4741 "PLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ;
-� HUI LOI NG PROJECT I DENTI FICATION PERMIT.NUMBER
r m,ILpING ,, / n // =BUILDING
CATION & PERMIT
ADDRESS/l//(00 LC.¢ f^/VD • 4741
,� / RICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
N ME
''f7� ELECTRIC PERMIT FEE
• � , �0/E2Q� PXONdTJf(/_`'(T l/ QTY.
NAAMTRACTORs OUTLETS-SWITCHES-RECEP 5.00/1.00
ismI" LIC.NO. LIGHTING FIXTURES 5.00/1.00 - -
CONTRACTORS APPLIANCES
4.00 -
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
ARRCHITECT • SIGNS 6.00 PLAN CHECK FEE! P.C.NO.
ENGINEER -
• LIC.NO, SIGNS TRANS. 3.00
ADDRESS eec. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
. ZIP TEMP.METER OR POLE INS. 15.00
APPLI DRESrvrg
ADDDRESS MOTORS SEE FEE SCH.
oo SERVICE CHANGE 10.00 � )�IFjZD
wLICENSED CONTRACTORS DECLARATION OOU j/
a 0 .I hereby affirm that I am licensed under provisions of Chapter 9 - ISSUANCE DATE
G a i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELLEE�� PL
F w i Professions Code,and my license is in full force and effect. ❑ n r-' 'Lfs y�S-II'
' 0. - License Class Lic.Number J�• �Z "[]
o F Date Contractor
a tr w u OWNER-BUILDER DECLARATION _ - B�N� TIIRU
W O°' H I hereby affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
FILOy VALUATION $/FT.
¢ Law for the following reason(Sec.7031.5,Businessand Professions' PERMIT ISSUANCE 6.00 2
0 -t Code:Any city orcounty which requires a permit to construct,alter. r,.0 0
ELEGCONTR. LIC.NO.
X ¢O improve,demolish,or repair any structure,prior m its issuance,also ELEC. /
i it O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO �J f f
X $ m he is licensed pursuant to the provisions of the Contractors License (+ '4
F 2 > Law(Chapter 9(commencingwith Section 7000)of Division 3 of the Q ,,PERMIT
f TC
¢ Business and Professions Codes or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
F E o STORIES TYPE CONSTR.
¢ F$ the basis for the alleged exemption.Any violation of Section en LS
d ';; � by any applicant fora permit subjects the 00.).ant soacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(55001.1.
• ❑ 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,AR EA,COND. 4.00
Code:The Contractor's License.Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACREAGE
himself re through his own employees,forts Provided that such improve-
ments
mprove- .
himself a not throng his or empld ees,provided
that suhebuilding GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion,the ild . . .
owner- GAS-EASYSTEM-OVER 4(EA ) 100 BUILDING USE
owner-
battle,will have the burden Of proving that he did not build or im- RES -IND CON PB .Omar
prove for purpose of safe.). INDUSTRIAL WASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑ •
❑ d as owner of the property,and rojectiv See. 044, ing with
licensed contractors ID construct Ne project La 7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Coop:The Contractor's License Law does not apply
to anowner of progeny who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a cuntrtrumor(sl licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-ST %ORD.
TRACT NO. PARCEL NO.
❑ I am exempt under See. ,B.&P.C.for this WATER HEATER W/V
anon
Date /( 6r- ? owner WATER SYSTEM ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATIN I ,
1 hereby affirm that 1 have a certificarcof consent.to sell'-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,Or a certified -copy th creof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
_z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFEO Applicant Y N Y ❑ N~ m PERMIT ISSUANCE PkooO zoNE A.L.u.c.
j CE RTI FICATE OP EX FMFT[ON FROM WO KK ERS'COMPENSATION INSURANCE: PLc.CONTR. LIC.NO. v N V Nd O (This section need not be completed if the permit is for one ❑ ❑ ❑ ❑
::) Z hundred dollars(S 100)or less.)
0,C) I certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H' not is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers'Com enation Laws of California.
P G(L
y Dam ApplicantBUILDING
ALTER OR ADD TO MECH. 4,00
} m NOTICE TO APPLICANT: Jr,uftu making this Certificate of Ex..
F. Z emption,you should become subject to the Workers'Compensation APPLIANCE 4,00 PLAN CHECKX20 1
provisions of the Labor Code, you must forthwith comply with FEE sJ7
V such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10A00GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of she work for which this permit is issued(Sec MICROFILM
'- 3097,Civ.C.). I HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 10
Lender's Address 0,000 B.T.U.)7.50 •ELECTRIC
I certify that I have read(tis application and state that the above VENTILATION FAN (SINGLE) 3.00 CA,
information is Correct, I agree to comply with all city and county PLUMBING 0
ordinances and state laws relating to building construction, and 130ILER-COMP(3H.P.or100,000B.T.U.) 4.00
herchy authorize representatives of this city to enter upon the BOILER-COMP low,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree t0 save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
'Cupertino againsi liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 3.00
gmnti of sptf I. MECH.CONT. LIC.NO. MECH.
-- Z'�7C"' t �L ,B�_ TOTAL TOTAL 7 77��
Signature of Applicant/Contractor Uete
OFFICE COPY -
l+ �r CITY OF CUPERTINO INSPECTION RECORD
ft (OFFICE COPY)
PERMIT NO. ADDRESS EMU.—
�SOLA_lz PROJECT ONNER
5Y ►�l LA P �rz+✓
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
u�i in
ec�� trica
Plumbingy Power Pole
Mechanical Underound
Temp as ecRough,;iring
SolarIls
FireSprinkler
ei in
bign
Pixtures nt xt
Rotors
Misc. Grounding
emp Power
Other
FINAL INSPECTIONS DATE INSP, Not :Approved
Gas
Electric
um ing "PLUMBING DATE INSP.
_ eMcnanical
"olar "Backflow
�o er uri
ra inR r oor. .
plannm Partial
Fire t, 4�ou i _ � Me
ea t e t. o�lar�u
ui in ater ', Insulation
Other
oDrain
Gas
Other
BUILDING DATE INSP, Not Approved
Pad Certification
oUn anon ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Nlem rane Underfloor S.M.
Bond Beam U
cts nsu anon
Undeer 'Toor Girders ireRers
MoorSteel Fire lace
1ie�owns Urease Puct 4 Hood
is rams a our Shaft
eismec Bracing Condensate Drain—
Walls-Panels
rainba s- ane s uiu1 ment Anc ora e
rame Fluesom r
t er .
W-11boards Int/Ext. Nof rove
Firewalls
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
•
MECHANICAL
MISCELLANEOUS
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