6945 > Id°LICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT I DENTI FICATION PERMITNUMBER
•.} u% AEss APPLICATION & PERMA4.00
-Lz03 Q/J �E�� `s IQZ�rj BUILDING - ELECTRICAL-PLUMBING- 6945
owNE9's ' )ty }`
NAML.• Q. { I�lolA�y`� "IELECTRIC`PERMIT•4;ti-� PLAN CHECK VALIDATION
A.. _ UTLETS-SWITCHES-RECEP 5.001sci LIGHTING FIXTURES 5.0000NTRACTORS
ADDRESSI' '�y ` PPLIANCES-RESIDENTIAL
'
1040%,o I/`�� `, PHONE L.�`j-4-t9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.N0.
! OR ( L " SIGNS 6.00
f
ENGINEER rt O tom•
' 1` sea Na. �S SIGNS TRANS. 3.00
ARCH
Ess ENG' SPECIAL CIRCUIT '5.00 PERMIT VALIDATION
I
Oh-. zip I EMP.METER OR POLE INS. 15.00
APPLICANT'S r�
ADDRESS MOTORS SEE FEE SCH. J
O� D I0rA Ian SERVICE CHANGE 10.00
Foo
LICENSED CONTRACTORS DECLARATION
e, sac u I hereby aflinn that 1 am licensed under provisions ol'Chapter'1 ISSUANCE GATE
P, a u (Cmnmencing with Seclioci 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
z oN z Pro4•ssions Cole-S my license is lq full force.�yLI�IIy Fes' ❑ ❑ ❑ ❑
- License Class_12__Lin. ...I., _y_`?J_J• sy
p v,y- Date�R 1-�� Ctrnlranlor�� p
Disc m M 1 OWNER-BUILDER DECLARATION r� 1 k,'Ta•/;BUILDING PERMITur$j_'!p-
'r�'4rp�Y
A
;O r I herby aflinn that I um exempt imm the Conractnr's License MISC.- REFER TO ORD
F w o j Law fur the tollowing reason.lSec.7071.5,Business and P,.f...ions VALUATION $IFT.
Code:Anycityorcounty which requires a permit to construct,alter, PERMIT ISSUANCE 6.00
a,' a?7 D
a Q improve,demolish,or re Pair unY 9ruclurc,prior la its issuanac,alw ELEC.CONTR. LIC.NO. ELEC. U Q�
i n 0 Q requires the applicant I'ur such permit to file a signed statement that TOTAL
w m ti he is licensed pursuant to the Provisions of the Contrnctni s License )PERMIT TO
� z >
Law(Chapter 9(commencing with Section 7000)of Division 3 of the t 'S fN { ) _
x p Business and Professmns Code)or that he n exempt tllere(rom and DTY (� a-- c"+PLUMBING PERMIT v}i t tr' h�FE_EU ail / c - 7
as r m lha basis for the alleged c.en+pumi.Any violation of Section 7031 $ Lr{,' n;;:, ,.xr :'L( !,v.' '.h.i. ,+,;i.f!.,;IQ:c lt. iu(,.t,v�L STORIES TYPE CONSTR.
t. ; - by any applicant for a permit subjects the applicant unit civil penalty +IpQ!�11i l
of not more than live hundred dollars(85001.1: ALTER-DRAIN&VENT-WATER (EA.) 4.00 t,lty Or Lam.
❑ I,as owner of 1111 property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00
their sop
Right comenwtion,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec. 7044, and
and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4,00
Cade:The Contractors License Law dues not apply to an owner of
properly who builds or improve thercon,and who does such work FIXTURES-PER TRAP 4.00
himself or through his own employees,Provided that such D"Prove-
SQ FT.FLOOR AREA TOTAL ACREAGE
menuare lot inlentleJornll'creJ lot sale.It,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4,00
or
improvement is Sold within one year of cumplclion,the owner
builder will have the harden of Proving Him he did nut build o,ins- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTERREE IND CON PB On.,
❑ I,as owner of the property,am .exclusively Contracting with 20.00 Cl ❑ ❑
11"Pla•d can(raclor5 w construct the project tSee.7044,Business LAWN SPRINKLERS 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Prmfessions Code:The Cmicae nr',License Law does nut apply -
to an owner of propery who builds or improves thereon,acid who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for fuel Prajecta wilb a conlraetmix)liealsed pursuant to
the Contract.,',License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exenip(under See. ,B.AP.C'.for this
reawn WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00
ACC.DATE ACC.FILE NO.
WURrin that
I Have NSATIUN DECLARATION WATER TREATING EQUIP. 4.00
I hereby al Gem that I Have agRcr amhr ofconsent N,sell cHilu,d
or a cc,c,c.f(c of Works3800, s'Con+pcnwtion IluurunCe,ser a ccrtillcJ ZONING ENG.SITE NO.
copy thereof(Sec.780(1,Lab C.).
Policy No. ComPanyW_PC_
0 ❑ Certified copy is hereby(umished.
