their sole compensation, will do the work and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec. 7044. Business and Professions
Code: The Contractors License Law dues not apply to in owner of
w
FIXTURES - PER TRAP 4.00 --
GAS - EA. SYSTEM - 1 1 NC. 4 OUTLETS 4.00
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
ments are not intended or offered for sale. If, however, the building
SO. FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or int-
GAS - EA. SYSTEM -OVER 4 (EA) 1.00
BUILDING USE
prove for pumper of sulcal.
❑ I, as owner of the properly, am exclusively contracting with
RES IND CON PB Otter
El El ❑ 1:1 Elns
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.D0
'
liceed cn ntramors to construct the project ISce, 7044, BGsinese
and Professions Code 1'he Contractor v Liccnx Law dues not Tply
to an owner of properly who builds or improves thereon. and who
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for Such projects with a contracmrlsl licensed pursuant In
the Contractor's Licenw Low.
O lam exempt under Sec. ,H.kP.C. for this
reason
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4,00
Date Owner
WATER SYSTEM 4.00 ^
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4,00
' WORAERS'CONIPECS,VION DECLLRA'IION
1 hereby affirm that I have a c,THscute of consent to self -insure,
ZONING
ENG. SITE NO.
or a certificate of Workers Campenwlimn Insumace, or a certified
copyT-
PolicyTMo. ---
Zzlmlran
O Certified copy is hcrcbyt arnishcJ.
Q/Cerlifiebi,gpn fled wlhhe I)' impeclion division.
Applicant ((LL Y (I t,U1�
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N❑
MISC. - REFER TO ORD.
—
CERTIFICATE OF EXEMPTION FROST WORKERS'
COMPENSATION INSURANCE
Hhis section need of be completed if the permit is for one
PERMIT ISSUANCE 6.00
PL000 ZONE
-
Y ❑ N
A._.LTC.
Y ❑ N❑
PLG. CONTR. LIC. NO.
PLG. N
TOTAL 119
hundred dollars IS 1001 or le,of
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner w as to
QTY MECHANICAL PERMIT FEE
,
FEE SUMMARY
become subject to the Workers' Compensation Laws of California.
ALTER OR ADD TO MECH. 4.00
Date Applicant
BUILDING
NOTICE '10 APPLICAN"I': If, after making this Certificate of Ex-
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=CF.M.) 3.00
PLAN CHECK
FEE
emption, you should become subject In the Workers' Compensation
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNITIOVER IO,DODCF.M.) 5.D0
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
31017, Civ.C.f
EXHAUST HOOD (WITH DUCT) 2.00
-
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T. U.)7.50
ELECTRIC
-
I certify that I have read this application and stew that the ahove
information s correct. I agree to comply with all city and couty
ordirwnces and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
6e
BOILER-CCfeP 13 H. P. or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter noun the
above mentioned property lot inspection purposes.
BOILER -COMP Over 100,000 BTU( SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
MISC. - REFER TO ORD.
Cupertino against liabilities, judgments, costs and enocuses which
may in any way uccruc aunt said City in consequence of the
Y`taW of h peanut.
per\^1*L 31{ay �
V "'a
PERMIT ISSUANCE 3 DO
CONST. TAX
MECH. CONT. LIG NO.
MECH.
TOTAL
TOTAL
Signature of pppll¢x�nt/iC ntra o'Is LI r Bate
OFFICE COPY
Ll
0
0
CITY 01' CU1'EIMNO INSPECTIOl! RECORD (Office Copy)
39,30 _ /00/-z
PET?JII'r NO. SANITARY DISI. NO. LOT 110. ADDRESS
PROJECT ff OWNER JOB SITE PIIONE NO.
PERMIT ISSUED Date II ELECTRICAL
6u LIdinc - -
Insp.
IJ ectr Leal
I'LumhfnL
Nech.anical
'Temp. Gas/Elect.
_
Solar
Fire Sprinkler
Sirn
_
Hisc.
FINAL INSPECTIONS
BUILDING
Date
Pad Certification
Insp.
Foundation
Pre-Gunite
Slab -Membrane
Bond Beam
_
Underfloor Girders
Floor Steel
Tiedowns
_
Diaphrams
Seismic Bracing
_
halls -Panels
Frame
Lath
Uallbonrds
Firewalls
Other
Not Approved
Date
Power Pole
Insp.
Linder ,round
RouFF'h Nirin
Ila Lls
Ceiling
_
Fixtures Int/Ext
Hotors
Grounding
_
Tem2. Power
Other _
_
Not Approved
PLUMBING
Date
Backflow
Insp.
Underp,round
Underfloor
Partial Rough
Rough Complete
_
Solar Rough
Water & Insulation
Main Drain
_
R/of/S Drain
Gas
_
Other
Not Approved
HECIIANiCAL
Date
Underfloor S.N.
Insp.
Ducts -& Insulation
Fire Dampers
Fireplace
Grease Duct & flood
_
One flour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
t -I