3717 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILDING PROJECT IDENTIFICATION P MIT NIGER
BUILDING !' APPLICATION & PERMIT 3717
Q e�'e 4 q�0 BUILDING -.ELECTRICAL-PLUMBING -MECHANICAL
y-"NAmE PLAN CHECK VALIDATION
C'Up'T,�"y ySSd�€7 c"' DTY• ELECTRIC PERMIT FEE
CONTP TORS
,J NA �/ OUTLETS SWITCHES-RECEP 5.00/1.00 -
T I L � LIC.NO. ( LIGHTING FIXTURES 5.00/1.00
ONTO ACTO
ADDRESS �JG?� ( / /6Y/�q APPLIANCES-RESIDENTIAL 4.00 -
q91D '1,1IyQ + HONE 7 -1 PANELS 5.00
DATE OF APPLICATION
APCHITECT ,
OR SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
-
AENG. UC.NO, . SIGNS TRANS. 3.00
ADDRESS SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
w TEMP.METER OR POLE INS. 15.00
APPLICANT
ADDRESS MOTORS
SEE FEE SCH.
SERVICE CHANGE P 0.00
o 0 i
n ec o LICENSED CONTRACTORS DECLARATION' (/
< v I hereby affirm that um licensed under pinv inions of Chapter 9
Q u (commencing Willi Section 7000)of Dwislon 3 Of the Business Ind ISSUANCE DATE
H Z Professions C a (1 r¢y I'S• us in full OM BLDG. ELECT. PLG. MECH.
QO - License Cla �Q I V� �. er "'� City Of Cupertino � �
9 m r Uatc-__!e Contractor I
H
le e: w 4 OWNER-BUILDER DECLARATION BUILDING PERMIT
K 3: LL y. 1 hereby affirm that I um exempt from the Contractor's License MISC.- REFER Z
h INFORMATION
u O j Law for the following reason.(SIC.703 1.5,Business and Professions VALUATION $/FT. -
- PERMIT ISSUANCE
� w> Code:Any city or county which rcyuiresa permit toconstruct,ager.
K c, a0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO.Oa, requires IIIL•apphcent for such permit to file a Signed statement t tat he is licensed pursuant to the provisions olthe CmImC(Gr'e LicensePERMIT TO
Law(Chapter 9(commencing with Section 7000)ofDivision 3 oftheZo Business and Professions Code)or Ihat he is exempt therefrom and DTV. PLUMBING PERMITa I- the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
byanyapplicant fora permit subjects the applicant toacivilpenaltyof not more than five hundred dollars($500).): ALTER-DRAIN& VENT-WATER (E
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE
their sole compensation,will do Ila work,and the structure is not 2.00 OCD.GROUP RES"UNITS
intended or offered for at, (Sec 7044, Business and Professions 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 docs such work FIXTURES-PER TRAP 4.00
himself or through his own employees,provided(hat such improve- 50.FT.-FLOOR AREA TOTAL ACREAGE
ments are not intended or Offered for sale.If,however,the building - GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion.(he owner
builder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
prove for purpose of sale,). INDUSTRIAL WASTE INTER.' 20.00 RES IND CON Pe Omar
❑ 1,as owner of the property,am exclusively contracting with El IN 1:1 1:1 ID
contractors to Construe( (he project ISec. 7044,Business LAWN SPRINKLERS- 1 INC 5 VB
and Professions Code:The Contractor's License Law tines no(apply V.B. 5.00 ASSESSORS PARCEL NO.
to an owner of property who builds or inlpmves(hereon,and win LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts fur such projects with u conimctuds)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA, 200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sac. ,B.&I'.C.for(his
veason WATER HEATER W/VENT 4.00
Date Owner WATER SYSTEM
4.00 ACC.DATE ACC FILE NO.
WORKERS COMI`I;NSAfION DECLARATION WATER TREATING EQUIP, 4.00 �
I hereby affirm (hat I have a certificate nfconsent to self-insure,
of a certificate of Workers'Compensation Insurance,or; xr dWd ZONING ENG.SITE NO,
copy(hereof f c.J 00,Lob CJJ�/moi.�
Policy No. Compaty` ¢/
0 ❑ Ccrtif py is hcrch f lishel. (j'8 •2 29
Z 2 ❑ Cer( copy is f d ilh th ray Inspeclon�O Nisi n. F
IRE SPRINK ENERGYT-24
O Annlican( MISC.- REFER TO ORD. N� y CJ N�CIi RrIRICAIi OI'IiXEMI'TION('ROM WUItKIiRS• PERMIT ISSUANCE 6.00L'� COMPEN'SATION INSURANCE PLG.CONTR. NE A.L.U.C.CL UC.NO. PLG.