Z Z 1�L allied i y u Illc with the city inspection division. FIHESPRINK ENERGY T24
0- A,,Tbt j.+..�-_ _M1�•Y MISC.- REFER TO ORD. Y0 N[:] Y[D N�
~ ERMIT ISSUANCE
Lu m Cl:CIiRTIPICCOWI F I ATI NINS FROM WORKIi RS' 6.00 FLOOo ZONE A.L.U.C.
W COAII'IiNSA'1'ION INSURANCE PLG.CaNTH. LIC.No. PLG.
d This .,IRn need nut be completed if Ine Pe nu it is for one TOTAL Y N Y ry
Z hu dr dJ ll n(EI00)or less.)
EI
V O I fDIY th'1 m 1111 performance of the murk for which Ibis F nm I al
LL ran is mined,I shall employ any parn In an,menncr lu DTY -i+� 'il+. MECHANICAL PERMIT �"y y 'r' t FEE*r s, !:�„S+kFEE SUMMARY+"n .1t'
Q w become subject IN the Worker;Compc avliun Law w m of Culilnrnia. a R `^ti I *"X'f ". ,aS'.:1 T t+h*.:
y �j�� 0,11J
Data Tnl BUILDING O
} N NOTICE TO APPLICANICANT:. If,alto nuking this CerldALTER OR ADD TO MECH. 4.00iwlc of I:a-
♦- ? emploa,you should become subject to We Wurkeri Cunipenamiun APPLIANCE 4.00 PLAN CHECK
prosisions of the Labor Cute, you mull forthwith comply with
U such Provisions or Bib permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=12.F.M.) 3.00 FEE
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE Vo
I hcrcby alfain that that is a cunsuuctiun lending agency for EXHAUST HOOD (WITH DUCT) 2.00
(he perlirtmance of the work 1'ur which this permit is issued(Sec.
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
I.enderi Name A
Lender's Address HEATING UN IT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
" r I Certify llWt I have read(his application and state chat the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all City and county PLUMBING
r ordinances acid gate haws ,eating to building construction, and BOILER-COMP 13 H.P.of 100,000 B.T.U.) 4.00
hereby aullm-ac representatives of Ibis City to enter upon (ILL•
a1 ole nentimhed properly for RHpc,RRR purposes. BOILER-COMP (Over 100.000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to sale, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way "•rue against mid City in Consequence of the PERMIT ISSUANCE 3.00
gran;lisp cid( MECH.CONT. LIC.NO. MECH.
TOTAL
Sig ngl weo A gtlmal l Con Naaor / 7 DateZ -A
OFFICE COPY P
�yeuVCANT TO FILL IN INFORMATION•WITHIN REDLINES - USE BALL POINT PEN ONLY
-BUILDING PROJECT IDENTIFICATION PERMITNUMBER
C91Nc APPLICATION & PERMIT ^
DRESS b
-"3q/J IT-505W C Z'5 BUILDING -ELECTRICAL-,PLUqqMBING-MECHANICAL
rvAML•.- - MC '�`X' yk� - M945
-. f$ y .,`$eW PLAN CHECK VALIDATI ON
ow^Hs �..,' ... � ' 4br0{j OTYL.{+ks'"f''�i' ELECTRIC PAERMIT >,f
�.. PHONE
I:bNTH4LTOP'
.NAME p_ UTLETS-SWITCHES-RECEP 5.00/1.00
CAL Qw1 LIC,No. 1S LIGHTING FIXTURES 5.00/1.00 '
CONTRACTORS - PPLIANCES-RESIDENTIAL 4,00
A CORESS
AD01AD/� ` PHONE �,
- W� Q 6.x.'9 PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.NO.
.on SIGNS 6.00
ENGINEER
Q `I/• p(-
LIC.No. 1J SIGNS TRANS. 3.00
ARCH.Ess ENG' ' SPECIALCIRCUIT 5,00 PERMIT VALIDATION
O.. IP I EMP.METER OR POLE INS. 15.00
APPLICANT SMOTORS SEE FEE SCH.
DRESS
AeDon Ess
140D20 SERVICE CHANGE 10.00
0
a0 0 LICENSED CONTRACTORS DECLARATION
a i w I hereby affirm that I am licensed under provisions of Chapter'I ISSUANCE DATE
(commencing with Section 70,QQ)of Division 3 of the Business anA
rA a BLDG. ELECT. PLG. MECH.
H N i Professions Cod it my license is in full forte lfrys��- ❑ ❑ ❑ ❑
z o m - License Class Lic.Number 3_J
9 r ° Uutc_r� Contmmnr_ _C1p��Q
a r E BUILDING PERMIT.
¢ Se w a OWNER-BUILDER DECLARATION :}' ��+-
0Ba MISC.- REFER TO ORD t"SINFORNIA'TION
X g LL N I hereby aflinn Nal I am exempt from the Contractor's License
au u.oJ law for the billowing reason. 7031.5,Busionvand Professions pERMIT ISSUANCE 6.00 VALUATION S/FT.
Code:Any city or county which requires a permit to construct,alter,
F.:9 Oo�
ic au¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. TE EC.
