6805 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT-PEN ONLY
BUILDING PROJECT IDENTIFICATION _ 'PERMIT NUMBER
ADAPPLICATION & PERMIT 0
ADDRESS DRESS /07(00
4107' N AI BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
68
owNEH'S
OU,
,,t at'An7#''t p,4 A h 4 PLAN CHEC VALIDA ON
111 •NAME 77-F 'ry}•,*y,x j,ELECTRICs`P. ,ERMI
f4 iI'r *
' FEE 1^ ! '
e PHONE � I a.4r 'x ' y, n yl> } W'4a+vn
_CONTRACTORS /
N E aOUTLETS-SWITCHES-RECEP 5.00/1 00
-���'S•r�•"`K�T�- uc.rio. LIGHTING FIXTURES 5.00/1.00
CONTRACTORS q PPLIANCES-RESIDENTIAL 4.00
OiVAL,,
P,eaONE77,17,3sz PANELS 5.00 . . DATE OFAPPLICATION
ARCH��ITTTECT PLAN CHECK FEEP.C.NO.
ENQIyg�eL � , , q p SIGNS '-6.00
kfq UC.NOC_ p SIGNS TRANS. 3.00
ADDRESS
ARCH.ORENG. • - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ADDRESS rs MOTORS SEE FEE SCH. / -
7'30!lEmr,34 " d��L• VA�IVOdE SERVICE CHANGE 10.00 / / G ,
O ¢.i o /y'
'02 LICF-NSED CONTRACTORS DECLARATION
0 w I hereby affirm(hat 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
y a'w (commencing with Section 7000)of Division 3 of the Business and BLO ELECT. PLG. MECH.
0 w z ProlBssions Codry ry license is in full for a ysjec4 O ❑ ❑
zO z m W License Cuss Li,Number ,( ON
Date-�/-" Coulractor�
a x - • $UILSDING PERMIT'
rc w OWNER-BUILDER DECLARATION ..{AI IV_FsDHMAt,T11QN ;
w ;u N 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD '
LL o j Law for the following reason.(Sec.703 L5,Ba.messaod Professions n VALUATION it, 3/FT.
� - g PERMIT ISSUANCE 6.00 ( " 2 b'�f tt
Code:Any city or county which requirese permit to is inane,,also
(/�fL 4�
a,¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. /_
i iL m LL requires the applicant for such permit to file a signed statement that TOTAL PMI
he is licensed pursuant to the provisions of the Contractor's License Jlrl J rem e
RT TO gHJ
i Law(Chapler9(commencing with Section 7000)of Diviaon3ofthe S��f/{j�.Zsu}
io Business and Professions Code)or that he is exempt therefrom and QTY: PLUMBING PERMIT
I-m the basis for(he alleged exemption.Any violation of Section 7031.5 '} STORIES TYPE CONSTR.
u3 - by anye..than five permit subjects $500).licantIns civil penally ALTER-DRAIN -WATER (EA.) 4.00 y �/✓
of not more than five permit
dollars the applicant
p li - -♦♦
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OC .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 Conlractor'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 LAREA TOTAL ACREAGE
himselfor
Do( ugh intended
own employees,provided if,however,
the
improve- GAS•EA.SYSTEM-1 INC.4 OUTLETS 4.00 941r
•'. mems are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the ownFr. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder r p have the burden of proving that he did not build or im-
proveforpownerofthe.). - INDUSTRIAL WASTE INTER. 20.00 RES IND CON Pa oma.
❑ d as owner of the property,he exclusively. 7044,Bu with
'licensed contractors to construct the project(See. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's s License law does,at apply
to an owner of property jec who builds tr improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00contra .3•S'6 /•�
the Contractor's
ctor'sor hcenecLts wilhn contractor(s)licensed pursuant to SEWER-SANITARY-STORM,EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor s Licensc.Law. ' ^
❑ lam exempt under Seca ,b&P.C.forthis WATER HEATER W/VENT 4.00 A ? 7
reason
Owner Date WATER SYSTEM 4.00 ACC.OATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent m self-insure,
or a cer(ifcate of W11oorke�e a'Co Insurance,or a certifiJed ZONING ENG.SITE NO. '
PoPYafUi �i✓Tj[M"fH'�j /�- /
O ❑ CerIifie2. is he yfumished. FIRE SPRINK ENERGY T-24
Z Z *�Cc I DO Is led wish fl city inspection division.
MISC.- REFER TO ORD.
O Applicant '� � V [3 N Y IN
~ rn - PERMIT ISSUANCE
ir - _ CERTIFICATE.OF EXEMPTION FROM WORKERS' , B'DD FLOOD ZONE A.LU.C.
LU COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
CL Z (This section neednotbe completed if the permit is for one TOTAL Y N� Y N�
hundred do1lars(s100)or less.)
U O I certify that in the performance of the work for which this per. DTV; , MECHANICAL PERMIT.'' :FELE' FEE SUMMARY
IL U mit is issued,I shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California.
W Date Applicant _ ALTER OR ADD TO MECH. 4.00 BUILDING ���
} W NOTICE:TO APPLICANT: If,after making this Certificate of fix.
emp(ion,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 10AWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.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 the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name FIOH 6 FEDSPIIL-
-
Lender'sAddre HEATING UNIT(OVER 100,000 B.T.U.0.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION,FAN (SINGLE) 3.00
. information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 4.00.
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. g01 LER-COMP (Own 100.000 BTU)BEE FEE SCH. MECHANICAL
(We) agree to save, i do If y and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babi'les,judgments, costs and expenses which CONST.TAX
may in any way ac a against said City in consequence of the PERMIT ISSUANCE 3.00
granting of this pe 1. MECH.CONT. LIC.NO. MECH. "` - '-
Signature of Applican/ onhactor TOTAL' r"T.OTgL•�r�
• OFFICECOPY
i
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
S to led,
Ph111111' N11*
UWNhK
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
-Building
h-Lectrical
Plumbing Power Pole
Mechanical r un
e as ec u irin –T
oar waiis
Fire Sprinkler 1 m
bign
Pixtures nt xt
tors
Misc. Grounding
utne ower
er
FINAL INSPECTIONS DATE INSP, Not ApproveT
Gas
Electric
Plumbing _� _ PLUMBING DATE. INSP.
.mechanical
•,o a'� — Backflow
O0 r un
rrad= — r
r oor �-
Planning Partial Rough _ S—
Fire_pt. Kougn LmMlete <_ _
Health t. bolar Hough
1 ino - Water ', ns y
at�on _yl`
er in . rain _
- s
o ain
Lias -r3
Other
BUILDING DATE INSP. Not Approved .
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
glab-Membrane Underfloor S.M.
Bond cts ns ation - s
r oori rs-k _ a- ire ers
Floor tee ire ace'—'
Me owns brease Duct & Hood
rams a our t
Seismec bracing adnate Drain
Wirfs- ane s ui ment Anchorage
Frame s u ¢d V ues r
.Lathter
a oar
Int/M. of rove
virewa s
Other
Not Approi