C 7200 ICANT TO FILL IN INFORMATION WITHIN RED LINES.- USE BALL POINT PEN ONLY
=. BUILDING PROJECT IDENTIFICATION
' - - PERMIT NUMBER
INA
ss APPLICATION & PERMITO0
0 a0 ST- f K BUILDING-ELECTRICAL-PLUMBING-MECHANICAOes F "?,Ay '; :, a PLAN CHECK VALIDATION
(. I( 1, DTV: + •`ELECTRIC�BERMIT �" FE
CCZ- COC• V ONE F4b 'o�
CONTRACTOR'$
rvAME f/x^ OUTLETS'-SWITCHES-RECEP 5:00/1.00 P^'}�
O•- \ LIC.N0.39� S LIGHTING FIXTURES - 5.00/1.00 l'�V Q`
ADDREACroRs - - - APPLIANCES-REBID ENTIAL.Y 4.00 �q 19p7
A D VJCL L' PHONE b PANELS - 5.00 EWT1EOFAPPLICATION
ARCHITECT - EC
PLAN CHK FEE P.C.NO.
Da SIGNS 6.00 of Cupe�j 0
ER NGINEER r vfosL6�- 4-7N
• a ,
sec.rvo. \ SIGNS TRANS. 3.00 Lilly
nooaess eNa. SPECIAL CI RCUIT '5.00 PERMIT VALIDATION
calV.l_
Foo\N���- ZIP TEMP.METER 08 POLE INS. 15.00
ADDRESIS MOTORS SEE FEE SC
H.
H.
`PLICA
Y. F SERVICE CHANGE 10.00
o ¢ i
Foo LICENSED CONTRACTORS DECLARATION
a u u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
vv,a w (Commencing with Section 7000)of Division 3 of the Business and LO ELECT. PLG. MECH.
'^ P,Ofessions C,ahaiind my license is in full 1'
oi w W License Coss_n Lia Number orc s -1-1� - .
w r Date !L- (_ ontmcmr_-_
m BUILDINGIPERMIT
¢ ¢ ¢ OWNFR-BUILDER DECLARATION H-^
d a a v • 'INF•ORMATION
w g LL y I hereby affirm that 1 am exempt from the Contractor's License MISC.-. REFER TO ORD • -
Fuoa Law for Ore following reasou.(Sec.70JL5,BusinessandProfessions PERMIT.ISSUANCE VALUATION 4$/FT.
Code:Any city or county which requires a permit to construct,alter,
6.00 ,y 6
a �� ELEC.CONTIT - LIC.NO.
¢ ¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.
O ¢ requires the applicant for such permit In file a signet stffiem.H that - TOTAL
la m m he is licensed pursuant to IIIc provisions of the Contr:minr'l Lice nsc PERMIT TO
la Z a Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
f 4 o Business and Professions Code)or that he is exempt therefrom and OTY.` PLUMBING PERMIT 'FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n ; _ by any applicant for aperitif subjects the applicrosl macivil penally ALTER-DRAIN -WATER (EA.) 4.00
of not more Ilion five .
ve.hundred dollars(5500).): _
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RE UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF;AREA,COND. 4.00
Critic:'I'lie Contractor's License Low does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP . 4.00 50.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvensent is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 7,00 BUILDING USE
builder will have the burden of proving that he did not build or int RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 2000
❑ I,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.
anti Professions Code:'rim Contractors License Law does not apply to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractility)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 - TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec. 0.&P.C,for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that 1 have o certificate ofconsunt to sell'-insure,
or a certificate of Workers'Compensalion Insurance,Or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lah.C.).
Policy No. Compuns,•1 \a4'1_6 6ii,yQA.=
O ❑ CertifSedcrrpyieherehy Tarnished' FIRESPRINK ENERGY T24
Z Z �[L Certified opy s filed with the city inspection division. MISC.- REFER TO ORD. '
F O Arl{rlicanlp.M'1 Z1 Y❑ N •❑ Y ❑ N❑
EX PERMIT ISSUANCE 6.00
LU - CIiRTIFICco OFIiX 6ON INS PROM WOR KERS' FLOOD ZONE A.L.u.C.
.W � -' C'OMPENSAT'ION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL z
(This' section need not he completed if Ilse permit is for one TOTAL YC] N❑ Y[J N
❑
hundred dollars($100)or less.)
V O 1 certifythat In the performance of the work for which this per- b v' d: N_vI JN_ t
p p QTaYI�y;� a MECHANICALERMIT Sr. r,FEE SUMMARY
LL {- mit is issued,1 shall not employ anY Person in any mannerso as to ,xy"r" ,"+ '- J-•'"+P dfT.f�u#gl"{s x, A ..-.dsl
0 w b•come subject 10 the Workers'Compensation Lews of Califons a. ± `
CL Dale-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING f/V
>_ ran NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject In the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Cute, you must forthwith comply with FEE
U such provisions or Ibis permit shall be deemed revoked. AIR HANDLING UNIT(TO 10S=MC.F.M.) 3.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10ACC.EM.) 5.00 SEISMIC FEE
I Irerehy affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perlormance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). 1 HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name $- HEATING UN IT 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
'1 Certify fl a,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
urdinances.and state laws relating to building construction, and BOILER-COMP(3H.P.or 100,000B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Cee,100,000 BTU)SEE FEE SCH. MECHANICAL )
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
may in any way accrue against said City in consequence of the
gnmum oft cnoit. MECH.CONT. LIC.NO. MECH, t ^
TOTAL v-.' �fO
TOTAL°- 37S
Signature of Applicant/Contractor Date
OFFICE COPY -
CITY OF CUPERTINO INSPECTION RECORD
r: t ' (OFFICE COPY) C",
LOT NO.
UWNtR
PERMIT ISSUED ELECTRICAL DATE INSP:
BuildinL7
t.Lectrical
Plumbing Power Pole '
anica r un
e as ec u irzn
Solar Walls _off
Fire Sprinkler ei in
Sign ixtures Int/E57
motors
Misc. ro�tor �in _
�eT—Power
Other
FINAL INSPECTIONS DATE INSP, Not ApproveT
Gas
Electric
uun in -7- PLUMBING DATE INSP.
anica
Solar Backflow
•
Pool tat
Gr r oor
anning PartaRough
ire t leteF
ea a Solar Rough
ui w 3%2 – Water ' Insulation
ein rMain Drain
oDrain
bas
Other
BUILDING DATE INSP. AOt Approved
Pad Certification
oun ation ELECTRICAL DATE INSP.
re- unite
Sa -•Ffem rare Underfloor S.M.
Bond eam Ducts & Insulation
Undertloor Girders Fire nampers
Floor Steel Fireplace
ie owns Grease Duct 4 Hood
Diaphrams Une Hour Shaft
eismec racinge,__//. Condensate Dram
s- ane sui ent Anchorage
Frame a e a F ues ombit
Latn Other
Ra oar nt ct. of rove
�)tnew s
er �
Net Approved
rew