0135 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
0- 113U I LDING P ROJECT IDENTIFICATION PERMIT NUMBER. -
�(P�
BUILDING
3 J
APPLICATION & PERMIT 01.
ADORESs
/ao4?7 Scenic Blvd. Lot 4 BUILDING - ELECTRICAL-PLUMBING-MECHANICAL ' I J_
OWNER'S - PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
M.C. a lintartnerPNDE7739-54461
CONTRACTORS
Name OUTLETS-SWITCHES-RECEP 5.00/1.00
Ma co Construction ,c.No. 395525 LIGHTING FIXTURES 5.00/1.00
CONTRACTORS
OR's
ADDRESS -PPLIANCES-RESIDENTIAL 4.00
ADDRESS
21060 Homestead CUD i RDNE 733-9693 PANELS .�xf 1 5.00 DATE OF As
ARRCHITECT SIGNS 1' - 6.00 PLAN CHECK FEE P.C.NO.
EN NEE
LIC.NO.. SIGNS TRANS. 3.00
ARCH.OR END. SPECIAL CIRCO S.OD PERMIT VALIDATION
SS
3238 McKinley, S.C. CA ZIP 95051 FEMP.METER OR POLE_INS 15.00
ADDRESrvrs MOTORS FEE SCH.
21060 Homestead Rd. ,Cup.CA 95014 SERVICE CHANGE 10.00
00 LICENSED CONTRACTORS DECLARATION V/��/r'/
4 o 0 1 hereby affirm that I am licensed under provisions of Chaplet 9 ISSUANCE DATE
r z w (commencing with Section 7000)of Division 3 of the Business and
BLDGs ELECT. PLG. MECH.
1:1 El 11
I-w i Professions Code,a my license is in full for -
pi w o License �ylj Le.Number
t w Date =J_l!_QJ-Contractor `}�'P
¢ se a OWNER-BUILDER UECLAR 10 •t / -• ' I INFORMATION
BUILDING PERMIT
La ; I- 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
La w o J Law for the following reason.(Sec.7031.5,Business and ProfessionspERMIT ISSUANCE 6.00 VALUATION $/FT.
yv+ Code:Any city or county which requiresapermit LOCOnstr..t,altet,
R so<2O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. $102 f 000•00
D u requires the applicant for such permit to file a signed statement Thal TOTAL
A whe is licensed pursuant to the provisions of the Contractors License PERMIT TO
rii Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe SFD
F i¢o Business and Professions Code)or at he is exempt therefrom and OTV. PLUMBING PERMIT FEE
WL
It the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
TR by any applicant for a permit subjects the applicant loacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.0D 2
of not more titan five hundred dollars(S500)J: ,
❑ 1,as owner of the property,or my employees with wages as BACK F LOW 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 SQ FT.FLOOR AREA TOTAL ACREAGE
himself re Through his own employees.Provided that such improve-
mentsarenorinlendbdoroffereoyeesalc.Tided that such
cmprong GAS-EA.SYSTEM-1INC.4OUTLETS 4,00
or improvement is sold within one year of completion,the owner- 2153 4f 598 $f -
builder will have the burden of proving that he did not build or am- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. RES IND CON PB oma,
131,as owner of the properly,am exclusively contracting with 20.00 ® 0 0 D 1-1
licensed contractors ro construct the project tSec.7044,Business LAWN SPRINKLERS-I INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 IEA.) 1,00
contracts I'or such projects with a contractors)licensed pursuant to
the Contractors License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No, PARCEL NO.
IJI am exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 4.00 700 rJ
reason
Dale Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to sell=insure.
or a certificate of Workers'Compensation Insurance,or a"ni0ed ZONING ENG.SITE NO.
copy there '
Policy No.�hIp8D�6-Fremant Tnii nni � ;el Z110 -
O ❑ Certified copy is hereby furnished I FIRE SPRINK ENERGY T24
❑ Certified Is filed i I thy y� Ip syyedioa division.
F p Applicant r,( aNt$sdKZa: MISC.- REFER TO ORD. Y E] NFL]® N�
y CERTIFICATED EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCE PLG.CONTR. sec.NO. - PLG,
Z (This section need not be completed if the permit is for one TOTAL Y C] N Y [:] N
L) O hundred dollars C$LOO)or less.).
I certify that in the performance of the work for which this per- FEE SUMMARY
LL H mit is issued,I shall not employ any person in any numner so as to DTV' MECHANICAL PERMIT FEE
O Wbecome subject to the Workers'Compensation Laws of Calit'ornia. -
Datc � Applicant BUILDING
DU
>_ N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must WTURVIIh comply with FEE
O such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1QOOf3C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0=11FM.) 5.00 SEISMIC FEE 7.14
1 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(See. MICROFILM
3097,CN.C.). H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name B of, IHEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Addre ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comely with all city and courtly BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
information
and state laws, relating m building construction, and
hereby authorize representatives for ins ec this city IO COIL'r 0p0R•1he .BOILER-COMP Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned propertytarvespof this
city tv.
(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
may in any way accrue a inst said City in consequence of the
gmnling (This permit - MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL297.14
n Ap 1 can/ onlractoN Dae -
OFFICE COPY
I
CTTY OF CUPF1111HO II1SPECTIOC RECORD (Office .0 py)
d
i4"
0135 lL_ 10(7127 Scenic Blvd,
Pl:Pd1I'T MO. SANITARY DIST. N0. LOT MO. ADDRESS V
Single FamilyDwelling M.C. a limited partnership
PROJECT 01-ZIER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildinr 5-13-81 Date Insp.
Electrical Power Pole
Plumbing - Und_e_r ,round
Mechanical < -
G�f/ P.ou ,h WiringrY/ �
'fent). Gas/Elect. 11aIia
Solnr Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign llotors
Grounding
Misc. Temp. Power
Other
FINAL I14SPECTIONS Not ApProved
Date Insp.
.s PLUMBING
Electric Date Insp.
Plumbing Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rough co
Grading Rough Complete
Planning Solar Rough
Fire
—
FirDept. Water & Insulation
health Dept. Main Drain
Building R/of/S Drain
Other Gas
Other '
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Ilembrane Ducts & Insulation
Bond Beam I Fire Dampers
Underfloor Girders Fireplace
Floor Steel _ Grease Duct & hood
Tiedowns One flour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
halls-Panels Flues & Comb. Air
O
Frame I' 1 Other
Lath Not Approved
Wallboards 1'.xt.
Firewalls
Other
Not Approved
AA` 0&Lp-
BUILDING
mw
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS