6571 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMITNUMBER
So
An= "04-00 V q; APPLICATION'& PERMIT ^
/G�u�]PEW NQp CA- � �/� BUILDING q ELECTRICAL-PLUMBING-MECHANICAL b
inLNANERS V/\ NENo - curve /I�x/ "6 kF. :'?"el �1iSy''..� } _: PLAN CHECKV LIDATION
r "'-EL'ECTRIC(P.ERMITq :xis s�A) F�EE� �`) _L_yA/)
/ PHON y4/•/•�
NAME"AcroRs RwPO,cp/ bL -cLzrrEN1 lnr, UTLETS-SWITCHES-RECEP 5.00/1.00 30d
uc.No, LIGHTING FIXTURES 5.00/1.00
CONTRACTORSADDRESS 102^3a dTlERrui.I RORG APPLIANCES RESIDENTIAL 4.00 -
• Air VIEW CA- M¢Z.'. PITON V PANELS 6.00 DATE OF APPLICATION
ARCNIT[CT. V.Co. WONG `: SIGNS -1 6.00 PLAN CHECK FEE .P.C.NO.
OP p�/y�
ENGINEER gLyJW�f4•T�s'�ING• - ,
uc.rvo. SIGNS'TRANS. 3.00
ARCH.OR ENG. PERMIT VALIDATION
ADDRESSCAAJIOI� VE• SPECIAL'CIflCUIT 5.00
avP FEMP.METER OR POLE INS. 15.0 ,
APPLICANT'S X90/ 60A�VN r' MOTORS. - - SEE FEE SCH.
aooREss
u,¢, S" dAPqq, , WS SERVICE CHANGE '10.00
N 0/
F o o LICENSED CONTRACTORS DECLARATION
a U u I herchy affirm Iia( I am licensed underproviiionsuf Chap(er9 ISSUANCE DATE
N<"' (commencing with Section 7000)of Division 3 of the Business and BLDG �L�CT� PLG. MECH.
H D z Professions Cossds��,and my license is in full fort 'ffrYl. ❑ p1n ❑ ❑
0 o m License Cf�s_IS Lia Number (JfO /•�!y/
2 Dam_ G 8 Contractor
< Y s SIe p'1(±� ILD( "MIT
It a m u OWNER-BUILDER DECLARATION AU 47 lFD IDN,
wDa - - MISC.- 1 REFER TO ORD `
; N 1 hereby ullinn liar I am exempt from the Contractor's License
F u o j Law for the following reason.(Sec.7031:5,Business and Professions PERMIT ISSUANCE 6.00 VALUATION - $/FT.
,ate Coda Any6tyorcounty which requires a permit to construct,alter, 8j}UP11f.r>1111Gr6(IQ
ECQ ¢ p Improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONT". LIC.NO. ELEC. l•Y�'/W"'
y w m u requires the applicant for such permit to file a signed statement that TOTAL PERMIT
he is licensed pursuant to the provisions of the Contractor's License Q
Law(Chapter 9(commencingwith Section 7000)of Division 3 of(he +. V E'�(•� GJ��iLN
g i a Business and Professions Code)or that he is exempt therefrom and OTY. , PLUMBING PERMIT FEE
¢f m the basis for the alleged exemption.Any violation of Section7031.5 STORIES TYPE CONSTR.
a-T by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN&VENT-WATER (EA.) /
of not marc than five bombed dollars($500)): .L az �V
Cl I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND- 4.00 _
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves(hereon.and who does such work F IXTUR ES-PER TRAP 4.00 SO,FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- �-• y
mems um not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
a'
improvement is sold within one year of completion,the owner
builder will have the burden of proving that he did not build or im-GAS-EA.SYSTEM-OVER 4(EA.) 1,00 BUILDING USE
RES IND CON PS Other
Prove 11. purpose ofsale pr6pur INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the properly,be exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to The
the project(Sec. 7044,Business LAWN SPR_ IN KLEfl$-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
" and Professions COTIL:property
The Contractor's!improv Law dues not apply 316
to as cts for
of property who builds improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts far such erne L with a contracto[(sl licensed pursuant to
the Contractor's License Law.". -+.. SEWER-SANITARY-STORM EA.200ft/6.00 , TRACT NO. PARCEL No.
