4027 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY.
• BUILDING PROJECT I DENTI RCATION - - PERMIT NUMBER
ADDRESS - APPLICATION & PERMIT -
ADDRESS - a
• � .r�l�H�a�. '0 'BUILDING -ELECTRICAL ' 4027
O/x•17
-PLUMBING-MECHANICAL - 4 1./J 1/
NAME gyapp- � - ---�-
• PLA
/14,.C7. �beel a -Z S'aP 177 'OTY• ELECTRIC PERMIT FEE N cHE K va uoanoN -
PRarvE. '8.3•S 2
CONTRACTOR'S
NAME - 'a OUTLETS SWITCHES-RECEP 5.00/1.00, sem" _
'l .'LIC.NO. - LIGHTING FIXTURES . 5.00/1.00 3� ��/
70NTRACTOR'S '
ADDRESS APPLIANCES-RESIDENTIAL
.,PHONE' PANELS 5.00
ARCHITECT - DATE OF APPLICATION
OR - SIGNS, 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LiarvO: SIGNS TRANS. 3.00 -
ARCH.OR.ENG.
.AOOREss '' . SPECIAL CIRCUIT, 5.00 PERMIT VALIDATION
ZIP TEMP. METER OR POLE INS. 15.00
APPLICANT'S n '
ADORESS MOTORS SEE FEE SCH. J\
SERVICE CHANGE10.00 -
�00 LICENSED CONTRACTORS'DECLARATION �
- r te( �
r i u1 hereby affirm that I am licensed under provisions of Chapter 9 ISSU/NCE DATE-
m Q (commencing with Section 7000)of Division'3 of file Business and -
o, BLDG. ELECT. PLG. MECH.
r Z Professions Code,and my license is in full force and effect. -
z O vi - License,Class Le.Number MAY
❑ „ El ❑ _ O
o z r w Date Contractor '
¢ ¢ w OWNER-BUILDER DECLARATION.' city - BUILDING PERMIT
w ; LL y I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD I INF ATION
r u O j Law for the following reason.(Sec.7031.5,Business and Professions VALUATI N $/FT.
fw> Code:Any city or county which requiresa permit loconstruct,all,xBr, ,PERMIT ISSUANCE 6.00 / n _
¢ ¢ 4 improve,demolish,or repair any Structure,prior to its issuance,also ELEC.CO_NTR. LIC.N0. ELEC. / S
o u requires the applicant for such permit to file a signed statement that TOTAL to
n w m,A he is licensed pursuant to the provisions of the Contractor's License ERMI 0
C z> Law(Chapter 9(Commencing with Section 7000)of Division 3 of the - O
a Business and Professions Code)or that'he is exempt therefrom and QTY. PLUMBING PERMIT FEE
a m the basis for the allegetl exemption.Any violation of Section 7031.5 STORI
i3 .- 'by any applicant foraperinit subjecis-[lie applicant toacivil penalty - ALTER-DRAIN&VENT-WATER (EA.) 4,00
of not more than five hundred dollars($500)J'.
❑ 1,as owner of the'property,or my emplo"yeas with wages as BACK F LOW PROTECT. DEV 2,00 ICE
their sale compensation,will do.the work,and the structure is not 'OCC.GROUP RES.UNITS
intended or offered for sale (Sec: 7044, Business antl
ons DRAINS-FLOOR,ROOF,AREA,COND. -4.00
Code:The Contractor's License Law does not apply to an owner'of
prope![y WllO ballds Or lmprOVes theleOn,and'WhadoCS snCh Work FIXTURES-PER TRAP 4,00
ve- Q SFT.FLOOR AREq TOTgLgCflEAGE
himself or through his own employees.Provided that such impro ,
mems are not intended or offered for sole:if however,'tlm hudding GAS-EA.SYSTEM-1'INCL40UTLETS 4.00 4e a-f
or improvement is sold within one year of completion, [he owner-
builder will have the burden of proving that he did not huild or im- GAS;EA.SYSTEM-,PVER 4`(EA.) 1,00 auILOING USE
prove(or purpose of sale J. - - - RES IND . CON PB Other
❑ I,as owner of the property,am exclusively contracting with INDUSTRIAL WASTE INTER. 20.00 El El. ❑ ❑ ❑
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 en owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 ' �'S^7-/6
contracts for such projects with a conlractor(s)licensed pursuant la -
theContractorfsLicenseLaw. SEWER- ANOOft/8.00 TRACT No. .PARCEL NO.
