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3139 APPLICANT TO FILL IN INFORMATIONMITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTI FIC N PRM UMBER ADVp,N�, p APPLICATION & PE•IT •• AOQRF66 IZ _ _ _ _ 3139 5 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL it 4 wNER�s - PLAN CHECK VALIDATION NAME CITY. ELECTRIC PERMIT FEE , C PHONE .NTRATORs OUTLETS-SWITCHES-RECEP 510/1.00 L uc.No. L -LIGHTING FIXTURES 5.00/1.00 ' I NTRACTORS - PPLIANCES-RESIDENTIAL 4.00 ADOREss T OTC PANELS 5.00 DATE OF APPLICATION ARCHITECT SIGNS 6,00 PLAN CHECK FEE I P.C.NO. ENGINEER LIC.NO. SIGNS TRANS. 3.00 ARCH,OR ENG. PERMIT VALIDATI ADDRESS SPECIAL CIRCUIT 5.00 ZIP TEMP. METER OR POLE INS. 15.00 APPLICANTS MOTORS - i SEE FEE SCH. ' ADDRESS - Ip SERVICE CHANGE 10.00 a � 1983 ao o LICENSED CONTRACTORS DECLARATION Clfy Of CUg&{ IIID a Iu H i I hereby affirm that I am licensed under provisions of Chapter 9JUN I SUANCE H< (commencing with Section 7000)of Division 3 of the Business and BLOC. ELECT. PLG. MECH. H D Professions Coit d y license is in full fort a d of d2 ion - License Class.,.J�,-�y,�_J/n�Lie.Number City of CupertinoCon in BUILDING PERMIT ¢ ¢ ¢ OWNER-BUILDER DECLARATION oA. - MISC.- REFER TO ORD INFORMATION w . I hereby affirm that I am exempt from the Contractor's License VALUATION SLLoJ Law for thefollowingreason.(See. uiresa,BusittocodProfessions PERMIT ISSUANCE 8.00 i Code:Anymolish coo ntywhiny structurep rio ittoconstance, lso I'D QDO S e a FO improve,demolish;or repair any structure,prior to its issuance,alto ELEC.CONTR. LIC.NO. ELEC. C/ N V O LL requires the applicant for such permit to file a signed statement that TOTAL I IT T u w$ he is licensed pursuant to the provisions of the Contractor's License H Z c Law(Chapter 9(commencingwith Section 7000).(Division 3 of the P 4 tr Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT •FEE ¢ I- $ the basis for the alleged exemption.Any violation of Section 7031.5 STUFTIEs TYPE CONSTR. d ; - by any applicant for a permit Subjects the applicant lost civil penalty • ALTER-DRAIN&VENT-WATER (EA.) 4.00 W of not more than five hundred dollars($500).): ❑ 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,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 *73m, / Code:The Contractor's License Law docs not apply to an owner of - property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SDa,FT,FLOOR AREA TOTAL ACREAGE himself re through his own employees,provided that such improve- me buildi o N r meats are not intended or offered for sale.If,however,(ht building GAS-EA.SYSTEM-1INC.40ETS UTLq,00 or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 1.00 BUILDING USE builder will have the burden of proving that he did not build or im- provefor purpose ofsale.). INDUSTRIAL WASTE INTER. REs �1ta0 CON PB Other O 1,as owner of the property,am exclusively contracting with 20.00 r�/ [I C3 O. Cl licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 1!7 ASSESSORS PARCEL NO. and Professions Code:The Contractor's License Law does not apply ED owner of property who ballon or improves thereon.and who LAWN SPRINKLERS-OVER 5'(EA.) 1.00 r contracts m for such projects with a contractortsl licensed pursuant to the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO, PARCEL No. ❑ 1 amexempt under See..,B&P.C. or this WATER HEAT ER WI 111 4,00 Alcon, Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORKERS'COMPENSATION DECLARATION WATER TREATIN91fNiq4.00 - 1 1 hereby affirm that 1 have a certificate ofcousent Io rel Ginsum, ZONING or a certificate of Workers'Compensation Insurance,or a certified ENG.SITE NO. copy thertpf e- 8 ab.0 f'1 n Policy Nq/��rNpem '1'S �// /V 1�- O ❑ CeltlD dcop is here y f0ted. FIRE❑SPR IN_ K ENERGY Tp4❑ Z p Ap❑pli Certlfe I the city inspection division. MISC.