1397.APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT lDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
3J 1
`J
BUILDING0 5
A0
MI 24,424
OWNEP'9
"AME
'
CITY. ELECTRIC PERMIT,,„ FEE,
PLANCHECK VALIDATION
PHONE
oNTRICTORS
NAME
UTLETS-SWITCHES -RECEP 5.00/1,00
LIGHTING FIXTURES 5.00/1.00
[,Gn't"VeP i✓ LIC. NO.
DATE OF APPLICATION
PLAN CHECK FEE P.C. NO.
COrvrR AGTOR'sAPPLIANCES
ADORES$ 1
Q f j Ab. PHONE %33-9693
ARCHITECT
OR
ENGINEER
,47vLIC
C, NO.
• RESIDENTIAL 4.00
PANELS 5.00
SIGNS 600
SI GNS TRANS. 3.DD
ARCH. OR ENG.5
ADDRESS
U2 AAAIVcC�
SPECIAL CIRCUIT DG
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
APPLICANTADDRESS
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
Zlt160Iti afETJTcA90
A
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Busipess a
BLDG. ELECT.
PLG. MECH.
Professions Code, d my license is in full for t. °
Licenu CI s Lic. Number kt'
Date Contractorv4`14 "Mait.
❑
❑ ❑
_
OWNER -BUILDER DECLARATION
I hereby affirm that I am exem t from the Contractors License
P
equir .5,Business and Professions
citylowing oun(y which(Sec.
Code; Any alter,
Code: Any city Or cor r ey it any s tr uires a p no it o its issuance,
improve, demolish, of repair any structure, prior m its issuance, also
DING
.BUIL"DING IM
EKde+, •..'INFORMATION�C!,W5,
MISC. - REFER TO ORO
VALUATION
/� ee
ESO 194
g/FT.Law '
PERMIT ISSUANCE 6.00
ELEC. CONTR. LIC. N0.
ELEC.
requires the applicant for such permit to file a signednt statement that
he is licensed pursuant en the provisions of the Contractor's License
Division o of the
(Chapterand
BusOr
inev and Professions Code) ar that he is ezempl ther<(rom and
Bus processions Code) a, Section is 00) exempt
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant toa civil penalty
of not more than five hundred dollars ($500).1:
TOTAL
PERMIT TO
U
Ali�r(4/ w
STORIES TYPE CONSTR.
/ ��
,
G P q d?
DTV. q (PLUM. I -1 RMITvnTI t „- FEET'
' „'- .r.....:.:.r'�`'..Q.._ >'
gLTER-DRAIN-VENT-WATER(EA.)4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
intended Or offered for sale (Sec. 7044, Business and Professions
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA COND. 4.00
Code: The Contractor'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 AREA
TOTAL ACREAGE
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If. however, the building
3
GAS-EA.SVSTE INC.40UTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Sec. 7044, Rosiness
.
GAS • EA. SVSTE (EA.) 100
BUILDING USE
RES IND CON PS fisher
❑ ❑ ❑ ❑
INDUSTRIALW TE IN 0.00
LAWN SPR IN KL INC 5 V.B. .00
ASSESSORS PARCEL NO.
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds or improves thereon, and who
LAWN SPRINKLERS - OVER 1 1.00
contracts for such projects with a contractods) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY M EA. 2001t/6.00
TRACT NO.
PARCEL NO.
WATER HEATER W/V 4.00
❑ I am exempt under Sec.-. BAP.C. for this
reason
Dale Owner
WATER SYSTEM 4,00
ACC, DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK ERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure.
or a Certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO.
copy thereof ( Sec. 3800, Lab ,C.6f��
Policy No. Company
FIRE $PRINK
ENERGY T]4
p rer(Ified copy is hereby form yyheg,� „
eCertified 0 wifiit e-coonion divisionvision.
Applicant //Ass
y N
❑ ❑
Y❑ No
MISC.- REFER TO ORD.
