5814 APPLICQAAT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
'BU ILDING PROJECT lDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT
HDORE55
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 5814
OWNER 5 PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
LPHONE
-CONTRACTORS
NAME UTLETS-SWITCHES-RECEP 5.00/1,00
Lie NO. LIGHTING FIXTURES 5=/1.00
ADDRESS rafts PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5:00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
NGINEER
' uc.NO. , SIGNS TRANS. 3.00
nooniss Era SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 15.00 {fJ�
APPLICANT'$ - �./
ADDRESS MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00 �-7
o o LICENSED CONTRACTORS DECLARATION
Fi W I hereby affirm that I am licensed under provisions of Chapter') ISSUANCE DATE
G (corm ouncing with Section 7000)of Division 3 of the Business and BLDG, ELECT, PLG. MECH.
F w i Professions Code,and.my license is in full farce and effect. ❑ ❑ ❑ ❑
o i m o License Class Lic.Number
Date Contmclor
BUILDING PERMIT
w a OWNER-BUILDER DECLARATION
A O a v INFORMATION
X ;u_y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
HUO,J Law for the following reason. 7031.5,Businessand Professions PERMIT ISSUANCE 6.00 ATION 'f/FT.
f w Code:Any city or county which requires a permit to construct,alter, C
Q Q Q Improve,demolish,Or repair any Structure,prior to Its Issuance,the ELEC.CONTR. LIC.NO. ELEC. SL
o•LL requires the applicant for Snell permit to file signed statement that - - TOTAL V IT
n w m y he is licensed pursuant IDJIm provisions of the Contractor's License
r2 > Law(Chapter 9(commencing with Section 7000)of Division 3 of the '
4 Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEgj
W 1-
tc F r� the basis for the alleged exemption"Any violation applicant OfSection7031.5 malty TYPE C STR.
IV
u;_ by any applicant fora permit subjects $500). loacivilp¢natty ALTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than five hundred dollars(8500).1:
❑ I,as owner of the property„or my employees with wages as BACK FLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.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
Code:The Contractor's License Law does not apply to an owner of
` po,I who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsamnot intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS EASYSTEM-OVER 4 (EA) 1.00
builder will have the burden of proving that h • . . BUILDING USE
e did not built]or im- R[5 .IND CON E Omer
pr l'orpurposcofsaleJ. INDUSTRIALWASTE INTER. 20.00 RE El ElVveI,as owner of the property,am exclusively contracting with - 0 El
licensed contractors In construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's 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 u contractorts)licensed pursuant to
the Contractor's Licensc La SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO,
.� ❑ tum exonmt under ' c- ,B.&I'.C.II
reason WATER HEATER W/VENT 4.00
Owner Date WATER SYSTEM 4.00ACC.DATE ,ACC.FILE NO.
y WORKERS' PHNSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
or.'certificate of Workers'Compensation Insurance,or a certified
Copy thereof(Sce.3800,Lab.C.). -
._
O Policy Na• Company 1
. '❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z - ❑ Certified copy is riled with the city inspection division. y
♦- 0 Applicant MISC.- REFER TO ORD. Y Q NE] Y N�
cc rn CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COhO'F:NSAT'ION INSURANCE: PLG.CONTR. LIC.NO. PLG. ❑ ❑ [:] ❑
Z - (This section need not he completed if the permit is for one TOTAL V N Y N
hundred dollars($100)or tem.)
U 0 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY'L
LL I-` mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
- D.le Applicrost ALTER OR ADD TO MECH. q-q0 BUILDING
>_ D. NOTICE 'I'O APPLICANT: If,after making This Certificate OFT, _
Z H emplian,you should become subject to the Workers'Compensation_ APPLIANCE 4.00 PLAN CHECK
provisions the Labor Code, you must forthwith comply with FEE
- C.1 such provisions or this permit Shall be deemeddrevoked. � AIR HANDLING UNIT(TO 10,000GF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IWIDDGRM.) 5.00 SEISMIC FEE P�
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. - MICROFILM
3097,CIV.(..). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT 100,000 B.T.U.)7.50
Lender's NAddleames ELECTRIC
I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00
information n estate. I ague to comply with all ucti COUBIY PLUMBING
ordinances and stale laws relating to building l city and co :md BOILER-COMP(3 H.P.or 100,0006.T.U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property far inspection purposes. BAILER-COMP (Over 100,000 BTU)SEE FEE SCH. •MECHANICAL
(We) agree to save, ind¢nmify and keep harmless the City of MISC.- REFER TO ORD.
F Cupertino against liabilities,judgments, casts and expenses which CONST.TAX
may in any way 41m
gain t vie City in consequence of the PERMIT ISSUANCE 3.00
granting of isApe / MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL 0Ignat re,ofAppltmctor Date
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
• (OFFICE COPY)
PADDRESS � -
C .��
PERMIT ISSUED DAELECTRICAL DATE INSP.
Eleui nh
ctriiccal
Plumbinz Power Pole
Mechanical ljncter roan
Temp as ec � uh Wiring
Solar Walls
ire Sprinkler ei in
Sign ixtures Int/Ext
tors
Misc. Uroundlng
eT mp Power
Other
FINAL INSPECTIONS DATE INSP, Not .Approved
Gas
Electric _
Plumbing PLUMBING DATE INSP.
Mechanical
Solar Backflow
oa
:Lng
or
Planning arty u
Fire Dept. u ete
Health t. oar u i
ui in
Water '4 Insulation e _ t,- ee �. !- - rain
o ain
Dther
BUILDING DATE INSP, Not rove
Pad Certification
oun =tion t 6 ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Membrarie Underfloor S.M.
Bond Beam E ns =tion
Undertloor it ers Fire
ampers --
oo�teel Fire lace
LRFD s L2rease j3uct 4 mood
is rams a our t -
�isme�in on ensate rain
s- ane s uI�meAnchorage
r�ame ues o r
Lath ter
�t�'Ia oar Int/Ext. Not App-ro—ve-T—
irewalls
t er
Net Approved
Blo�rc �V s7ee)
G`Y D 6a �-pv l�hr�B'(Cozlw.,-rFvc-1 t(-27-fs`F
BUILDING ,
ELECTRICAL
PLUMBING
MECRANICAL
MISCELLANEOUS