5329 APPLICANT TO FILL iN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDINGPROJECT IDENTIFICATION - PERMIT NUMBER
BUILDING APPLICATION & PERMIT r n
ADDRESS - `� G
.rO saryams c, BUILDING-ELECTRICAL-,PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDA ION
NAME PHONE I U. ELECTRICgPERTF FE
CITE
Wr_
CONTHACTURS .f���/s/
NAME •UTLETS-SWITCHES-RECEP 5.00/100
uc.No. LIGHTING FIXTURES 5.00/1.00ACT '^ '/
ADDRESS .E,0 1 NTA PPLIANCES-RESIDENTIAL 4.00 ✓{I J//ur.
ADDRESS
PHONE PANELS 5.00 DATE F LIGATION
ARCHITECT SIGNS 6.00 PLAN CHECK E P.C.NO.
OR
ENGINEERkni-Lih -r NO. SIGNS TRANS. 3.00
ADDRESS ENG
SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
2- zIP EMP.METER OR POLE INS. 15.00 /^I
ADDRESNrs MOTORS SEE FEE SCH. (�
ADDRESS `J
SERVICE CHANGE 10.00 P
Or O LICENSED CONTRACTORS DECLARATION
Q U w -I hemby alfino Ilial 1 am licensed under provisions Df Clmoc,9 ISSUANCE DATE
N a N (commencing with Section 7000)of Division 3 of the Business and E G. MECH.
r N z Professions Code,unit my liceasu is in full force and effect. �❑ ❑
gimp License Clans Lw.NDOlber r
w H J Dam C.mCmI.
¢'Q w a OWNER-BUILDER 1)1;CLA RATION - 1 Y pry+tERMIT T' .
o a U -SIN ,O, INATIO'N
w ;LL m 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
s- .. m J Law for the following mason.(Sec.7031.5,Business and PrUfesslons PERMIT ISSUANCE 6.00 VALUATION $/FT.
Code:Anycity Brcounty which requires a permit to construct,alter, r--OO
as ¢ Improve,demolish,Or repair any structure,prior 10 IIS Issuance,also ELEC.CONTR. LIC.NQ ELEC. / ,S
wce R requires the lipplicanl for such permittofile a signed statement that TOTAL PERMIT TO
m' he is licensed pursuant to the provisions of the Contractor's License _
Fzr Law(Chapter 9(commcncing with Section 70001oIDivision 3 oflhepL.C(X
i c Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT a FEE-"
R I-o the basis for the alleged exemption.Any violation of Seclicn 7031.5 STORIES TYPE CONSTR.
s- ; by any applicant for a permit subjects the applicant to a civil penalty gLTER-DRAIN&VENT-WATER IEA) q00
of not mom than five hundred d . -
dollars(5500).1: -
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2,00
their sole compensation,will do the work,unit the structure is not OCG GROUP RES.UNITS
intended or offered for sale (Sea 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00 '
Code:The Contractor's License Law does nor apply to an owner of
properly Who builds or l arpr"ves thereon,and who does such Work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTALACflEAGE
himself or through his own employees,provided that such is .
meats arc hitt intnWed or offered for sale.It,however,the building GAS-EA.SVSTEM-11NC.40UTLETS 4.00
or improvement 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 So.
IT for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES IND CON PB Omar
1,as owner of the property,am exclusively contracting with ❑ ❑ 0 1:1 Ellicensed contractors to construct tire project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. ,5.00 ASSESSORS PARCEL NO.
and Professions Code:'I'lie Contractor's License Law does not apply
to an Owner of property who builds or improves thereon,mid who LAWN SPRINKLERS-OVER 5(EA.), 1.00
contracts for such projects with a contractors)licensed PUauan(t0 -
theContraclor'sLicenseLaw. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ Iwo exempt under Sec. ,B.&P.C.for this
reason WATER HEATER W/VENT 4.00 -
\,
7 Ow^n` Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKI:RS'COMPRNSAITON ECI.AR,1T'ION WATER TREATING EQUIP. 4.00
I hereby affirm that I haven certificate Of consent t0'el Giusum, ZONING ENG.SITE NO.r
or a certificate of Workers'Compensation Insurance.or a certified
copy thereof(Sec.3800,Lab.C.).
