4880 PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BUI LDING PROJECT IDENTIFICATION vERMIr.NUMBER
e L.H,G APPLICATION & PERMIT n Q Q 0
ADD E 4 8 11
/1 /1 w� BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
1 NER'S •L (I PLAN CHECK VALIDATION
-- "AME ryl` OTY. ELECTRIC PERMIT FEE A
A C+U L/ PNONE 111( V U V
*GM7ERAc7oRs� OUTLETS-SWITCHES-RECEP 5.00/1.00
1 NO. LIGHTING FIXTURES . 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
ADDRESS
009 A" QCL �e fonE 7y,1I 007 ' PANELS 5.00 DATE OF APPLICATION
A c• -.�- 1 A f��+ �yT • Jk00 -SIGNS 6 PLAN CHECK FEE PC.NO.
` ENGINEER v /1 uj /HdI
/1 T / L' �u(c./No. ��(J SIGNS TRANS. 3.00
ADDRESS ARCH,OR ENG O �I 0 �/CI)rl-I R w" SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
�-� W_ j, La zIP I. EMP. METER OR POLE INS. 15.00 p
APPLICANTS MOTORS
ADOREss SEE FEE SCH.
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
1tl (commencing with Section 7000)of Division 3 of the BIISIOL•SS and BLDG. ELECT. PLG. MECH.
O w i professions d` my license is in full to it effgc(. �C ❑ ❑ ❑
z O u, - Licamc C ass Lic.Number J.l_t 11la
H y H Detc Contractor PA,7 r�,�.�
f BUILDING PERMIT
ic i ¢ ¢ OWNER,BUILDER DECI.ARA'fION - INFORMATION
ovU - MISC.- REFER TO ORD
w F I hem
the affirm that I am exempt from the Contractor's License .V A ON 5/FT.
r w0 j Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Cale:Any city or county which requires a permit to construct,niter, aTo-'d'O
S ¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
G Q' requires the applicant for such permit 10 file d signed statement Ih'ul TOTAL LILY ERMIT TO
o_W m he is licensed pursuant to Ihe.pro asions of the Contractor's License ^
FiQ Law(Chapter 9(commencing with Section 7000)of Division 3 oftheQdG�
i O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
Ic I the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ca _F by any applicant for a permit subjects the applicant lD a civil penalty ALTER-DRAIN& VENT-WATER MA.) 4.00
of not more than five hundred dollars(5500).1:
❑ 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 not
intended or offered for sale(Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License law does not apply to an owner of
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.PT FLOOR AREA TOTAL ACREAGE
himself re Got
hde or offered
provided however.the
ibuildic GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
mems me not intended or offered for sale If,however,ILC building
or Ira novel have
is sold within ane year of be did ion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builde for p have the burden of proving tlmt he did not build or im-
pr n for,owner of the
INDUSTRIAL WASTE INTER. 20.00 RES IND0 0 PB orae
❑ L us owner of the property,um e,o hi t(Se c7044.Bu with ❑ ❑ ❑ ❑ ❑
Nacos,. comradoCode: c Contrt the pmier (Sec 7044,Busiir ly LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL No.
and Profusions propThe who
's License law Joos not apply
to tr owner a progeny who builds tr improves licensed
thereon and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such cense L with a comractorlsl iia nxd pursuant to
the Contractor's License Law. - SEWER-SANITARY-STORM EA. 200ft/8.00 TRACT No. PARCEL NO.
0 Iwncxcmptundcr Scc.' .BAP.C.forth'° WATER HEATER W/VENT 4.00
Iscr,am
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILENO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
�( 1 hereby at Firm that have a cerci ficdte of consent to xlGimure.
or a certificate sit'Workers'Compenwlion Insurance,or a cc,UR l ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.L
Policy No. Company
O ❑ Cenitted Copy'iahereby'fumished. FIRESPRINK ENERGY T 24
Z Certified copy is fled with the city inspection divisimt' MISC.- REFER TO ORD.
Apoplicam � v ❑ N❑ V ❑ N❑
y CERT IFICA'I'Ii 017 EXIiMPT1ON'FROM WORKERS" PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.G.
LU 1 CO)IPENSATIONINSURANCE PLG.CONTR. LIC.NO. PLO_ V❑ NE) V [:] N❑
0-Z (This section need not be completed if the permit is for one TOTAL
hundred dollars IS 100)or less)
00 1 certify that in the Nuturmance of 1h n r which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued, I shall not employ a manner so as to
U becom"e sybje t'ty the Workeri ws o gyp,
O a Date=/=p_y_Applican ALTER OR ADD TO MECH.� 4.00 BUILDING
} w NOTICE TO APPLICA - m mg this CeRifcate of En-
Z cnlption,you should Inc Hb to the Workeri Compensation APPLIANCE 4.00 'PLAN CHECK
provisions of the L bor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNff(OVER 10MOC.FNL) 5.00 SEISMIC FEE SS'
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the perfornmnce of the work for which this permit is issued IScc. - MICROFILM
3097.Civ C.) HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name H EATI NG UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Name
ELECTRIC
('certify th.corn have aa,,cc application and,tate c ty a the county VENTILATION FAN (SINGLE) 3.00
Inlorearces n Correct. I ngrco m cote b with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.0) 4.00 PLUMBING
vdinanees unci store laws relW ing m huilding consvuq ion, and
hereby authorite representatives of this Cil)' to enter upon the BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property inspection psi s.
(We) agree to- pd rani d e armless the City of MISC,- REFER TO ORD.
Cupertino a 'f go is and cspunscs which CONST.TAX
R
in an - ai yin conscy ucnce of the PERMIT ISSUANCE 3.00
granting MECH.CONT. C.NO. MO
])are ECATOTAL `)H.
3
nl t or utc
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
RE'SS
F�2-kvior
EM V�
��Dd�l A11D
PERMIT ISSUED DATEI "ELECTRICAL DATE INSP.'
ing
i
Rectrlca
Plumbing Power 'Pole
Mechanical rground
ems as ec Rough Wiring
bolar Walls 9.,; _ o �
Fire Sprinkler i in Z_z
1 rxtures nt xt
tors
Misc. Grounding
e ower
Uther
FINAL INSPECTIONS DATE INSP, Not :Approved
Gas
ectric 4 a[t df
um In PLUMBING DATE INSP.
ec anica
ar Backflow
wool . .Under l . . . . . . .
j
Grading er oIIlor. .
anninPartial 0
ire ept. oug Complete
Healt t. o a�-I r ogh
i ing Va—t—e—r7 Insulation
t er Main Drain
07
P19f r �- S -E fi� as
Drain
-Other
BUILDING DATE INSP, Not Approved
Pad Certification
7-35nanon ELECTRICAL DATE INSP.
re- unite
Slab-Membrane Underfloor S.M.
Bond ewn Ducts & nsu anon -/
On de r o o r it ers
Floor teelire ace
ie owns Tease Buct F Rood
is rams One Hour Shaft
eismec Bracing I -g Condensate Drain
balls- ane s uiE�ment An ora e
rame (0-8�/ ues , Com . Air
ter 1
3�oar n xt. _ 2 „
Firewa s tE
Other SNtgT x e c / m N! sloe
Not Approved P,g A T „ [ w 9 t c v /Z O's. 3, 28 gg
S l 2-0 ,c am
(J--
BUILDING
QLi.oas
ELECTRICAL
PLUMBING
MECHANICAL
Tff SCELLANFAUS