❑ lmnexemptunder Sec. ;B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
.1 hereby affirm that I have a certificate of consent to seti-inshm, ZONING
• ar h certificate of Workers Compenmlion Insu,.0 ,,mcerti ed ENG.SITE NO.
copy thereof(Sec.3800,Lab.C. iAtIK�'
Policy No. Company.
0 Certified copy is here. furmhed,4C FIRESPRINK ENERGY T74
Z .� Certif co i fit with (hk cit in pec ion vision.
MISC.- REFER TO ORD.
O APPhcunt_I_WJs Y❑ N❑ Y ❑ N❑
~ w ~/'- PERMIT ISSUANCE 6.00
LU -
CERTIFICATE COMPENSATION
PTINS FROM WORKERS' - FLOOD ZONE A.L.u.C.
W > COMPENSATION INSURANCE: PLG.CONT". LIC.NO. . PLG.
Q. D (11ns section need not he completed if the permit rs for oil TOTAL Y❑ N Y❑ N❑
D Z hundred dollars IS 100)or less.) ° l
ION
L) O I certify that ten tie Crformance'of the work far which this per § ?? hT SMI
P k �. "'FEEISUMMARN
QTY. x MECHANICAL PERMIT FEE
LL F Intel Is issued, I shall not employ any Person in anY hnanner sn as to 1,x , *"
0 W become subject to the Workers'Compensation Laws ofCalifornia. p
C.
W Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING / an
} N NOTICE"f0 APPLICANT: If,after making this Certificate of Ex.
F. entption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLANCHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000CF.M.) 3.00
CONSTRUCr'IONLENDING AGENCY AIR HANDLING UNIT(OVER 10p00C.EM.) 5.00 SEISMIC FEE •�66
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,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name - HEATING UNIT(OV ER 100,000 B.T.U.P.50
Lender's Address ELECTRIC
I certify that 1 have read this application and state that the above VENTILATION FAN (SINGLET 3.00
information 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
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above:-mentioned properly for inspection purposes. • _
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, cosls,and expenses which r. CONST.TAX
coy any way ac a against MW City in consequence of the PERMIT ISSUANCE 3.00
pm n oft 's mit MECH.CONT. LIC,NO, MECH,
8l0
TOTAL TOTAL g9 f
Signature ol ApplicantfContractor Fulm
OFFICECOPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
fov�� 1 -�iD��UI
D . , do
r
• ADDRE6b LOT NO. (: r7 a
sh �
---
PERMIT ISSUED
DATE ELECT MDATESP.'
ui. in
e Prica
I'lurrbing Power Pole
Mcnanical, UnLr un .
,emp as ec balls firing . - 3 '7,FT-
Solar
ooh ar
Fire Sprinkler ei in
bign Fixtures Int/Ext
otors
Misc. rounding
e ower
Uther
FINAL INSPECTIONS DATE INSP, Not : rove
Gas
ectric _
canal -9- PLUMBING DATE INSP.
o ar Backflow
�o r un
r� j
ra ing underfloor
Planning Partial Rough _
Fire
Dept.-O- mlz rc� Rough omp eT to
ea ti ept. polar ou
Fuuil3ing _�-�;- Water *4 ns atia
Other Main Drain
o o Main(
✓� -wJv � • as n
to
BUILDING DATE INSP, Not Approvea -
W,,IrS AP
Pad Certification °
oun anon aP i E CTRICAL DATE INSP.
re- rte ® �r (/,o�
a - m rane Uriderfloor S.M.
Bond emncts nsu atio
Undertloor Uirders . ire ampers
Floor tee ' Fire lace
leis Grease Duct 4 Hood
is rams G e ramie(fourShaft
b&a6V0eN!rMNng Condensate Drain
WFffs- ane s E Mte
nt An ora e
rame 3- Gon : r
,ddjikat
OH
s Int/Ext. of rove _
irew-11 a . s
Other
Not Approved
BUILDING c
O
Sb.0 yµ,e W ud, crW.t. el e �yro�jp 6+W,t-T fit. GTU
L h. �fC` 2V.a'f C%i(+4 [G
cL IN11 . . . .
sYu1e to, s.d� bb�vd y a6 VC ewrt� a (J
2 �8 �a t est 7 ud
71Z�1� i�ydYac d 'e
rCVp., %Ar d S,/����- E�CTR�ICAL-
PLUMBING
ol CwL
f2 w P 1,��71 tf ,
DEMMICAL
Lat rL�
D'QSCELLANEOUS