- REFER Tan O ORD. y (1�,y�J1 Y(118,1/ N f" m PERMIT ISSUANCE 6.00 cc - CERTIFICATE F.XIiMP'I'ION FROM WORKERS' '� FLOOD ZONE XPC7 LU > COM :NSATION INSURANCE PLG.CONTR. LIC.NO. PLO, CL 2 (This section need-not be amnpleled if the permit is for one _ TOTAL Y N hundred dollars($100)or less'.) U OF I certify that in the performance of the work for which this per CITY MECHANICAL PERMIT FEE FEE SUMMARY LL U mil is issued,1 shall not employ any person in any manner so as In become subject to the Workers'Compensation Laws of California. i Datu ApplicantALTER OR ADD TO MECH. 400 BUILDING et- } m NOTICE TO APPLICANT: If,after making this Certificate of 1: . . F 2 emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK provisions of the Labor Code, you must forthwith comply will FEE U such provisions or this permit shall he deemed revoked AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT C.F.M.) 5.00 SEISMIC FEE � S'D I hereby affirm that there is a construction lending agency for EXHAUST HOOD ( ITH DUCT) 2.00 the performance of the work for which this permit is iserm I ISIc. MICROFILM 3097,Civ.C.). HEATING UNIT 1 0 0 .1 4.00 Lender's Name HEATING UNI ( 1 0, 0B.T.U.)7,50 1 ^1 Lender's Address ELECTRIC I certify that I have read it is application and stale that the above IVENTILATION A 1 3.00 information n corroe l I agree to comply with all city and countyPLUMBING ordinances and state laws relating m building construction, and BOILER-COW(3".dir1 0, OOB.T.U.) 4.00 hereby authorize representatives of this city t. enter upon the above mentioned property for inspection Partin BOILER-COMP IOver 100,000 BTU)SEE FEE SCH. MECHANICAL ses. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgment c and expenses which PERMIT ISSUANCE 3.00 Vy CONST.TAX may in any ac' a ago' sat in e.nseruencl .f the granting u is MECH.CONT. LIC.NO. TOTAL Op S� /� ✓ TOTAL , J 'ign re of Applicant/CrIjaWgIm, Date OFFICE COPY - _ . ,•. . •.• •••,. .,......., RL UURU kUCTlcer l,0pl'1 313^ _ * �?�cHBS:SStevena ,Creelc Rou'evard' FT1IT 110. SANITARY DIST. NO. LOT ]i0• AUUIIESS - ----- --------- c •_ P.emodel A moved struct' I Ubaldo Perez _ _. • PROJECT' OM1IFIER JOB SITE 1-1FOFi I.I PERMIT ISSUED Date ELECTRICAL Buildin 6 1 83 \ Date nsp. I:Iectrical 6 16/83 ]'ower Pale PIuml,Lnr 6 16 33 Underground ------ Mechanical 6/16/83 P.ouu�(,h Wiring �..1 'J• Tem,. Gas/lilect• lalls --- z'� Solar Ceiling, _ fire Sprinkler Fixtures Int/Ext Sign llotors — Grounding - — 11isc• Temp. Power --�-- Other --`- f1NAL INSPECTIONS Not Approved _ Date sp. Ors Y� Electric _ PLUMBING Plumbing a -dY-YS i_ Date LnSp . Mechanical }� s �.�----- Backflow 1rZ_ Underground _ Solar Pool Underfloor -�_ Grnding Partial Rough Z-�-S 1` V �. PlanninRough Complete g Solar Rough Fire Dent. Water & Insulation Health De t. !lain Drain -��-b l l' Buildinr OKkt C1 rfl�+ nay _ R/of/S Drain �V Other Gas Other BUILDING Not Approved Date Insp. — 1•ad Certification IIECIIA141CAL Foundation Pre-Gunite Date Insp. Slab-liembrane Underfloor S.M. Bond Ream Ducts & Insulation x _25 �� f� Underfloor Girders Fire Dampers Fireplace Floor Steel Grease Duct & flood DiTiedhramowns One flour Shaft a beams --- Condensate Drain Seismic Bracing Zquipment Anchorage_ halls-Panels flues & Comb. Air --- Frame Lath Ober _gam/U-8c Not Approve -- Wallboards Int Iixt. Firewalls / Aor30C .9Tie 1, sq o- cyl; :q t Other 9 =vt Not Approved CERTIFICATE OF COMPLETION BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO DATE_ -( f 19E BLDG. PERMIT NO. THE BLDG. LOCATED AT-2 26 3� STe Vff L 1 ('P J l R f OWNED BY P P r It! 2- i, (COMPLETED)_ HAS BEEN AL` TEREDIFOR USE AS ©. • `i BUILDING INSPECTOR