7247APPLAICANT•TO FILL MINFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' BUILDING PROJECT IDENTIFICATION
APPLICATION PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
,
7247
BUILDn4C.
A DRESa
OWNER'S
I NNAME
T V l k. � PHONE �V
-
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
ON
CONTRACTOR
NAuRFR "crDers
OUTLETS • SWITCHES - RECEP 5.00/1.00
R. Llc. No.38511a
LIGHTING FIXTURES 5.00/1.00
DATE OF APPLICATION
rorvTRAc7oR's SS gSIa9
nooREss .`
3' S. c a, SfX�I(THONE 14
PPLIANCES-RESIDENTIAL 4.00
PANELS, 5.00
ARCHITECT
OR
ENG
lO rvo.0
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS-'
�aIO Oiacl`'aW
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
/
EMP. METER OR POLE INS. 15.00
ADDRESS A 5 rvrs
MOTORS SEE FEE SCH.
1,�,..
�Y� Q5 QW
SERVICE CHANGE 10.00
p
LICENSED CONTRACTORS DECLARATION
1 hereby. from that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Civilian 3 of the Business and
1'mfr 41,C , and my license is in full IF
Licenre I- a Lie. Number 1 0l
lull'_ Co it l mctor.
ISSUANCE DATE
BLDi.
IjVWR-r
E EC
PL CH
BUILDINGPERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hemh y affirm that I xnl exempt from the Contractor's License
Law for the following mason. (Sea 703 1.5, 13ustnessand Professions
Code: Any city m county which requirese permit no construct,
- -
MISC. - REFER TO ORD
-
PERMIT ISSUANCE 6.00
VALUATION
/
$/FT.
issuance,Sher, also
requires the applicant for such permit to fila a signed statement that
requiresimprove, irerapplic. Or for su any sl it torfi eprior a si to Its atemetthat
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Uus'iness un I Professions Code) or that he is exempt therefrom and
ELEC. CONTR. LIC. NO. ELEG. 8o /
TOTAL
OTY. PLUMBING PERMIT FEE
�g¢DOO 1
-PERMIT TO
'
STORIES
TYPE�COJISTp.
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant fora permit subjects the 0).): am on civil penalty
or not more than five hundred dollars the applicant
'1
��
ALTER -DRAIN VENT -WATER IEA.) 4,00
. ❑ 1, as owner of the properly, m, my employees with wages as
their sole compensation, will do the work, and the Structure is not
intended or offered for sale (Sec. 7044, Business and Professions
'Codn•I'he Contractor's I.I.ols, law does not apply loan owner of
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
/yam
K
, 1
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
FIXTURES - PER TRAP 4.00
I GAS - EA. SYSTEM -1 INC.4 OUTLETS 4.00
So. FT. FLOOR AREA
TOTAL ACREAGE
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
mems are not intended roffered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -
builder
builder will have the burden of proving (hat he did not build or tm
prove fors owneeol the ).
❑ as owneor., the ran exclusively contracting with
. .
- EASYSTEM -OVER 4 IEA) 1.00
BUILDING USE
IND CON PB Omer
❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
d
licensed contractors no construct the project (Sec. 7044, Business
mistproperty et'
o License Law does not apply
and Professions Code: The who
to owner of property who builds or improvesehereon, and who
ASSESSORS PARCEL NO.
' ' ,
ti /I.
tr
contracts 1'or such projects with o cnntraulnrf s) licensed pursuant to
ate Contractor's License Law.
❑ tum exempt tinder Sec.., B,&p.C. foi this
reaSO11
SEWER-SANITAR V -STORM EA. 200ft/5.00
_
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4'ID
Owner Date
WATER SYSTEM 4.00
ACC.DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS',COMPENSATION [47CLARATION
I hereby affirm that I have a certificate of consent to self -insure,
or a certificate of Workers Compensation Insurance, or a certified
ZONING -
ENG. SITE NO.
ropy thereof (Sec..3800, Lah (: L�e.� C-7Policy
Z
No. Company `+'
❑ Cerlilied copy is hereby furnished.
IV Certifirdg n_p�yy'�is filed with the city inspection division.
Applicant 1-4l L3-.Crr
FIRE SPRINK
Y❑ q❑
ENERGY T-24
v❑ N❑
MISC.- REFERTOORD.
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOODZGNE
A.L.U.C.
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one
PLC. CONTH. LIC. NO.
-
PLG.
TOTAL /_.
Y ❑ N ❑
Y ❑ N ❑
hundred dollars IS 100) or less.)
1 certify that in the performance of the work for which this per.
mit is issued, I slmll nor employ any person in any manure so as to
QTY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject no the Workers' Compensation Laws of California
Dam Applicant
'f0 Certificate Ex-
ALTER OR ADD TO MECH. 4.00
NOTICIi APPLICANT: If, after making this of
emption, you should become subject to the Workeri Compensation
provisions of the Labor Code, you most forthwith comply with
such provtsio rs or this permit shall he deemed revoked
APPLIANCE 4.00
-
AIR HANDLING UNIT (TO 1QODOQF.M.) 3.00
PLAN CHECK
FEE
/
AIR HANDLING UNIT (OVER 10MDCF.M.)5.00
SEISMIC FEE
5
CONSTRUCT ION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ.C.L N(a
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
/
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name.HEATI
Lender's Address
NG UN IT ER 100,000 B.T.U.)7,50
ELECTRIC
80
I certify that I have read This application and stale that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all cil-and county
ordinances and stale laws relating to building construe) ion, and
PLUMBING
- BOILER -COMP 13 H.P. Or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,1100 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
-f L
(We) agree to save, indemnify and keep liarndess the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of (lie
anling of this p mit. - /
1:jx in 14/to UQO
Signature of Applicant o tractor Date
MECH. CONT. LIC. NO.+ TOTAL
Q'
O t
TOTAL
r
I ' - OFFICE COPY
CITY OF CUPERTINO INSPECPION•RECORD v
(OFFICE COPY)
'7
-ADDRESS
UWNhK
�DuJL�
FINAL INSPECTIONS DATE I INSP.
Gas
_ ELECTRICAL DATE IINSP.'
Power Pole
PLUMBING qty DATE I INSP.
Backflow
ELECTRICAL DATE I INSP.
S.M.?/ F!5 .*i _
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
TffSCELLANEOUS
CERTIFICATE OF COMPLETION
1; BUILDING INSPECTOR'S OFFICE
1'.4 .. CITY OF CUPERTINO
DATE Z� 1 7 19-2:r BLDG. PERMIT NO. Z E�
THE BLDG. LOCATED AT 9 SS �Gi-61 lE c�
OWNED BY -2� %� L
HAS BEEN (COMPL TED) OR USE AS S ,�
i