,B&P.G for this 4.00
reason am eft .- ,WATER HEATER,W/VEN -
Data U - WATER SYSTEM .00
ACC.OATE ACGFILENO.
WORKERS'COMPENSATION DECLARAT N WATER TREATI G P. .00 '
I hereby affirm that I have,a certificate of consent lu self-insure,
or a certificate of Workers'Compensation Insurance,or a certified- -,_ }�r wt P,,,, ZONING ENG.SITE NO.
copy lherea P(Sec.3800 Lab.C.). q vs VIJIJ
Policy No. Company - -
0 ❑ Certified Copy is hereby furnished. ' - FIRE SPRINK ENERGY T-24.
Z Z U. Certified copy is filed with lbc city inspection division,
C) Applicant MISC.'- " REFER TO ORD. v �. N� v ❑ No
CCH CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 ` FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTH. u0.NO. PLG.
1 O (This section need not be completed if the permit is far one TOTAL .0 Y N� Y 0 No
Z hundred dollars IS 100)or less,) -
U O 1 Certify that in the performance of the work for which this Per- QT,, MECHANICAL PERMIT FEE FEE SUMMARY
mit is.issued, I.shall not employ any person in any mariner so as to -
becomesubject fothe Workers'Compensation Laws of California. BUILDING a�s�
Date -Applicant ALTER OR ADD TOni , 4.00
l
ozNOTICE TO APPLICANT: If,after making[his CertlPlcate of Ex-
emption,'you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with
•O such provisions or this permit shall be deemed revoked. AIR HANDLING (}'I .I 3. 00 FEE -
CONS TRUCTIONLENDING AGENCY AIR HANDLING UNIT(OVER IMOOC.F.M.) 5.00 SEISMIC FEE
1 hereby,affirm that there is'a construction lending agency for EXHAUST HOO -O o 1110 2.00
the performance of theswork for which this permit is issued ISce, MICROFILM
30nder97, 's .ame _ _ HEATING UNIT'(TO 100,000 B.T.U.) 4-.00 '
Lender's Name '
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)7.50 ,ELECTRIC
I certify That I have read this application and state that Ihu above VENTILATION FAN (SINGLE) 3.00
lointration is correct. I agree to comply with all city and county PLUMBING Q
oNinances and state laws,relating to building construction, and BOILER-COMPI3 H:P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city'tn enter upon the. - -
above-mentioned property for inspection purposes. 801 LER-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 expenses which- - - CONST.TAX
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE . - . 3.00 .,3 �'/z�,a..
\ granting of fit is permit MECH.CONT. LIG NO. MOTAL V_
r �/e _
I/V Signature of pp' t/Confrac D e � 7 -' TOTAL
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PERMIT - c>?/n!>/ Lance
77°lel
PERMIT ISSUED DATE "ELECTRICALTE INSP.
Tu-1-1 n
ctrica
um in Power Pole
ec anica Underground
lemp Gas/ETe—c ��ouhwiringi.�
Solar Walls
Fire Sprinkler i m
bign Fixtures int/hxt
Fut—ors
Misc. Grounding
e ower
uther
FINAL INSPECTIONS DATE INSP. Not ,Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
anica
•so ar Backflow
00 r un
r m oor e
FlanninLy Partialu
Fire Dept. u Complete
eat t. oar u
i m water -4 insulation
ermain Drain
o ram
Gas
Other
BUILDING DATE INS, P. Not Approved
Pad Certification
orm ation ELECTRICAL DATE INSP.
►bra oe wh
Ak6lal)-Membrane Underfloor S.M.
Wbond beam cts nsu ation
Undertloor Girders ireers
oortee i ace
ie owns cease OR o Flooci
Diaphrams One Hour Shaft
eismecracm Condensate ram
a s- ane sclum ent ora e
Frame -Agues r
ath NFe—r
NMViallboardsInt/Ext. Not Approved
Firewalls
Other
Net rove
7 --lo^ ^- ,4-1
2 —l��$/r J^�✓ur�ocK — 6i J'