0470 I Plii-APPLICANT TO FILL IN INFORMATION WITHIN RED. LINES - USE BALL POIN PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDINGAPPLICATION & PERMIT 0470 4 O.
ADDREas ( d
'OPL BUILDING - ELECTRICAL-PLUMBING-MECHANICAL p
- _
OWNERS � - PLAN CHECK VALIDATION
E 7 , DTV. ELECTRIC PERMIT FEE
Is O O t PHONE
NOMERACTOR's UTLETS-SWITCHES-RECEP 5.00/1.00 �s�s
Q 0 to k--- LIC.NO, LIGHTING FIXTURES 5.00/1.00 ' Ssrs
CONTRACTORS
R's
A - PPLIANCES-RESIDENTIAL, 4.00 40
PHONE PANELS 5.00 SCoo DATE OF APPLICATION
CITY. IF6IN
H (fPER?IN SIGNS s.00 PLAN CHECK FEE P.C.NO.
' .
ER
LIC.No. SIGNS TRANS. .3.00
J OW E SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
MOTORS SEE FEE SCH.
A
e /j
1 SERVICE CHANGE 10.00' n ��
o O LICENSED CONTRACTORS DECLARATION /
S,u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
1° (commencing with Section 7000)of Division 3 of the Business and
y 4 01 BLDG. ELECT. PLG. MECH.
D x Professions Code,and my.license is in full force and effect.
o 0 W License Class Lie.Number
Date Contractor
a y f d BUILDING PERMIT
M4 OWNER-BUILDER DECLARATION
E o i U j INFORMATION
X ; I- I hereby affirm that 1 am exempt from the Contractor's License 'REFER TO ORD
F _ oj Law for the following reason.(Sec.7031.5,Bus inessund Professions p f1MITIl UA E 6.00 VALUATION '$/FT.
my Cade:Any city or county which requires a permit toconstruct,alter, 9
Q u, 4 2 Improve,demolish,or repair any structure,prior to Its Issuance,also ELEC ONTR. .NO. ELEG 3�0 -1
LL requires the applicant for inch permit to file a signed statement that TOTAL
n w m he is licensed pursuant to the provisions of the Contractor's License PERMIT TO
H t a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
4 Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r the basis for the alleged exemption.Any violation ol'Section 7031.5 STORIES TYPE CONSTR.
n ; by any applicant for a permit subjects the applicant Ina Civil penalty
o(ryrt more than five hundred dollars lS500).): ALTER-DRAIN& VENT-WATER (EA.) 4.00
I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 Q0.
t el ole 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 G
property who builds or improves thereon,and who does such work FIXTURES-'PER TRAP 4,06 50.FT.FLOOR AUEA TOTAL ACREAGE
himself re through his own employees,provided that such improve.doing
orments improv not intended w thinoffered
onefor
year
If,however,the the owner-
GAS-EA.SYSTEM-I INC.4 OR TS 4.00 t'a 0 3
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 1EAJ 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- INO CON PB Done,
prove for purpose of pRES ie.), INDUSTRIAL WASTE INTER. 20.00
C1as..net of the property,am exclusively Contracting with _ ,El 0 El 13 E]
licensedd contractors construct the project(Sec. 7044, Business LAWN SPRINKLERS-1 INC 5 V.B. 500 ASSESSORS PARCEL NO.
and Professions Code::Th .
e Contractor's License Law Does not apply r '
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 3 xJ 7 -00?-(5,9
contracts for such projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL NO,
I❑ I am exempt under Sec. ,B,&P.C.for this /
reason WATER HEATER W/VENT 4,00 O
Date _ - ArA I nwncr WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP, 4.00
1 hereby affirm that I have a certificate ufc.nsent to self-insure,
or a certificate of Workers'Compeuat ion Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
Policy No. Company
O ❑ CCrtlfted Copy is hereby furnished. FIRE SPRINK ENERGY RZa
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD. � ❑ ❑ ❑
V N V N
Fy Q Applicant PERMIT ISSUANCE 6.00 W FLOOD ZONE A.L.U.C.
� CIiRTI FICCOMPE 1 ATIO TION FROM WORKIiRS'
W � � COMPIiNSATION INSURANCIi PLG.C,ONTR. LIC.N0. PLG.
d O (This section need not be completed it the permit is for one TOTAL Y❑ N� Y No "
D Z hundred dollars IS 100)or less.)
U OI certify that in the performance of the work for which this per- OTY. MECHANICAL,PERMIT FEE FEE SUMMARY
W F mit is issued,I shall not employ any perso s in any manner so as to
U becomef sub��'ee�Pi t {he Workers' p ngat'�n Laws of California.
0 y Do,, St -A Applicant ALTER OR ADD TO MECH. 4.00 'BUILDING a Qr0
} W NOTICE TO APPLICANT: If,after make his Certificate of F,x- - -
? emption,you should become subject to the V orkers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10ACCF.M.) 3.00
CONSTRUCTION LENDINGAGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE �✓
'1 hereby affirm [list there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00 Do
the performance of•the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 (}�
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.17.50 ry
Lenders Address ' - ELECTRIC
I certify that l have read this application and stale that the above VENTILATION FAN (SINGLE).. 3.00
information is correct. I agree to comply with all city and county PLUMBING / ICIZ 00
ordinances and state Ines relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 v
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL / -00
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 /,5-0 0-0
may in any way cone against m City in coniL
IS 'ng of ild a mit. MECH.CONT. - LIC.NO. - MECH.
TOTAL 1S-ooTOTALSignature of ApPllcanl/
OFFICE COPY
CT'rY OF CUPERTINO INSPECTIOI' RECORD (Office .Copy)
0470 10205 Scenic Blvd. _
PhPd1IT NO, SANITARY DIST. NO. LOT MO. ADDRESS
I ' Single Family Dwelling Ron Jones 494-3241
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildinc7-2-UT— Date Insp.
Electrical 7-2-81 Power Pole
Plumhinr7-2-TF— Underground✓a ak/-[,00 '29-Y
71
Ilcchanical T--T-o I Rou�,h Wiring
Temp. Cas/Elect. hails
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Misc. Temp. Power _
Other
FINAL. INSPECTIONS Not ApVroved
Date Insp.
(' s PLUMBING
Electric Date Insp.
Plnmbin , Backflow
Mechanical Underground' _
Solar Underfloor -71-
Pool Partial Rough
GradingRough Complete
- 3
P.iannin Solar Rough
Fira Dept. Water & Insulation
health Dept. Main Drain
Building R/of/S Drain
Other Gas /
Other -"7470
BUILDING Not Approved
Date Insp.
Pad Certification U IIECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M. 7,17-8(
Slab-Membrane Ducts & Insulation i
Bond Beam Fire Dampers
Underfloor Girders - L Fireplace
Floor Steel Crease Duct & hood _
Tiedowns One flour Shaft
Diaphrams Condensate Drain
Seismic Bracing Equipment Anchorage
Halls-Panels Flues & Comb. Air
Frame 'li Other
Lnth Not Approved
Wallboards Int/lixt . $
Firewalls
Other
Not Approved
.<'i•w I-
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BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS