1054 ,nPPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALI. POINT PEN ONLY
BU I LDING PROJECT I DENTIF I CATION PER IT ER
OULDING APPLICATION & PERMIT . 1054
ADDRESS
BUILDING—ELECTRICAL-PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
��JJ`� q CITY. ELECTRIC PERMIT FEE
LG./LL on rc PHDNE/!P'U—''G/
CONTRACTOR / •��3/by
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
Z,-1 /A,e—rycr C - LIGHTING FIXTURES 5.00/1.00
CONTRACTORS E �'/^r�` APPLIANCES-RESIDENTIAL 4.00 .I
/x&2:,2 4;-7pACG •PHONE ,7/f/-e3c,5p PANELS - -5.00 - ` DATE OF APPLICATION
ARRCHITECT SIGNS 6.QQ PLAN CHECK FEE P.C.NO.
ENGINEER
LSI Ch �06111V uc.ND. SIGNST c 3.00
A.PCH OR DDRESS ENG, SPEDIA GIRGUI C S.QQ PERMIT VALIDATION
LDS G/}kd z SG a EMP.M R POLE I 15.00
APPLICANT'S `(
ADDRESS MOTORS SEE FEE SCR. '
J-e,a?f, 41 //t< (( _lsm- y' SERVICE GE 10.00
In
00 LICENSED CON'T'RACTORS DECLARATION
o re
�/
a I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
Hw (commencing with Section 7000)of Division 3 al'Ihe Business and
may BLDG. ELECT. PLG. MECH.
r N z Professlons Codupapd my license is in full force and effect. 11El ❑
oC H License .loss Li,.NumbqJ - -
r m H j Date Contractmr. "v/ r.�.
a m s BUILDING PERMIT
¢ ¢ a OWNER-BUILDER DECLARATION
a a vINFORMATION ,
wg w I hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
H u_o a Law for the following reason.(Sec.7031.5,Rusinessand Professions PERMIT ISSUANCE 6.00
VALUATION• $/FT.
mj Code:Anycity or county which requiresa permit loconstR¢t.alter,
� QaO improve,demolish,or repair any structure,prior to its issuance,also ELEO.CONTR. LIG NQ ELEC. ��•
O'c be is E"1,a applicant for such permit t0 file a signed statement that TOTAL /—'w PERMIT TO
a w $m he is licensed 9(commencing
en the provisions of the Contractor's License -
H Z 4 Business
(Chapterand
Professions
Code)Th Section 7s 00)exempt
therefrom
the
and
a Business end Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
f i D
¢ r $ the any
basis pli the cora exemption.cube Any alitilica of Se ction703L5 STORIES TYPE CONSTR.
a3 � by any applicant fora permit subjects the t,1acivil penalty - ALTER-DRAIN of mol tnom than five hundred dollen(55001.1'. `
0 I,as owner of the property,or my call with wages as BACK FLOW PROTECT, DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and IIm 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 an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTAL ACREAGE
himself re of rote his own employees,provided that such improve
ments mselfo through
or offered employees,
or provided that such
emprovg GAS-EA.SYSTEM-11NC.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 im-
provefor purpose ofsale.). INDUSTRIALWASTE.INTER. 20.00 RES IND CON PS Omer
❑ 1,as owner of the property,am exclusively'contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec. 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
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a conlractons)licensed pursuant to
the Nnranar's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
,DI am esempt under Sec. .B.&P.C.for this
1.x1,11, WATER HEATER W/VENT 4.00
Date owner WATER SYSTEM - 4.00 ACC.DATE ACC.FILE No,
WORKERS'COMPENSATION DECLARATION - WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate ofconsent to self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certifjed
copy thereof(See,3800,Lab.C�IJ
Policy No. Company^
❑ Certlfi¢d COpy�shereby f�r�furp 151 �� FIRE$PRINK ENERGY T24
_Z Z ❑ C�rti(�'u'b��p y is fled �ul�t the fly inspection division.
O APP4( r ;ky I MISC.- REFER TO ORD. Y ❑ N❑ v ❑ N❑
= N CERTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.uL.
DJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLG.
M. 2P
( his section need not be completed if The permit is for one TOTAL Y[:] N❑ Y [3NEIN
hundred dollars($100)or Tess.)
U O 1 certify that in the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE - FEE SUMMARY
LL
F. out is issued,I shall not employ any person in any manner so as to
O U become subject to the Workers'Compensation Laws of California.
y Datc Applicant BUILDING
>_ N NOTICE TO APPLICANT: If,after making(his Certificate of Ex- ALTER OR ADD TO MECH. 4.00
(_ Z emption,you should become subject to The Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with - FEE
U such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 3.00 -
CONSTRUETIONLENDINGAGENCY AIR HANDLING UNIT IOVER 10=1C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which This permit is issued(Sec. MICROFILM
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify That 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
hit ornmUnit is correct. I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordintinccs and state laws 'relating to building construction, and
hereby authorize representatives h of this city to enter upon the
ahovaan authored property for inspection purposes,
BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of-the
grantingo This permit ( MECH.CONT. LIC.NO. - MECH. �T
�^ /y-ai _ TOTAL TOTAL
ofinature GO A p Tcan ontractor Dae
OFFICE COPY
CITY 017 CUPE.RTINO INSPYGTION RECORD (Office Copy)
1054 _ Rainbow's End Lot 3
11I1P31IT NO. SANITARY DIS'r. N0. LOT NO. ADDRESS
Retaining Wall Larry Willard 774-0303
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Bu_Lldi.nr Date Insp.
Electrical Power Pole
Plumb Ing Underground
ifechnnical Rough Wiring _
Ten). Cas/I;lcct. 11 alis
Solar Ceiling
Fire S rinkler Fixtures Int/Ext
Sign Hotors
Grounding
Hisc. Temp. Power
Other
FINAL. INSPECTIONS Not Approved
Date Insp.
"s PLUMBING
Electric Date Insp.
Plumb in . Backflow _
Mechanical Underground
Solar Underfloor
Pon.l Partial Rough
C,rading Rough Complete
• 1'lannin Solar Rough
Fire Dept. Water & Insulation _
Health Dept. 'fain Drain
Buildin R/of/S Drain
Other Gas
Other _
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Ilembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One (lour Shaft
Diaphrams Condensate Drain
Seismic Bracing; Equipment Anchorage
1lalls-Panels flues & Comb. Air
Frame Other `
lath Not Approved
Uallboards Int/Ext.
Firewalls
Other
Not Approved