6092 AFfLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY-
1. BUILDING PROJECT IDENTIFICATION � 'PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS . 6092
V /L JAN UILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNERS PLAN CHECK VALIDATION
Rick /� _a TV. ELECTRIC PERMIT FEE
./ LT T7
CONTRACTORs PRUNE OUTLETS-SWITCHES-RECEP 5.00/1.00
AtiCia-n T LQ Lie... LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S APPLIANCES'-RESIDENTIAL 4.00
ADD Ess - S"
/ Z.e (/'• vRONE ,S'/3 PANELS 5.00 DATE OF APPLICATION
nry�H l �C,To �y�1 /iy/g SIGNS 6.00 PLAN CHECK FEE P.C.NO.
SIGNS TRANS. I 3.00 -
ARCH.ORE G. PERMIT VALIDATION
DRESS ((��/'+' Gl SPECIALCIRCUIT 5.00
x0 - .>a'r nP /S/� EMP.METER OR POLE INS. 15.00
eESS p'FACTORS SEE FEE SCH. r
T i
S 10.0
a
Foo LICENSED CONTRACTORS DECLARATION {r
rt U U I hereby affirm lint I.em licensed under provisions of Chapter 9 ISS ANCE GATE
v,Q a (commencing with Section 7000)of Uivislan 3 O(tI1C BusinCS,and B 0 ELECT. PLG. MECH.
r y' Nofessinns CodC it my license ix in full fnr'
License£1 ss }�^�� Lie.Number +}��j� ❑ ❑
ON Dah .�/L Contractor •�� L
a y g BUILDING PERMIT
¢ ¢O re O OWNER-BUILDER DECLARATION INFORMATION
X
; u_y I hentiy affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD VALUATION $/FT.
L
0 j law for the followingreason.(See.703 L5,Business and I'rD fessions 6.00
I- - PERMIT ISSUANCE
Code:Any city or county which requires a permit to construct,alter,
a �' improve,demolish,Or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 4t
C requires the applicant for such permit to file a signed statement that TOTA "Jr� PERMIT TO
e w he is licensed pursuant to the provisions of the Contractor's License -
H, i Q
Law(Chapter 9Commeneiagwilh Section 7000)of Division 3 of the
14 o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
ic I- m the basis for the alleged exemption.Any violation of Sermon 7031.5 STORIES TYPE CONSTR.
La by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not mom than Five bandied dollars(S5001.):
❑ 1,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 docs not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 sO.FT.FLDDR AREA TOTALACREAOE
himself or through his own employees,provided that such improve.
mens,are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-l1NC.40UTLETS 4,00
or impmrventenl is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
Dodder will have the burden of proving that the did not build or im- E IND CON PB Other
prove 11,aso neeose or ofthe.). INDUSTRIAL WASTE INTER. 20.00
❑ L as owner of the properly,he exclusively contracting with ❑ ❑ ❑ ❑
aril11.. contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and 1'mfcstians Code:The Contractor's License Law docs not apply
to an owner of property who builds or improves thereon,and who LAWNSPR IN KLERS-OVER 5(EA.) 1.00 '
contracts for such projects with a mnVactor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I ons exempt under Sec. 0.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.GATE ACC.FILE N0.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00 �)
I hereby affirm that 1 have a certificate of consent to sol Ginsure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(See,3800,Let,CA '
Policy No. Company
O ❑ Certified copy is hereby finished. FIRE SPRINK ENERGY T-24
Z, Cl Certified copy is filed with the city impoction division. MISC.'- REFER TO ORD.
Applicant Y❑ N❑ Y ❑ N❑
= T CE it 1]1;ICA1 1:OF ExEm PTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. y❑ N❑ Y El NE]
0( This soction need not be completed if the permit is for one TOTAL
hundred dollars(5100)or less.)
U O I certify that in the performance of the w rk r which this per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any per; R y manner so as to
U IiccnrrlDSubjc t T orkers' !n fm aws of Cal,
for
0 C. Date =tom_ pplicant ALTER OR ADD TO MECH. 4.00 BUILDING
} N NOTICE 'r0 API' (CANT: It,after making this Certificate of fix.
f" 2 emptiou,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK -11
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 10AWC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10010C.RM.) 5.00 SEISMIC FEE
1 hereby affirm tat there is a construction lending agency I'.. EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work bar which this permit is issued(See. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B:T.U.) 4.00
Lender's Nddr HEATING UNIT(OVER 100,000 B.T.U.)7.50 /
Lender's Address ELECTRIC
I certify that I have read this application unit state that the above VENTILATION FAN (SINGLE) 3.00
information is carnet. I agree to comply with all city and countyBAILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00 PLUMBINGell
ordinances and state laws relating to building construction, and
hereby aulhnrire representatives of this city Its enter upon the BOILER-COMP (Ce.,IWOOOBTUI SEE FEESCH. MECHANICAL
above-mentioned property for ins action purposes.
(We) agree toj%ave e y and keep harmless the City of MISC..- - REFER TO ORD.
Cupertino against I'' i' a gnnnv costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way a mss said Cily in consequence of the /
gra Igo is c16 ECH.CONT: - LIC.NO. - MECH.
TOTAL TOTAL 2l0
u Appli nt/Contractor Date
OFFICE COPY
r !
y
loo
C '
486
c
IH
co
, .
I
CITY OF CUPERTINO INSPECTION RECORD
(OFFT(E COPY)
ADDRESS
�j9
IiLG��'�1Yt.J .�LlihlC.G'J.rili-,
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
uB—i1din .
EIectrica
FfMin "Power Pole '
an3F5 Underground
Tem as ec xough Wir:Lng _ —
Solar ells
rk_erCeiling _.
Si— ixtures Int/Ext
motors
Misc. Grounding
e ower
er
FINAL INSPECTIONS DATE INSP. ot . prove
Gas
Electric
Plumbing "PLUMBING DATE J INSP.
.%'-cFianicar —
o ar flow
T—_— Backr �
` •� m
URoor
Plann3mg Partialu
Fire �eppt. u ete ,.�. 3 3r�S—
hea,th Dept ar u
ttierBuildingWater '& Insulation
i
_tUFie
oDrain
Gas _
Other
BUILDING DATE INSP. Not rove
i Pad Certification
oun ation _ ELECTRICAL DATE INSP.
re- ite
Slab-Membrane Underfloor S.M. (�
Bond eam ijucts4nsu insulation
Unoor it ers ire ers
Floor tee ire ace
ie owns brease uct & Hood
Diaiapphirams
Seismec race® a Condensate Drain
1�s- ane I.s ui ment orage
Frame _ - —
aL-"Fi _ n eta s r
X11 oar Int/Ext. 3-T3 of prove
rewawa . s
t ' 3-
u�
Met ApproVed 9
a�-��
0,14 -
BUILDING
ELECIMCAL
PLUMBING
MECHANICAL
MISCELLANEOUS