3272 APPLICANT TO FILL IN INFORMATION WITH IN'RED LINES - USE BALL POI PEN ONLY
BUILDING PROJECT I DENTI FICATION WPEE•4c -APPLICATION &.PERMIT PERMIT NUMBER
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ADDRESS '` F^y y f`V��
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.g BUILDING -ELECTRICAL-PLUMBING=MECHA -
Owry R'S PLAN CHECK VALIDATION
""ME DTV. ELECTRIC PERMIT FEE '
- P.O.E252 !'AIS
c NIRA TORSOUTLETS-SWITCHES-RECEP' 5.00/1.00 `{
AE Mgy2C
.Llc.rvo. LIGHTING FIXTURES 5.00/1.00 '7)v J p
DDNTRADTOR'S PPLIANCES-RESIDENTIAL • 4 �
,00 ''� C%f 19O
ADDRESS Y Of C
PHONE PANELS _ 5.00 DATE OF APPL
ARCHITECT SIGNS 6.00 PLAN CHECK FEE O:
OR
ENGINEER
LIC,NO. SIGNS TRANS. - 3.00
APDH.GRENc. SPECIAL CIRCUIT rj,QO PERMIT VALIDATION
ADDRESS _ ••
ZIP. TEMP.METER OR POLE INS. 15.00
•,
APPLICANT rvs' _ MOTORS SEE FEE SCH.
CH. '.
-
ADDRESS •
+ SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION ��
a I hereby affirm that I am licensed under provisions of Chaptcr 9 ISSUA CE DATE
w a H (commencing.wilh Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. FOR.
F n z Professions Code,and my license is in full force and effect. ❑
Z O w - License Class Lie.Number �- ❑
Q z r Date - Contractor
< y s BUILDING PERMIT
E ¢ w a OWNER-BUILDF-R DECLARAPION INFORMATION
w ;LL hereby uffnn that 1 am exempt fens the Cuntructor's License MISC.- REFER TO ORD
LL 0 sc Law for the following reason.(Sec.7031.5;Businessand Professions PERMIT ISSUANCE dy VALUATION $/FT.
- Code:Any City or county which requiresu permit toconstniCLalter. _ 6.00 -
E 2 Q p improve,demolish,or repair any structure,prior to its issuance,also ELEG.CONTR. LIC.NO. ELEC.
0`=
iL 0,¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
u w m he is licensed pursuant m the provisions 01 the Contractor's License _^✓
F Z Q Law(Chapter9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and' DTV. PLUMBING PERMIT FEE
¢ t$ the basis forth,alleged exemption.,Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).1:
❑ L as owner of lire pm Perry,or it,,employees with wages as BACKFLOW 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 all owner of -
property who builds or improves 0mreon,and who dues such work FIXTURES-PER TRAP 4:00 SO.FT,FLOOR AREA TOTAL ACREAGE
himself a of intended
own em Pluyces,provided that such ibuildi g
meals a re notlnth.his or ofend for Rmh.y"su4.ILed that suhe...pro ng 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 int-
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 20.00 RES IND CONPB ornx,
❑: I,as owner of tire property,am exclusively contracting with ❑ - ❑ ❑ ❑ ❑
licensed contractors Io consvuet 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 does not apply '
• 1. to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA:) 1.00
contracts fur such'projecls with a CORtraeturfs)licensed pursuer m
the Contractor's License Law. SEWER-SANITARY-STORM EA'.200ft/8.00 TRACT NO. PARCEL NO.
❑ I ant c,ennounder Se,,-.B,&P.C.,fo,this WATER HEATER W/VENT 4.00
reason
Date_ .vim owner _ WATER SYSTEM - 4.00' Aee.DnrE ACC.FILE No.
wORA1iRs'co>1 PIiN'SA'1'1 Iv DliC1.ARA'l'ION WATER TREATING EQUIP: 4.00
I hereby affirm that I have a Certificate of consent to self-insure. - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified•
copy thereof(Sec.3800,Lab.CA '
Policy Na Company -
O ❑ Certificdcupyisherebyfunlished.- .FIRE SPRINK ENERGY T 24
Z_ 2 ❑ Certified copy is filed with the city inspection division. MISC.- - REFER TO ORD.'