Ol'his Wetton need nal be completal if the permit is for one TOTALN EI Y NUO hundred dollars($100)or lass.)I certify tat h the performance of Iho work Ior which this per- OTV MECHANICAL PERMIT E SUMMARYC) H mit is issuede I shall e w employ any person in any mann,r m:a rn FEE0 becoDate csubjce[to lam Wlicant COntpennulinn Lnws ofCllifnrniu.DateApplicantALTER OR ADD TO MECH. q,Op G} W NOTICE TO APPLICANT: If,after making this Certificate of rx-
emplion,you should become subject m the R'orkers'Compensation APPLIANCE4.00 ECKprovisions of the Labor Code, you mui f uthwilh conprly withsuch provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10,000OF,M) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 FEEI hereby affirm (hat (here is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of(he work for which (his permit is issued ISec. LM3097.Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) .4.00Lender's Name
Lender's Address HEATINGUNIT(O VER100,000B.T.U.)7.50 C //`�
I cartil y that l have read(]its application and stale that l he above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances unit state laws relating to building mnstnm(inn. and BOILER-COMP(3 H.P:or 100,000 B.T.U.) 4.00
1 hereby Iuthnriw rcpresett lniives of this city tO enter upon the
above-mentioned property liar inspection purposes. BOILER-COMP (Over 100,000 BTU(SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify .,,it keep hurniless the City of MISC.-
Cup- REFER TO ORD.
lino gainer Iiubili[ieS jud.man ls, costs and expenses which
ma in y way ac' re gain said City in consecm •e of the• PERMIT ISSUANCE 3.00 CONST.TAX
g li of this pc MECH.CONT. LIC.No. MECH.
- TOTAL TOTAL
3SIRSalunc Applicant/ on(mctor D
ifie
OFFICE COPY
CTiY OF CL'i'FUINO IUSPECTIOt! RECORD (Office Copy)
369S - as o 9 0
PCPdfIT PIO. 'SANITARY DIST. NO. LOT NO. ADDRI;BS
PROJECT OI,IMrR JOB SITE PIIONE NO.
PERMIT ISSUED Date ELECTRICAL
BufIdinr _-- Date insp.
Fle_ctrical lo/6.53 lower Pole
PLumhinr, (�- 3'�3 Linder ,round
Ifechanical - C�'�""'t L-3o•�3 _
Rough Wiring
Temp. Cis/£sleet. ITa11s ---
Solar Ceiling
Fire S rinkler Fixtures Lnt/Ext _
Sign ilotors
Grounding
111sc. Temp. Power _
Other
FINAL. INSPECTIONS Not Approved _
Date Insp.
Flectri-c PLUMBING
Fl.e � Date- Insp.
Piu ,mbinBackflow _ _
llechanical Underground -30
Solar f / �3' —
Pool Underfloor
Partial. Rough
Gradin, Rough Complete
Planninp Solar Rough _
Fire Dept. Water & insulation _
Ilealth Dept. "lain Drain
Building R/of/S Drain
Other Gas
Other _
BUILDING Not Approved
Date Insp.
1'ad Certification MECHANICAL
Foundati.on —
Date Lnsp.
Pre-Gunite Underfloor S.M.
S]-ah-Ilemhrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders _ Fireplace
Floor Steel Grease Duct & flood
Tiedowns One flour Shaft
Di_aphrams Condensate Drain _
Seismic Bracing
Equipment Anchorage _
Ilalls-Panels Flues & Comb. Air
_Frame Other
Lnth tJot Approved
Uallboards Int/lixt .
Firewalls
Other
OPNot Approved