Policy No. Company
O ❑ Ce,lificdcopyisimmilyfurnislmd. FIRESPRINK ENERGY T-24
Z 2 ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O APPliratt Y ❑ N� Y ❑ N[]
~ vee
LU CER'I'I EICEXEMPTION FROM WORKfiRS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.LU.C.
W COMPE� COMI'IiNSAT'ION INSURANCE - PLG.CONTR. LIC.NO. PLG.
CL D (I his section need not be completed if the permit is for one TOTAL Y❑ N[3 V 0 N
hum red•dollars($100)or less.)
U O' 1 cerWy that in the Performmxe of the work for which(his per, PTV. MECHANICAL PERMIT -FEE a F.EE SUMMARY h "
W F mil is Issued I shall not employ any person in any manner so as m s .�'..
O w becnne subject to the Workers'Compensation Laws of California.
u Dale Applicant ALTER OR ADD TO MECH. 4.00 BUILDING O
>_ N NOTICE 1'0 APPLICANT': If,after making this Certificate of fix
F ? caption,you should become subject tD the Workers'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 10=r-F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE AR_21 -_
1 hemby uffini that (here is a construction lending agency tor EXHAUST HOOD(WITH DUCT) 2.00
tire 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(OVER 100,000 B:T.U.)7.50
Lender's Address - ELECTRIC
I certify that I have road this upplicnion and stale that rhe above VENTILATION FAN (SINGLE) 3.00
i infor"tatio" is correct. I agree to comply withfaR city and.County BOILER-COMP(3 H.P.Of 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposesBOILER-COMP(Over 100,000 BTU)BEE FEE SCH. MECHANICAL
:
(We) agree to save, indemnify and keep harmless�thc 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
gan1 ofillis permit. ME CH.CONT. LIC.NO. MECH.,
TOTAL TOTAL 63 a 7s
Si a[ureo licant/Co actor Ute
OFFICE COPY
i
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
- L(777--
otyc
PTMZL;i UVV1'4tX eh)
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
ui in
ctrl
Plumbing Power Pole
Mcnanicai uncier s y s (-
Te as ec u irin
Solar va s
Fire Sprinkler Leiiing
Sign Fixtures Int/Ext
tors
Misc. ro� 3in
e ower
uther
FINAL INSPECTIONS DATE ISP, Not Approved
Gas
ectric
Flumbins PLUMBING DATE INSP.
Mechanicai
Adftk,jo ar Balm,,
oo r un
Grading Underfoor
Planning Partialou
Fire u ete OVA
e t e t. oar Rough
Building ater -o Insulation
utnerMain Drain
S-i fd6 �o�wa • 3 ' Na. o E G h (i�e�y� DF Sa ° ain
o h I & to l0o-y! r S 'c7� e rS�1f an
5-5=tri fy v�.e w•- ILue C.A.,-t-,) �nGe( W411S V ft-her
BUILDING DATE INSP, Not rove
Pad Certification
oun ation Wtsf _ ELECTRICAL DATE INSP.
re- mite
Slab-Niembrane Underfloor S.M.
°� 77H-77— ns ation
Under±looT Girders Fire Dampers
Floor Steel Fireplace
liedowns Grease Duct & mooa
Diaphrams one Hour Shaft
eismecracin condensate Drain
Valls- ane sEquipment Anchorage
Frame N 7177, Flues—T-C&jE. r
Lath tt ei�—
Wallboards nt xt. of rove
relda s
het 4EProveci
no 2 wi` (r f 1,-F' K f r -)hal
ii 4 rr�(z
ew .�.ac ILo., e e,
pivot wd(1 Yr(A j c�- -rye;r t-f-jr —
BUILDING
(A& y
J- T
ELECTRICAL
CO Me7,Z-
PLUMBING
40
MECHANICAL
MUCELLANEOUS