3280 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI- POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION y P RMIT NUMBER
BUIDBLDING APPLICATION & PERMIT 0 O
ADRESS L•AC�'r.t cY
UILDING - ELECTRICAL-PLUMBING-MECHANICA 0
OWNER'S PLAN CHECK VALIDATION
ELECTRIC PERMIT FEE
5 1� DNE V
CONTRA ORS
NAME OUTLETS-SWITCHES-RECEP5.00/1.00
LIC,No, - LIGHTING FIXTURES 5.00/1.00 PAID
CONTRACTORS
DREAcroRs APPLIANCES-RESIDENTIAL 4.00
OQ(]AA^^ll
PHONE PANELS 5.00 MPP E PI MNJN
ARCHITECT SIGNS 6.00 P ECK FEE P.C.NO.
OR
ENGINEERu -
c.NO. SIGNS TRANS. 3.00 f Cu a 00
nooaess ENG. SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP. METER OR POLE INS. 15.00
APPLICANT'S MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 10.00
0 0 o LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
hz ce (commencing with Section 7000)of Division 3 of the Business and
¢ BLDG. ELECT. PLG. MECH.
D z Professions Code,and my license is in full force and effect. ❑ El 11 E]i 2 o License Class Lic.Nunther
m H w Dine Contruct
P: or m s - BUILDING PERMIT
¢ S w a mnOWNER-BUILDER
it,R-N UILDER DECLARATION
D a v INFORMATION
w g a- r I hereby affirm tlwl I ant exempt 31.5 the Contractor's License MISC.- REFER TO ORD
✓4Law VALUATION SIFT.
Fu0 ¢ Code:Any citylowingreason.(Sen. uiroa,Busin Business PERMIT ISSUANCE 6.00
2 Code:Any mulish coo rty epair any structure,
prior
it o its ns eniCt, me ,p^,
tr E ¢m improve,demolish,or repair an shucture,prior to its issuance,also ELEC.CONTR. LIC.NO. s(✓V Zr0
o P P y ELEC. VVV
i w m le¢ requires ilicensed
ne.dp pursuant
for such permit to file a signed statement that TOTAL PERMIT TO
he is licensed pursuanten the pubs Section
of the Contractor's License the
5 E i Law(Chapter 9(cammencingwithSection7000)ofDivision 3ofthe
4 o
Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
CE r m the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permltsubjects theapplicunt toaclvil penally ALTER-DRAIN -WATER IEA.( 4.DD
or hot more Than five hundred dollars($500).):
❑ I,as owner of the property,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 (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
property who builds Or improves thereon,and who does Such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees,provided that such improve-
ments arenot inghhisornffichel foremploy'ee sale.provided
that sthebuilding GAS-EA.SYSTEM-11BIC.4OUTLETS 4,00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM OVER 4 IEA (
builder will have the burden of proving that he did not build or im - . - .
1.00 BUILDING USE
RES IND CON PB Other
pave fors owner orf the
)' INDUSTRIAL WASTE INTER. 20.00 0 ❑ 0 ❑
❑ 1,as owner of the property,um exclusively contracting with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESS RS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.)' 1.00 3
contracts far such projects with a contmetonO licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT N . P RCEL NO.
❑ lam exempt under Sec. ,B.&P.C.far Ibis WATER HEATERW/VENT 4.00
reason _
Date- Owner_ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
rc)�kE S'c MPE ,ALN 11:CI.ARATION WATER TREATING EQUIP. 4.00
1 hereby of firm that I have a certificate of consent to self-insure.
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
ropy thereof(Sec.3800,I.ab.C.).
Policy No. Company
0 ❑ Certified copy is hereby furnished.
Z 0 Applicant❑ ted copy is Bled with the city inspection division. FIRESPRINK ENERGY T 24
MISC.- REFER TO ORD. v ❑ N Y No
~ rn- PERMIT ISSUANCE 6.00 ❑ ❑
-
CER'I'I FICA If:01'EXEMPI]ON FROM WORKERS' ZONE A.L.O,C.
LL COMPFNSWION INSURANCE! PLC.CONTR. LIC.NO. PLG.
CIL Z
P
( his section need not be completed if the permit N for one TOTAL Y E] No Y❑ No
hundred do11arS($100)or Ic,,J -
0 O I certify that in the performance of the work for which this per. OTV. MECHANICAL PERMIT FEE FEE SUMMARY'
IL 1- mit Is issued, I shall not employ any person in any manner sa as to -
0 w become subject to the Workers'Compensation Laws of Culifornia.
n
Dam Applicant ALTER OR ADD TO MECH. 4.00 BUILDING s�
>_ to NOTICE TO APPLICANT: If,after makinK this Certificate of F:x-
Z caption,you should become subject m the Workers'Contpmtshlion APPLIANCE 4.00
PLAN CHECK i
provisions io Ilse Labor Code, you must forthwith comply with FEE
U such provisions or this Permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE ,e5o
Ihereby "firm (hut Ihere is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the Performmice of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NameHEATING UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read this application and stale that theabove VENTILATION FAN (SINGLE) 3.00
information is state. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0006.T.U.) 4.00
hereby authorise representatives of this city to enter upon the
BOILER-COMP IDVBr 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property I'm mspeclion purposes,
(We) agree to save, indemnify and keep Ilurniless.the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmen ls, ostx and expenses which CONST.TAX
may in any way accrue against said ty in consequent of he PERMIT ISSUANCE 3.00
granting of this per it. MECH.CONT. LIC.NO. MECH.
o
TOTAL TOTAL / aD
Signature �
btraco Dal• s
OFFICE COPY
CII'Y OF CUI'l,IMNO INSPECTION RECORD (Office Copy)
10657 Rosewood__ /jd_ Dividers_._
• PEPJUT MO. SANITARY DISI. NO. LOT NO. ADURI;SS
Re-Tlodel Property Services
PROJECT ONNER JOB SITE PHONE NO.
PEF11IT ISSUED Date ELECTRICAL
RuiIdinr _ 5/25/83 Date 1.11sp.
Electrical Power Pule_
P lambing Underground --- ----
itr..chani.cal. Rough Wiring
'Temp. Cas/lilect. Uall.s
Solar Ceiling__
FLre Sprinkler Fixtures Int/Ext _
Sign Notors
Grounding
Misc. Temp. Power _
Other
FLNAL INSPECTIONS Not Approved _
Date Insp.
s PLUMBING
1i l.ectri.c Date Insp.
Plnmbin • Backflow
Mechanical Underground
Solar Underfloor _
Pool Partial Rough
• Gradin , Rough Complete
1'lannin{,, Solar Rough _
Fire Dept. Water & Insulation
Health Dept. "fain Dral.n
Building R/of/S Drain _
Other Gas _
Other
BUILDING Not Approved
Date Insp.
Pad Certification NECIIANICAL
Foundat[on Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One (lour_ Shaft
W aphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Ilal..ls-Panels Flues & Comb. Air
Frame Other
lath Not Approved
Uallboards Int/Ext.
Firewalls
Other
. Not Approved