CERTIFICATE Ob EMPfION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A,L.U.C.
PLG. CONTR. LIC. NO.
PLG.
TOTAL
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y❑ N❑
Y❑ N❑
'itpT' «'
PERMIT u;,'O.iY' y„ FEETmil
'+vDate
It undyed dollars IS 100) Or I.A.l
1 certify that in the perfonnane of the work for which this per -MECHANICAL
is issued, I shall not employ any person in any manner sir�z(-k,;aP� become subject to the Workers'Compensation Laws of California.
ApplicantALTER
BUILDINGNOTICE
OR ADD TO MECH. 4.00
TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the WorkeriCompensationqpP
such)sions of the provisins or thispermtor dshall he Jemed revoked ou must forthwith comply withAIR
LENDING AGENCY
LIANCE 4.00
r
PLAN CHECKv
/ ACONSTRUCTION
HANDLING UNIT (TO 10,0MCF.NL) 3.00FEE
AIR HANDLING UNIT(OVER 10=11F.M.) 5.00
SEISMIC FEEI
HOOD (WITH DUCT) 2.00
MICROFILM
hereby affirm that there is a construction lending agency forEXHAUST
the performance of I e work for which this permit is issued ISce.
3097, Civ.C.). A
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
Lender's N. - _
Lenders Address --
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and countyPLUMBING
ordinances and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
BOILER-COMPI3 H.P. or 100,000 B.T.U.) 4.00
I BOILER -COMP (Over 100.000 BTUI SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, cases and expenses which
may in any way accrue against City in conee9uence of the
grantingO Ispe L
/
Signa r of APPli nt Con actor Date
MISC. • REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIQ NO.
MECH.
TOTAL
•A. �U:e"y; �'7•?
s� TOTA'L14yY
n,. --w` ::: w- 4. `I
f l/
3 7 E
_1�/ OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD (Office Copy)
1397 Portal Plaza
•PERMIT NO. SANITARY DIST. N0. LOT NO. ADDRESS
Enclose Carport Mayco Construction 733-9693
PROJECT OFINER JOB SITE PHONE NO.
Date
Ruildine - -
Electrical
Plumbing
Mechanical
Temp. Gas/Elect.
Solar
Fire Sprinkler
Sign
Misc.
FINAL INSPECTIONS
Date Insp.
Gas
Electric
Plumbing
'techanical
Solar
Pool
Grading
. Planning
Fire Dept.
Health Dept.
Ruilding
Other
STRUCTURAL
Date Insp.
Pad Certification
Foundation
Pre-Gunite
Slab -Membrane
Bond Beam
Underfloor Girders
Floor Steel
T.iedowns
Diaphrams
Seismic Bracing
el;
Frame Frame
Lath
Wallboards Int/Ext.
Firewalls
ether
Not Approved
ELECTRICAL
Date Insp.
Power Pole
Underground
Rough Wiring
i•lalls
Ceiling
Fixtures Int/Ext
Motors
Grounding
Temp. Power
Other
Not Approved
PLUMBING
Date Insp.
Backflow
Underground
Underfloor
Partial Rough
Rough Complete
Solar Rough
Water & Insulation
Main Drain
R/of/S Drain
Gas
Other
Not Approved
MECHANICAL
Date Insp.
Underfloor S.M.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & Hood
One Hour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
Mayco Construction
Portal Plaza Carport Inspections
Roof
Carport Pi ers Nailino .FrAmo n 174..�1
111.
8-31-81
1 ✓s
9-16-81
#3.
9-1-81
c
l=�ti'a
114.
9-3-81
/1 ell
#5.
9-841
—134
Qi�cwG+Q-
#6.
9-8-81 9-8-81
117.
'JL 91j
Z
118.
119.
-8
#10.
3j23
1111.
1112.
1113.
1114•
r/
1115.
11 •3.81
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1116.
Additional"Comments:
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