5649 :INT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'R vmR 1tlUl LDING PROJECT IDEN%III
CATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT 5649
ADDd5o
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER - - - PLAtE�II(Y&LIDATION
�• NAME QTY. ELECTRIC PERMIT FEE r/'IL,u
1 `,O PE pp
CONTRACTORSUTLETS-SWITCHES-RECEP 5.00/1.00 JUL 13 19V4
e�uNAME
, 7 LIGHTING FIXTURES 5.00/1.00
11 �/ O,
CONTR TORSPPLIANCES-RESIDENTIAL 4.00 City of Cupertino
Eve4yi Ave ADOnfSa
E - QO PANELS 5.00 DATE OF APPLICATION
ARCHITECTS' AjkQ IG Gs M-(f / SIGNS 6.00 PLAN CHECK FEE P.0 NO.
OP V
ENGINEER3.D0
LIC. o. SIGNS TRANS.
ARCH,OR ENG, 5.00
PERMIT VALIDATION,
ADDRfssSPECIAL CIRCUIT
ZIv EMP.METER OR POLE INS. 15.00
APPLICANT'SMOTORS SEE FEE SCH.
ADDRESSay I/ SERVICE CHANGE /n+ 10.00 4l6 e-o D LICENSED CONTRACTORS DARATION �OI hereby afGru that I am licensed undvisions Of Cliapl cr 9 Q Ori ISSUANCE DAv, Qy (commencing with Section 7000)Of Divi3 of the Busine55 and BLDG. ELECT. LG. MECH.
Protessions Code,and my license is in full •rot f c£'try-7 0 ,- License Cls Lic.Nmnbzw DatC' �$/Z-_Cotruwor ` .!_-ii.r3_-
Y ` t/ec a�tG BUILDING ERMITAOWNER-BUILDER DECLTION INFORM TION
oA MISC.- REFER TO ORD
X
3 u y 1 hereby affair,that I :un exempt from, the Contractor's License VALUATION $/FT.
F .. 0 a Law for the following reason.(Sec.703 L5,Business and Professions ,PERMIT ISSUANCE 6.00 .QQ
Code:Any city or county which requires a Permit to construct alter,
u,a p improve,demolish,or repair any structure,prior 10 its issuance,also ^EL�E.C.CONTR. LIC.NO. ELEC.
O ¢ requires lire applicant for such permit to file a signed statement that �x Txp �Ptf�'1e 7" TOTAL rOQ ERMIT TO
e w m u he is licensed pursuant to the provisions of the Contractor's License xr
ria Law(Chapter 9(comnencing with Section 7000)of Division 3 ofthe
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
T the basis for the alleged exemption.Any violation of Section 703 L5 STD IES /Y E CONSTR.
La T byany'applicantforapermit subjeotr Gmapplicanl toacivilpcnalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(5500).):
❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES,UNITS
their sole compensation,will an the work,and the 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 docs not apply t0 an owner of
I 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-
mentsare Hot intended oroffered for sale.ll',however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of Completion,the owner. GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE
builder will have the burden of proving that he did not build or an. . . .
RES IND N PB Otue.
prove for purpose of sale.). INOUSTRIALWASTE INTER. 20.00 El El13 ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to cored ruel the project(Sec, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSOR PAHCELNO.
and Professions Code:The Contractors License Law does not applyto an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a conlraetons)licensed pursuant In
the Contmdor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sri.-,B&P.C.for this WATER HEATER W/VENT 4.00
ecavm
Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'CONIPENSATION DI'CLARATION WATER TREATING EQUIP. 4.00
I hereby ulllnn that I have a certuicale(31 consent to sellains rc. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy OereRt c.380
110 b1,
.yC-.l2V/r Lt:£
Q ❑
-
Certified copy is hereby furnished FIRE SPRINK ENERGY T 24
Z Z `IZ_ :nv Certified copy is tiled with the city inspection division.
nphcMISC.- REFER TO ORD. Y F] N[3Y [:] N❑
O
CC CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU >_ COMPFNSATION INSURANCE PLG.CONTR, ❑C.NO. PLG.
CIL 0 (Thin section need not be completed if the permit is for one 1TOTAL Y❑ N[3Y❑ N❑
0 Z hundred dollafs(SIOO)or less,)
U O 1 ceHiry tied in G,c performance of the work for winch this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P mit is issued.I shall not employ any person in any manner In as to
Uw beeURIC subject to the Workers'Compensation Laws Of California. BUILDING
ELDatc Appueant ALTER OR ADD TO MECH. 4.00
} to NOTICE TO APPLICANT': If,after making this Certificate Of IN-
F Z_ Cutption,you should become object 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 slmll he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,O00GFM.)'5.00 SEISMIC FEE
1 hereby atl'irm that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work I'or which this permit is issued(Sia MICROFILM
3097,Civ.0.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address r
i I certify that l have read this application and state that lire above VENTILATION FAN (SINGLE) 3A0
infonndion is correct I agree to comply with all city andcounty PLUMBING
Ordinances and state lows relating to building construction, and BOILER-COMPI3 H.P.Cr 100,000 B.T.U,) 4.00
hereby authorize representatives Of ties city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL
above mentioned property for inspection purposes.
(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
'pg any way accrue against said City in consequence of the
'hnpermit MECH.CONT. LIC.NO. MECH.TOTALTOTAL 10rc of ApplicantjC n[md r Date/
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICES COPY)
PERMIT NO. AW)FESS
Alwonkp'G -15 11— Ric oc� Y
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
F- i'Td n��
ectrl
Plumbing Power Pole '
anica r un
e as ec uwing
bolar halls
Fire. prin c ereZ i in
Sign 1=res int/Ext
otors
Misc. Grounding
Other Otear
FINAL INSPECTIONS DATE INSP. Not .Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
�fe-�aziica�
.,o ar Backflow
'oo r un
Urading oor
Planning artaRough
Fire lei— u i ete
He t. oar u
_ in ater ' Insulation
Other in aui
775779-Main
Gas
Other
BUILDING DATE INSP. Not rove
Pad Certification
7o—un—Ta—tion ELECTRICAL DATE INSP.
re- unF to
Slab-Membrane Underfloor S.M.
Som DYcts nsu ation
Undertloor Girders Fire Damperg
Floor Steel _Fireplace
Tied-owns reuse Duct 6 Hood
is rams One Hour Shaft
eismec racin Condensate a3.n
a s- ane s ui ment Anchorage
Frame y ues oMb. Air
.I:ath Other
Ei lboards Int/Zxt. of Approved
�ftrewalls
Other
Ret Approved