12484PPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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BUILD] NG PROJECT I DENTI FICATI ON
-i -
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
PERMIT NUMBER
12484
BUILDING,. <' Vic,
ADDRESS
22545; SALEM -AVE €,j
1 OWNER'S
NAME
HVST N(_i_ PHONE 4l ' 96F
CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
NAMERacrons -
OUTLETS - SWITCHES -RECEP 10.00/1.00 -'
LIGHTING FIXTURES . 10.00/1.00
% uC. No. /
9♦ DATE OF APPLICATION
ADDRESS ORs
ADDRESS - q,y
Z LAUD A/6S PHONE 9 9 7 `Q
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.0 6
ARCHITECT OR R .
aR
ENGINEERMK V40 D LIc. No,
PANELS (OVER 200 AMP) 20.00
PLAN CHfC � P.C. NO.
�„
SIGNS TRANS. 3.00
ARCH. OR ENG. sAMg
ADDRESS
SPECIAL CIRCUIT 5,00
_
F'RMjT VAT. DAATIION
11 -f
�A EA/6 zIP
EMP. METER OR POL 11NS. 20.00
SII
0,1
-711 Vf
APPucaNrs
ADOREss
2093 N N 6
MOTORS SEE FEE SCH. � ----
SERVICE CHANGE - -. d 4' 1- - % 20.00
LICENSED CONTRACTORS DECLARATION
-
/
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Cod nndlmy license is in lull fogy a i e f ct„
Licens-eCl:yss ILic. Number �
Date /1 Contractor
it 1 cu'palthau
ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
,
(BUILDING PERMIT
INFORMATION
'
OWNER -BUILDER DECLARATION
' 1 hereby affirm that I mn exempt from the Contractor's
ac[or's LI<ense
Lawforthe followingreason. (Sec. 7031.5, Business and Professions
Code: Anycilyorcounty whichrequilnsapeom, toconstruct, alter,
Improve, demolish, or repair any structure, prior to its issuance, also
requires licensed
he is ur applicant for such permit In lite o signed actor' Li that
pursuant en the provisions of Contractor's License
MISC.- REFER TO ORD
PERMIT ISSUANCEALUATION
10.00 Dom'
p
160 f 000
$/FT.
ELEC. CONTR. LIC. NO. ELEC.
TOTAL
PERMIT TO
(Chapter 00 of Division 3 of the
Law (Chaplet 9 (commencing with Section is exempt
Business and Professions Code) of that he is pt therefrom and
CITY. PLUMBING PERMIT FEE
'BFDWl.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).)
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
STORIES
'•2
TYPE CONSTR.
ALTER -DRAIN IEA.) 5.00
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS-FLOORROOFAREACOND. 5.00
, , ,
intended or offered for Sale (See. 7044, Business and Professions
Code: The Contractor 's License Law does not apply to an owner of
R-3
1
F IXTUR ES - PER TRAP 5.00
GAS - EA. SYSTEM -1 INC.4 OUTLETS 6.00
50. FT. FLOOR AREA
689
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such at tove-
mentsarenotintendedorofferedforsule. If, however, the building
or improvement is sold within one year of completion, the owner -
builder will have the burden of proving [hat he did not build or im-
prove for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -.V EA.) 2.00
BUILDING USE
RES INO CON PB Oma,
INDUSTRIAL WASTE INTER. 30.00
I contractors m construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
contracts for such projects with a contractor(s) licensed pursuant to342-12-061
the Contractor's License Law.
❑ tum exempt under Sea ,B.&P.C. I'ar this
reason
LAWN SPRINKLERS% 1 L C15(V.B.i 6.00
_
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
SEER-AN ITARY;STORfd';EA?1200h/10.00 eJ �
TRACT NO.
8016
PARCEL NO.
WATER HEATER W/VENT 6.00 --`
Owner Dale
WATER SYSTEM 5.00
ACC.OATE
ACC. FILE NO.
WORKfERS'COMPI:NSATION DECLARATION
WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate ofconsent to self -insure,
ZONING
ENG. SITE NO.
or a certificate of Workers' Compensation Insurance or a certified
copy thereof (See. 3800, Lab.C.L TATE U�io
m
Policy No. Cop:my K^ in t, 8(„
Cl Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection Division.
Applicant
MISC- . REFER TO ORD.
FIRE SPRINK
y � N❑,
ENERGY T@4
y [J N[3
CERTIFICATE 01' EXEMPTION FROM WORKERS'
(This section need not beTcompletedlif he .permit is for one
PERMIT ISSUANCE 10,00 Q-
FLOOOZOrNE
Y❑ IN
A.L.0 C.
Y[3 No
PLG. CONTR. LIC. NO.
TOTAL O
hundred dollars (S 100) or les, I
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
'
608.00
become subject to the Workers' Compensation Laws of California.
Date Applicant
ALTER OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after making (his Certificate of Ex-
APPLIANCE 5,00
AIR HAND T (TO 10=C.F.M.) 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers'Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANCLINGU (OVER 10=C.F.M.) 6.00
SEISMIC FEE
12.95
CONSTRUCT ION LENDING AGENCY
EXHA,IJ T 400 1 'TH DUCT) 5.00 S
1 hereby affirm that here is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.L t
MICROFILM
HEA ING ONI`T( 00,000 B.T.U.) 8.00
Lender's Name
Lender's Address_jjpl --
HE T T10 ER100.000B.T.U.)9.50
ELECTRIC
/6a �
1 I certify that I have read this application and state that the above
in formation is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
xJ
/ go
/Q 7
p-
VENT! A I ING LE) 4.00 a
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
this city es enter upon the
above-mentioned propertyforins of this
hereby authorize representatives for ins inspection purposes. -
BOILER-COMP(0., 100,000 BTUI SEE FEE SCH.
MECHANICAL
_ 3 �_
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs unit expenses which
may in any way accrue a ainsi said City in Consequence of the
gra ling of this permit.
p
.1 Jfrnt/ �i1 da
MISC. - REFER TO ORD.
PERMIT ISSUANCE 10.00 Q
CONST. TAX
280.00
MECH. CONT. LIC. NO. MECH.
TOTAL N
�1 -
TOTAL
_ _
00
Signature of Applicant/Contractor Uule
...�O�p i, vrrn.c s.vrr
OFFICE COPY ,
POST THIS CARD NEAR FRO.NT.OF BUI)_DING,_ ..
•'
CITY'OF CUPERTINO
PFRMIT NUMBER
12484
INSPECTION DIVISION
JOB INSPECTION RECORD
I (^ M7
3 �S ✓�
PERMIT EXPIRATION
JOB ADDRESS �2a .S•.sL�i�/ UNIT# LOT# y
PERMIT EXPIRES IF WORK
'/
OWNER 1y LIS 1, ✓ - CONTRACTOR T41,CrS 7' / �_ Rr
IS NOT STARTED WITHIN;,
,080 DAYS OF PERMIT•ISSU=
ANCE OR 180 DAYS FROM
INSPECTION DATE INSPECTOR
t INSPECTION RECORD "
FOUNDATION - '7
LAST CAL�EDA SPECTION.
LIFER
Y
PREGUNITE •
:7
PERMIT VALIDATION
/�
City Gf• CU;
v CITY OF CFJPERTINO
CERTIFICATE OF COMPLETION
BUILDING INSPECTOR'S OFFICE
,:e .............. 3-1.6 ............. 19..V6.. Building Permit No.
Located at .....e .......... .Q......
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o Ieted J t JV /�
Has wee (A tete) or Use As:. ......--- -N%-. .......................
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