C 6328APPLICANT TO FILL IN INFORMATION WIT4N, RkD LINES -USE BALL POINT PEN ONLY
'
BUILD,(NIG PROJECT IDE TI F1c
hPPLICATION & PERW
BUILDIN '-'ELECTRICAL- PLUMBING - MECHANIC L
. PERMITNUMBER
6328
FMOII;RE55 r �� s�i�d
N/ G6
NgMERsp y¢
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PMONE� O
At ..
�OECT
T��Y. ERIh C,PERMIT �kr a FEES,,
PLAN CHECK VALIDATION
'-Iro v1
T
DATE OF APPLICATION
NANrRgcraRs
NOME //////
`2. COK %R LT/ - .No,7•( 0q 9 ..
Q OUTLETS-SWITCHES-RECEP 500/100 110
LIGHTING FIXTURES 5.00/1.00
ADDRRgS '5 J CIS _
-/.IS-
ADDRESS 11 , 1 PHONE`�',
V
PPLIANCES -RESIDENTIAL 4.00
PANELS 5.00 '-
ORRCHITEC l d6 \ ;IF / •' r 1/f K,�1 7
ENGINEER f , t�FJ � ? �•t L•/lA E /(17
LIC N Z &4 L
!,. 1GNS 6.00
.✓
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG.
ADDRESS �//
I I^w 7 o �4nLaJ�L-/CP
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
/\\��\f�j4 `'
yJ�
EMP. METER OR POLE INS. 15.00 ,�
AUDRCA V CA -01 7
A.D.Eal LI 9 `' �JwpL
142 b .Ant fol tj b �
MOTORS SEE •�
SERVICE CHANGE
LICENSED CONTRACTORS DECLARATION
I
'x
1 hereby affirm thal.l am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod nd my license is in full fo a sd IT
License Class Lic. Number
-MAR 1 V `/
ISS ANCE DATE
BLD EL��Tff PLG. MECH.
„`.�, O
/�`
-
ate Contractor
OWNER -BUILDER DECLARATION
� '
-'
MJIT
._ p -
MISC. - REFER TO ORD
I hereby affirm that 1 am exempt from the Contractor's License
Law for the following mason. (Sec. 7031.5, Businessand Professions
Code: Any city or county whichrequiresa permit to construe(, alter,
improve, demolish, or repair any structure, prior to its issuance, also requires
requires the applicant for such permit to filo a signed statement that
hm
e is licensed pursuant the provisions of the Contractor's License
Law (Chapter 9 (Commencing with Section 7000) of Division 3 of um
Business and Professions Code) or (hat he is exempt therefrom and
VALUATION S/FT.
'
PERMIT ISSUANCEr
6'�
CONTR. - LIC. NO. .'
_
ELEC.
TOTAL
PERM IT TO
S/N GE ITT O L
we-(-( %�
_
STV. PLUMBING PERMIT FEE':
the basis fot the alleged exemption. Any violation of Section 7031.5STORIES
'ALTER-DRAIN&VENT•WATER
TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
/y-
(EA.)4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is nut
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for Sale. If, however, the building
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
SD. FT. FLOOR AREA
RES. UNITS
TOTAL ACREAGE
�` DRAINS -FLOOR, ROOF, AREA, COND. 4.00
/ FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM -1INC. 40UTLETS 4.00
or improvement is sold within one year of completion, the owner,
builder will have the burden of proving that he dirt not build or im-
prove for purpose of Sale.).
1, as owner of the property, am exclusively contracting with
- .
GAS EASYSTEM -OVER 4 (TL 1.00
-
BUILDING USE
REB IRO CON PB Omar
❑ E] ❑ 1:10
INDUSTRIAL WASTE INTER.' 20.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon, and who
- LAWN SPRINKLERS= 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - .5 (EA.) 1.00
gSSES50R0 PAfl CEL NO.
contracts for such projects with a conlractons) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 2001t/8.00
TRACT NO..
' PARCELNO.
❑ l am exempt under Sec. ,B.&PEC. for this
reason
ACC. DATE
ACC: FILE. NO,
WATER HEATE. / ENT4 JOJ 4.00
Owner Dale
WATER SYSTEM 4.00
WORK Ii RS'COMPENSA'I ION DECLARATION
WATER TREATIpWTt&I1;PP0r1IrIU 4.00
I hereby affirm that I have a certificate ofomsem toself-insure,
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE N0.
copy them.
ha coJ$ey. �AI[-)
Policy }s 1-1-7
,
MISC. -��+ REFER TO ORD.
FIRESPRINK
Y❑ N❑
ENERGY T$4
Y N❑
I] Car(if ieit copy is hereby famish Cd.
��( Certi coy N filed with the city -.inspection division.
Applicam�-� r....�-yL•xLd'7 ax.�
' CERTIFICATE OF EXEMPTION PROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A. L.I.C.
COMPENSATION INSURANCE
('Ps se
hiction need not he completed if the permit is for one
Y ❑ N❑
Y ❑ N❑
PLG. CONTR. LIC. NO.PLG.
TOTAL /
hundred dollars($100)or less.)
I certify that in the performance of the work for which this per-
mit is issued, 1 shall not employ any person in any manner so as to
STV. MECHANICAL PERMIT .. _ k,FEE.
FE -.
1`E�SUMMARY
.g
G(p
become subject to the Workers Compensation Laws of California.
Datc - ApplicantBUILDING
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT:•If, after making this Certificate of Ex.
ensption, you should become subject to the Workers' Compensation
provisions of the labor Code, you mus( forthwith comply with
m
such provisions or this permit Shall be deemed revoked.
APPLIANCE' 4.00
PLAN CHECK
FEE
'
AIR HANDLING UNIT (T O)1 O91M IOM 3.00
T
CONSTRUCTION LENDING AGENCY -
AIR HANDLING UNIT(OVER 10p00C.F.M.) 5.00
SEISMIC FEE
I hereby affirm9hat there is a construction lending agency for
EXHAUST HOOD 1 H U TIyIj J' 2.00 eZ
- -
VN
the performance of the work for which this permit is. issued (Sec.
3097, Civ.C.). _
Lender's Name s, / n�
MICROFILM
t
HEATING UNIT ( .M2, 4.00 i
HEATING UNIT IO pgJ7.50
ELECTRIC
•'
Lender's Address F'
VENTILATION FAN ( INGLE) 3.00
I Certify that I have read thisapplicatioealf�i *Aft• a above
information is correct. I agree to comply with all city and county.
ordinances and state laws relating m building construction, and
PLUMBING'
BOILER-CONtP (3 H.P.Or 100,000 B.TU.I 4.00
BOILER -COMP Ove, 100,1X)0 BTU) SEE FEE SCH.
MECHANICAL
✓
hereby authorize representatives this city to enter upon the
above-mentioned property farr inspection purposes.
ns
MISC. - REFER TO ORD.
(WE) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which erm
may in waagainst said y accrue againxaiJ Gity in consequence of the
gra lin if this p't '.
/ g �l
CONST. TAX
po
PERMIT ISSUANCE 3.00 ��'
MECH. CONT. LIC. NO.
MECH,
TOTAL (i'Vj
/� ✓
pj.� h bar
'IeflaT`OTA`L
iL { La'4 ri; x r
�2S
/
Signalure of pp icanl/Contmclor Ua c
OFFICE COPY
'0
IqF
CITOF CUPERTINO IASPECTION RECORD •
(OFFICE COPY)
PRCUECI
Power
Gas
BUILDING DATE INSP:
Pad Certification
oum ation� , 4, i.
Am ZZ �WMIAA
�.
S.
G
ELECTRICAL DATE JINSP.
PLUD�o DATE I MISP.
u
Not Approved
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AM
ELECTRICAL
PLUMBING
MECHANICAL
MCELLANEOUs
FINAL GRADE
OUT�t E SLIP
File No.
Datej/
Location
Subject
Notes FOAM4- &KAO
FYJS
Approved _ yl3/L'e�`
Date ° nspector
a
CIT )F CUPERTINO IASPECTION RECORD
(OFFICE Copy-)
_2
ADDRESS LUI NU
pl=
OWNER
PLUMBING DATE I ITNISP.
,BUILDING DATE I INS -P. Not Approved
Pad Certification
S. M.
R -et App-r—oved 7-
'C.-�A
9-1
DATE INSP.
4L -j4
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