3278 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU LDI NG PROJECT I DENTI FICATI ON WPIRMIT NUMBER
muoDINs No��tS�vnr APPLICATION & PERMITADRES7 Q
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL I 0
Oryryw��MNrv••ER'S PLAN CHECK VALIDATION
cEOTY. ELECTRIC PERMIT FEE
GrvE pplD
NAME cans OUTLETS-SWITCHES-RECEP 5.00/1.00
NAME
LIa No. LIGHTING FIXTURES 5.00/1.00 MA`f 2 51983
CONTRACTORS -RESIDENTIAL 4.00
ADDRESS
PHONE PANELS 5.00 IBQ
ARCHITECT 6.00 PLA C EE P.0.NO.
OR SIGNS
ENGINEER
uc.NO. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
O o LICENSED CONTRACTORS DECLARATION
a v sit 1 herchy affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
'sI (Commencing with Section 70000oIDivision 3 of the Business and
BLDG. ELECT. PLG. MECH.
Ni Professions Code,and my license is in full force and effect.
zQ Om r LiC.Number.
El 11 ❑
Date Contractor.
¢ y BUILDING PERMIT
a ¢w¢ OWNER-BUILDER DECLARATION INFORMATION
O REFER TO ORD
K
3 e. H 1 hereby uffirnt that 1 ass exempt I'roni the Chntacturs License MISC.- VALUATION S/FT.
H .. oj Law for the following reason.(Sec.7031.5.Businessxnd Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct.alter.
IS
¢¢ 0 improve,demolish•or repair any structure,prior to its issuance,also ELEC.CONTR. LIC,NO. ELEC.
Cr u requires the dp pursuant
for such permit to file a signed statement that TOTAL PERT i /
wCr he is licensed pursuant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencing with Suction 7000)st Division of the
i 4 o Business and Profe,sions Code)or lmi he is exempt therefrom and OTV. PLUMBING PERMIT FEE
¢F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONBTR.
n ;m by any applicant fora permit subjects applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of nut mare than five hundred dollars($500).):
❑ I,as owner of the property,o1 my employees with wages as BACK F LOW PROTECT.DEV ICE 2.00 DCC.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,CONE). 4.00
Code:The Contractor's License Law does not apply to an owner of
Property who builds or improves ihercon,and who docs such work FIXTURES-PER TRAP 4.00 50,FT FLOOR AREA TOTAL ACREAGE
himself through his own employees.provided that such implove-
mentsare remet intended oroUered for sale.If,however.the building GAS-EA.SYSTEM-1INC.4OUTLETS 4.00
or improvement is sold within one year of completion, the owner. GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or in, RESIND CON PB Omer
proveforpurposcul'sWc). INDUSTRIAL WASTE INTER. 20.00 E] E] E] 0 E]❑ I,as owner of the property,and exclusively chmrxutlng with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESS0 PARCEL NO.
and Professions Code:1'he Contractors License Law does not apply /f/
to an owner of property who builds or improves fiercer.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 Ji{
contracts for su ec tawithucomructur(sl licensed pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No PARCEL O.
the Contractor's Licenseproject,
Law.
0 teat exempt under SC,,-.11&PC for thisWATER HEATER W/VENT 4.00
reason
Dale Owner-fA6f>- WATER SYSTEM 4.00 ACC,DATE ACC.FILE NO.
Oh1PE
WORKERS'C � ATI N UECLA RAT ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a cef ificate of Clmsait to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,ur a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
0 ❑ Certified Copy is hereby fumisbed. FIRE SPRINK ENERGY T-24
Z_ 2 [I Certified copy is filed with the City inspection division. MISC.- REFER TO ORD. Y0 IN Y N�
Applicant
F' - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
ir CERTIFICA'I'1i 01:EXEMPTION FROM WORKERS'
LEI COMPI7NSA'1'IONINSURANCE PLG.CONTR. LIC.NO. PLG. YE] No Y [] IN
CL 0 ('Phis section need not be Completed if the permit is for one TOTAL
Z) 2 . hundred dollars I S 1001 or less.)
U 0 1 certify that in the performance of the work for which this per, OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued.I shall nut employ any person in any manner so as to
OU become subject to the Workers'Compensation Laws of California. BUILDING /
LEI Datc Applicant ALTER OR ADD TO MECH. 4.00
} Tab NOTICI7 TO APPLICANT: If,after making this Certificate of Es.
FZ Caption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00 c
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE eJ�
1 hereby affirm that there Cr a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097-CN.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have read Oils application and xtar that the above VENTILATION FAN (SINGLE) 3.00
. information n estate. I agree In comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and erre laws relating to building ttmsvuction, and
hereby authorise representatives ol' ibis city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. CONST.TAX
Cupertino .grinst "ba, c"judgnml s, Costs mid cx ptoses which PERMIT ISSUANCE 3.00
may in any way accrue against s' City in Conseil f the
granting of this PC Lit. A MECH.CONT. LIC.NO. MECH.
714�.1feo/ 33�k3
TOTAL TOTAL
Signa Ire�tlComr t r 1 arc y
OFFICE COPY
C11'Y 01' CUPERTU10 INSPECTIOL RECORD (Office Copy)
327;, _ _ 10648 Manlewood N.S. 'Dividers
PEPJUT P10. SANITARY DIST. 110. LOT 110. ADUBI'.SS " ----
Remodel Property Services 985-6928
PROJECT OWNER JOB SITE PHONE NO.
PERPIIT ISSUED Date ELECTRICAL
Buildinr. _ _ Date 1.11sp.
Electrical Power Pole_
I'tumbin,, _ Underground
Hechani_cal Rough [Airing
'Ienh. Gas/lilect. falls _
Solar Cei.li,
Fire Sprinkler Fixtures Int/Ext _
Sign tlotors
Grounding
Plisc. Temp. Poorer
Other
FINAL INSPECTIONS Not Approved
Date Insp.
s PLUMBING
G1.ectri.c Date Insp.
I'lrnmbin , Backflow
Ne.chanical Underground
Solar Underfloor
Pool Partial. ROU46 —
•
Grading Rough Complete
PLinni.nl; Solar Rough
Fire Dept. Water & insulation _
Health Dept . 'fain Drain
GUildinR/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification 11GCUANICAL
Foundati.on Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Hembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & Ilood
Ti.edowns One hour Shaft
Di.aphrams Condensate Drain _
Seismic Bracing Equipment Anchorage
Ualls-Panels Flues & Comb. Air
Frame Other
Lath Not Approved
Uallboards Int/Ext .
Firewalls
Other
. Not A roved