5762t
%ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
11 BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
L
PERMIT NUMBER
5762 ^
BUILDING
ADDRESS
OWNERS
NAPE G)/
CrQ0 P_ Li O v-�s o� .,NE
aTy. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
N
I\
CONTRACTOR '$I
NAM
UTLETS-SWITCHES-RECEP 5.00/1.00
� �. _JC. No. 117 41,
C J
onrE OF APPLICATION
LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
)0 ;V LQJ.,U (-. h• PHorv€
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
ARCRITECT
OR
ENGINEEn - C'��. �� �4--7
1 c�T1N LIc. o.
SIGNS 6.80
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG. 3Q
ADDRESS /
SPECIAL CIRCUIT 6,00
PERMIT VALIDATION
EMP. METER -OR POLE INS. 15.00
ADDRESSTµ'iE12$IL�ISkC.
11S
MOTORS SEE FEE SCH.(;
SERVICE CHANGE 10.00
LICENSED CON "TRACTORS DECLARATION
I hereby anion that I am licensed under provisions of Chapter 9
(cophmencing with Section 7000) of Division 3 of the Business and
ISSOANCE DATE
BLDG.
ELECT.,
PLG. MECH.
Professions Code, and my license is in full furce and effect,
License Class Lie. Numb
DateContractor
r! WNIi R -BUILDER DECLARATION 1'����:
1 hereby al Tum That I am exempt from the Contractor's License
Law 1'or the following reason. (Sue. 7031.5, Businessand Professions
Code Any city or county which re, irestipermit to Construct. alter,G
'n,ow,, demolish, or repair any m melure, prior to. its issuance, also
requires the applicant for such permit In file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 tit thet
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation to Section 7031.5
by any applicant for a permit subjects Ute applicant oa civil penalty
of not more Dorn five hundred dollars (5500),)'
❑
❑
❑ El
BUILDINGPERMIT
INFORMATION,
MISC.- REFER TO ORD
anON S/FT.
O (,S
MIT TO
.Q �ed
(- aV TYPE CONSTTR.
PERMIT ISSUANCE 6.00
ELEC. CENTS. LIC. NO.
ELEC. c r
TOTAL xJ C
QTY. PLUMBING PERMIT "tit6
bb I
ALTER-DRAIN&VENT-WATER(EA.)4.00
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
❑ role
owner of the property, or my employees with wages as
their salecnmpensution, will do the work, and the structure a not
intended or offered for sale (Sec. 7044, Business and Professions
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
Codee.'fhu Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work
himself or through his own mnpinyecs, provided that such improve -
meats are not intended or offered for sale. If, however, We budding
FIXTURES - PER TRAP 4.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
GAS-EA.SYSTEM-I1NC.4OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the. burden of proving that he did not build Or int-
prove for purpose of sale.).
ED 1, as Owner of ole properly, ten exclusively contracting With
licensed contractors to construct the project (Sec. 7044, Business
GAS - EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES IND CON PR Omer
INDUSTRIAL WASTE INTER. 20.00❑
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
and I'rol'essions 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 lot such projects with x contractor(s) Incensed mr,uant LLh
the Contractor's License Uw.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
❑ I and exempt under Sec... B.&P.C. for this
reason
Owner Date
WATER SYSTEM 4.00
AGC. DATE
ACC, FILE No.
WORKERS'COMPENSAI' ION DECLARATION
WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate ofeoment to sell -insure.
or it cerlificule tit Workers"' Compennution Insurance, or a certified
ZONING
ENG. SITE NO.
ropy thereof (Sec. 3800 Lab oy:.). " f' r, /r
Policy Nn. Company- lr
❑ Cctlilied Copy is re
ed
❑ Certified Is fie With the et(y inspection division.
Applicant_ J
''/
T
V FIRE SPRINK
E]N
ENERGY T 2
V [3N ❑
MISC.- REFER TO ORD.
PERMIT ISSUANCE 6.00
FLOOD ZONE
Y❑ N❑
A.Lu.C.
Y❑ NE]
CER'I'IFI Irl, F A iMPI O FROMWO
COMPENSATION INSURANCE
ecctlum need not be btmhpleted if the permit is for one
PLG. CONTH. LIC. NO.PLG.
TOTAL
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY. '
hundred dollars(E100) or 1cASJ
I certify that in the performance of the work for whiclh this per.
mit is issued, I shall not employ any person in any manner so as to
hccomC sunject to the workers'Compersalion Laws of California.
Date Applicant
BUILDING
/yC1-s3
ALTER OR ADD TO MECH. 4.00
NO] ICE "1'O APPLICANT: 11, ufmr making this Certificate of V.-
eruption, you should become subject to the Workers' Cmnp metiun
provisions of the Labor Code, you most forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 4.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,00D C.F.M.) 3.00
AIR HANDLING UNIT(OVER IOXMC.F.M.)5.00
SEISMIC FEE
oz/0
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.1.
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATING UNIT (OVER.1 00,000 B.T.U.)7.50
ELECTRIC
Lender's Name
Lender Address
I certify that I have read this application and State that the above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
BOILER-COMP(3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over tINl U00 BTU) SEE FEE SCH.
MECHANICAL
hereby aulhorue representatives of this city to enter upon the
uhove-mentioned property for inspection purposes.
(We) agree to save, indemnity and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
nmy in any way Beer g' st .s.''1yy'1�� Cit in CO quence of, the
gramtin of lh nhl.��/%) (Q
/ .. ✓✓✓
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH.CONT. LIC. NO.
MECH.
TOTAL
TOTAL
,
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Signatureuf Applicant/ onlrvctor Date- r
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
Gas
FINAL INSPECTIONS DATE I INSP.
N
C°
B LD IN DATE I INS, P.
Pad Certification
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ELECTRICAL DATE
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INSP.
PLUMBING DATE I INSP.
DATE
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INSP.
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