O Applicant - .Y❑ N❑ Y ❑ N❑
F- w " PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C..
� CIi R'I'I PICATIi ENSAX EXEMPTION FROMNCE RIi RS'
W 1 need not he com INSURANCE PLG.CONTR. .LIC.NO. PLG. Y❑ N❑ Y ❑ N❑
D. O I'fhis scditin need not he completed if the permit is fol.-or TOTAL
:)-Z bu ndred dollar IS 100)or less.)
U O 1 certify that in the performance of the work,for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY.
LL F mit is issued I shall not cntploy any,person in any manner so as to ..
U become subject to theWorkers'Compensation Laws of Cilil'ornia. BUILDING-
0
ED Date -Applicant ALTER OR ADD TO MECH. 4.00 a�' -
a
} to NO]ICE TO APPLICAN'1':,If;after staking this Certificate of Ev-
F2 eiption;you should become subject it)the Workers'Compensation r APPLIANCE - 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply,with FEE
U such Provisions or miss pennit shall be Jeumed revoked. AIR HANDLING UNIT(TO 10=C.F.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 lir EXHAUST HOOD (WITH DUCT) 2.00
the peflormance of the work for which this permit is issued .Sec. HEATING UNIT(70MICROFILM
3097:Civ.C.). - - ,100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC - Qv
Lender's Address
I certify thatl have read this application and state that lire above VENTILATION FAN (SINGLE)' 3.00
information is correct. I agree to comply with all city and county BOILER-COMPI3 H.P,or 100,000 B.T.U.) 4.00 PLUMBING
hereby as ori stole'laws relating to building construction.,and �.
hereby authorize representatives ec this city es enter,upon the BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL
shove-mentioned property for inspection purposes .
(we) agree to save, indemnity and keep hannlec the City of MISC.- , REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
iP y in any way accrue against s'' City all co Reyuenee t.the
granting of Wisp nt it. MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL T -
S igntureof A ppicanI CoA1,9I ate
• OFFICE COPY - '
-- - - -- ---- - -- ------- ----
CITY 01' CUPERT'INO INSPECTIOP RECORD (Office Copy)
Umit-A--_ _199D l Olivec34od-.N/S.-Dividera
1pPE11JIIT 110. SANIT'ARY DIST. NO. LOT NO. ADDRPSS
Re-klodel Property Services
PROJECT OWNER JOB SITE PHONE NO.
PER11IT ISSUED Date hLECTRICAL
Ruildi_nn _ 5T257-83 Date Insp.
Electrical 5/25/83 Power Pole
Plumhinr _ Underground --_ -
-
He.chanica.l Roul,h Uiring
'Temp. Ens/Elect. FIa1.1.s _
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext _
Sign Hotors
Grounding
Hi.sc. Temp. Power _
Other
FINAL INSPECTIONS Not Approved _
Date Insp.
PLUMBING
Electric Date Insp .
Plumbing Backflow
Mechanical Underground
Solar Underfloor _
Pool Partial Roul:h
. Gradin , Rough Complete --
I'Lanning Solar Rough
Fire Dept. I-later & Insulation _
Health Dept. Main Drain
Bui.ldinr R/of/S Drain _
Other Gas _
Other _
BUILDING Not Approved
Date Insp.
Pad Certi.ficat.ion HLCHANiCAL
Foundation Date Insp.
Pre-Ganite Underfloor S.H.
Slab-Ilembrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel Grease Duct & Hood
Tiedowns One (lour Shaft
Di.aphrams Condensate Drain _
Seismic Bracing Equipment Anchorage
llal.ls-Panels flues & Comb. Air --
Frame Other
Lath Not Approved
llallboards Int/Ext .
Firewalls
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
•
MECHANICAL
MISCELLANEOUS