�'C
c u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
d w m he is licensed pursuant to the provisions of the Conlucmr's License PERM
F z a Law(Chapter9(commencing with Section 7000)ofDmslon Sof the Yi E.'L,,
E i o Business and Professions Code)Or(hat he isexempt therefrom and QTY: -- PLUMBING PERMIT, TEFF ' 4 E
H $ the basis for the alleged exemption Any violation of Section 7031.5, a a a# STORIES t,n) TYPE CONSTR.
by any applicant for a permit subjects the applicant lox civil penahy LUPBC
of not more than five hundred dollars(5500).1: ALTER-DRAIN-& -WATER (EA.) 4.00
��y Of
❑ I,as owner of tiro property,or my employees with wages as BACK F LOW PROTECT. DEVICE - 2,00 OCC.GROUP RES.UNITS
their sole conlpereatian,will do the work,and lire structure is not
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
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.60 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or'through his own employees,provided that such improve"
mens are not intended or offered for sale if,however,the building GAS-EA.SYSTEM-111NC.40UTLETS 4.00
or improvement is sold within one year of completion,(he owner. GAS EASYSTEM OVER 4 IEA) - 1.00
builder will have the burden of proving that h - . - . BUILDING USEe did not build Or im- RES IND CON PB On.,
for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of the property,am exclusively Contracting with - ❑ ❑ ❑ ❑. ❑' •
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V:B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: [he Contractor's License Law does not apply
to an owner tilproperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractoroo licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8,00 TRACT NO. PARCEL NO.
O lam exempt muter Sec. ,B.&P.C.for this WATER HEATER W/VENT 4.00
11Y111
Owner Date WATER SYSTEM - 4.00 ACC.DATE ADC.FILE NO.
WORKF:RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconseni to self-insure, - ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sec.3800,Loh.C-.k
Policy No. CompanyWC 100'V09F4 -,
U' ❑ Certified copy is hereby furnished.
z Z 1�(Cerli(icd o y is fill�.MMMn,���with IIIc city inspection division. FIRE SPRINK ENERGY T$4
O A1T cavi i.� MISC.- REFER TO ORD. Y❑ N❑ Y 0 INC]
CERTIFICAI'Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > t COMPENSA'T'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CIL 0 (This section need not be completed if the permit is for one TOTAL Y❑ IN E] Y ❑ N❑
Z hundred dollms(S 100)or less.)
U O I Certify that in the performance of the work for which this per-
LL MECHANICAL PER - - 'FEE - }L FEE'SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as m •s= --^d'=
U w become subject m the Workers'Compensation Laws of California.
y Dale—Applicant ALTER OR ADD TO MECH. 4.00 BUILDING d
} to NOTICE'10 APPLICANT: If,after making this Certificate of E..
F Z emptio 1,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions oC this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNITIOVER 10=C.F.M.) 5.00 SEISMIC FEE �Yb
I hereby affirm that there is a construction lending agency OR EXHAUST HOOD(WITH DUCT) 2.00
tire performance of Ne work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). n / A HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Names (/• HEATI NG UN IT 100,000 B.T.U.)7.50
_ Lender's Address ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is-correct. I agree to comply with all city and county PLUMBING
`( orlinances and slats: laws relating In building construction, and BOILER-COW f3 H.P.or 100,000 B.T.U.). 4,00
hereby authorize representatives of this city to enter upon the BOILER-COMP(OV01100,000 BTU)SEE FEE SCH. MECHANICAL
s above-mentioned property for inspection purposes.
' (We) agree to save, indemnify and keep:hurmless 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 rue against said City in consequence of the
gran this p it. MECH.CONT.- LIC.NO. MECH.
\i(J
/ l -1 Z - TOTAL ;'NOTAL;' F]/ yo
SuS�[ure of Applical�l)Conlmctor Uale Y'
OFFICE COPY
t. CITY OF CUPERTINO INSPECTION RECORD
1 (OFFICE COPY)
lv� G �
ADDREM
tea;
n�r,�uzwt C,��y✓�a7�°n'u-roc'-f- n
PERMIT ISSUED DATE ELECTRICINSP.
ui in
h-Lectrical
Plumbing Power Pole
mechanical tjnderund
7eW Gas/Fiec Ko!gh Wiring
Solar Walls
i_ re Sprinkler Ceiling
bign P=res nt xt y
tors
Misc. Grounding
Te�ower
Other
FINAL INSPECTIONS DATE INSP, Not .Approved
Gas
Electric �S
Pl-u-mbing PLUMBING DATE INSP.
mclianicai
Solar Backflow
� oo rr�un
• - _
bra in nderf oor
FlarminR Partialug -y-a'4
Fire Dept. Rough Tete
�ealtn a t. zioiar xough
u ng Water '4 1nsulation
Utfter Main Drain
oDrain
Gas
Dther
BUILDING DATE INS,P Not Approved
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Membrane Underfloor S.M.
Bond am cts nsu ati
r oor Girders Fire ers }��
Floor Steel Fire ace
ie owns reale ct , Hood
is rams a our Shaft -
beisme- cBrracin Condensate Drain
Walls-Panels L ui mentAn ora e
rame - ues om r
LaT ter
.
a oar nt xt, of prove
irewa s
other
Not Approved
BUILDING
ELECPRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS