5742 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE•BALL POINT PEN ONLY
' BUILDING PROJECTIDENTIFICATION PERMIT NUMBER
D
AROWG APPLICATION & PERMITDDRESS
- •
ILD,.
L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL . 5742
OWN 'S
�E PLAN CHECK VALIDATION
DTVELECTRIC PERMIT FEE. '
p ' PHONE r- (n
CONTRACTORS
E '� UTLETS-SWITCHES-RECEP 5.00/1.00
C b_�
sec.rvO. Q LIGHTING FIXTURES 5.00/1.00
ADDRESS a PPLIANCES-RESIDENTIAL - 4.00
A . • q '
C C( 'y(z, VHONE PANELS 5.00 DATE OF APPLICATION
0RCHITEc - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER , WC.NO, SIGNS TRANS. 3.00
ADORRE RENc' SPECIALCIRCUIT '5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00
w
APPLICANTS C
ADDRESS
- MOTORS E SCH.
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS D17CLARATION S
W
i w 1 hereby affirm thin I am licensed under provisions of Chapter 9 ��( 0 U(�e' ISSUANCE GATE
to ¢ % (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH.
t- i Professions Cole, s ry license is in full f�I(Jr
' o. ; Licc C`Igss .ya�_r Lic.Numbe
O - pate -.5-tZ`-L Contractor
- L s w OWNIiR-DUILDFR DECLA811NFORMATIONT
E:
;LL y I h -by affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
_ PERMIT ISSUANCE 600 -- 2 I
,. o¢ Law for following reason.(Sec.]031.5,Business and Professions L
Code:Any ty or county which requires a permit to construct,alter, Q
rc ¢ 0 improve,dem ish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC, q s ��f QQ
iL DLL requires the ap 'cant for such permit to file a signed statement Gist TOTAL �-4
a w m m he is licensed po ant to the provisions of the Contractor's License I
to > Law(Chapter9(c Imencing with Section 7000)of Division 3 ofthe I�
¢ Businessand Profess Its Code)or that he is exempt therefrom and QTY, PLUMBING PERMIT FEE
¢ ro the basis'for the allege exemption.Any violation ofSection 70315 STORIES TYPE CONSTR.
by any applicant foray it subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hu red dollars(8500).):
❑ 1,as owner of the p petty,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00
their sole compensation,wi do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's Licen Law does not apply to an owner of
property who builds or improv -thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himulfor through hisoweempl ees,provided that such improve-
trope
mprove- GAS-EA.SVSTEM-11NC.40UTLETS 4.00
meals are not intended or offered r sale.If,however,the building
or improvement is sold within one at of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1,00 BUILDING USE
builder will have the burden of prove that he did not buil)or im-
Proveforpurpouofsale.l. INDUSTRIALW TER. 20.00 RES IND CON PB omar
❑ I,as owner of the property,am elusively contructing with 0 0 0 0 0
licensed contractors to construct the p 'cc((Sec.7044,Business LAWN SPRINKL NC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Li rise Law does not apply
ro an owner of property who builds or am l Dues thereon,and who LAWN SPRMT-TO IEA.) 7,00
contracts for such projects with a contmcm licensed pursuant to
the Contractor's license law. SEWER-SA -STD A.2OOft HO TRACT NO. PARCEL NO,
O-1 um exempt under Scc. ,B.&P.C.for this WATER HE ER VEN - 4.00
assn no
Ownet to WATER SY 4.00 ACC.DATE ACC.FILE NO,
WORK Ii RS'COMPI:NSAT1ON DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to sel Giesure. ZONING
or a certificate of Workers'Comp��eppsaal1 iOa�I sur3j, r a c�E,I�{ed ENG.SITE NO.
copy thereof(See.3800,Lab C.f CIfte-1 40-`-mss -
policy No. Company f I L.11C;U M1 LLb,
0 O Certified copy is hereby furnished- FIRESPRINK' ENERGY T 24
Cerci' co rs II with u' tUian division.
Z Z � Puglg c� �
O At L- T � MISC.- REFER TO ORD. y � N� v [] No
CC W CERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
L �_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the Renoir is for one TOTAL Oa�b Y O No Y❑- No
0 2 Imo dollars(S 100)or less.)
U O I ceryl in f ie performance of the work for which this per QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,I st employ any person in any manner so as to
O W become subject to the 'Compcnsmion Laws of Califon ta.
Dam Applica t ALTER OR ADD TO MECH. 4.00 BUILDING pal s�
} So NOl'ICI. 'f0 APPLICANT: II;alter n. this Certificate of fix-
? emption,you should became subject to the s'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must fotlwl hmpty with FEE-
D such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 3.00
• CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.FM.) 5.00 SEISMIC FEE
I hereby affirm That there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performmnce of the work for which this permi( is issued(Sec. MICROFILM '
3097,Civ.C.). HEATING UNIT 00 B.T.U.) 4,00
Lender's Nude ?✓ n I., to HEATING UNIT(OVER 100,000 B.T.U.)7,50 pZQ
Lender's Address ELECTRIC
I certify chat I have read Ih is application and state That the above VENTILAT (SI 3.00
information is correct. I agree to comply with all city and county PLUMBING a�p
ordinances and state laws relating to building construction, and BOILER (3 H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this City to enter upon the BOILER-000 1$EEFEESCH. MECHANICAL 7
above-mentioned property for inspection purposes.
(We) agree to seve,'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 3 -
may
of n perlIi`L / N
MECH.CONT. LIC. O. MECH.
/i ` / 1 TOTAL 7 - TOTAL /4
Signature o plicantjContractor Dale
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
PERMIT NO.57 lvo5 /�l A l (,[bliU/Ei =7757-
_ �. dal m
OWNER
PERMIT ISSUED DATE ELECTRICAL DATE INSP:
ui ink
Electrical
Plumbing „ Power Pole
Mechanical Under un
emp as ec ou n wiring
Solar Walls .
Fire prin c ereZr'Tiin
Sign Fixtures int/Ext
Motors
Misc. Grounding
f2�2 Power
Utfter
FINAL INSPECTIONS DATE INSP, Not .Approved
Gas
ectric
um ink _ PLUMBING DATE, INSP.
Mechanical
o ar "Backflow
•�O r un
in r oor
Planning Partial u
Fire t. RoughComplete
eat et. oar Roun
Building � atW err',Insulation
tt e0 �i r in ain .
o ain
Gas
Other
BUILDING DATE INSP, Not Approved
Pad Certification
oun =tion 'ELECTRICAL DATE INSP.
re- rte
Slab-Membrane / I V_ Underfloor S.M.
on eamDucts & Insula:Flon
Underfloor Girders Fire Dampers
oor teel Fire . ace
ie owns Grease Duct 4 Hood
is crams one Hour Shaft
$eismec Bracing condensate Drain
alls-Fanels _qm meant Anchorage
Frame Flues F, Comb. Air
�Ah Ot Fer
-11boards; Int/Ext. Not Approved
irewalls
Other
Net Approved
BUILDING
' r
ELECTRICAL
. . . . . . . . , . . . .
PLUMBING
•
MECHANICAL
MffSCELLANF,OUS