7141 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
• BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
APPLICATION & PERMIT
sDDRESS DDR ess O6 BUILDING -ELECTRICAL-PLUMBING-MECHANICAL 7141
O ry 8 PLAN CHECK VALIDATION
NAME DTV. ELECTRIC PERMIT FEE
PHONE S /O�
.teas
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 S�'
NAME
LC.No LIGHTING FIXTURES 5.00/1.00
CONTRACTOR 01rs
ADDRESS APPLIANCES-RESIDENTIAL 4.00
A
PHONE PANELS 5.06 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.NO SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIALCIRCUIT S.QQ PERMIT VALIDATION
ADDRESS
'rzIv EMP.METER OR POLE INS. 15.00
ADDRESS MOTORS SEE FEE SCH. (�
SERVICE CHANGE 10.00
o0z /
ra o o_ LICENSED CONTRACTORS DECLARATIONp S 5
I hereby ufGmt that I am licensed under Provisions of Chapter 9 ISSUANCE DATE
<a lest...nein,with Section 7000)of Division 3 of the Business and a BLDG_ ELECT, PLG. MECH.
r m z Professions Code,and my license is in full force and effect
hiccrosc Class Lic.Numbcr ❑ ❑ El 1:10 z� so° ;etc Contractor BUILDING PERMIT
`-¢ IS w ¢ OWNER-BUILDER DECLARATION
K S °' 1 hereby affirm Brit I am exempt from the Contractor's License
MISC.- REFER TO ORD INFORMATION
LL O¢ Law for the following reason. 7031,5,Businessand Professions �e VALUATION $/FT.
�._ PERMIT ISSUANCE 6.00 P-
Cade:Any CITY of county which reyuuesa permit to construct,elteq �.
as Q ¢ 20 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC,NO. ELEC. (�d
re o LL requires the applicant for such permit t0 file a signed statement that TOTAL / � PERMIT TO
w m he is licensed Pursuant to the provisions of the Contractor's License
zi
Law(chapter 9(conrmenciug with Section 7000)of Division 3,11 tire , lQ6i`70e C_ /w 7�„2rpn
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
i o
,c o the basis for We alleged exemption.Any violation otoaction 7031,5 STORIES TYPE CONSTR.
by any applicant fora permit subjects nc�avplieantmcivilpenalty ALTER-DRAIN&VENT-WATER MA.) 4.00
of not more than five hundred dollars(S500).).
❑ I,as owner of the".perry,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 DCC.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
property who builds orinlp.ves thereon,and who does such work FIXTURES-PER TRAP 4.00 SOI ET FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale,If,however,file building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,rhe owner- GAS EASYSTEM-OVER 4 (EA) 100 BUILDING USE
sl builder will have lire bund.,of proving that he did - . . .
not build or am- .RES IND CDN PB Omer
k pt�ve for purpose of sale:). INDUSTRIAL WASTE INTER. 20.00 1:1 El El 11 ElY� 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The C.mmemi s License Law does not apply
�1 to un owner W property who builds or improves Thereon,andwho LAWN SPRINKLERS-OVER 5(EA.) 1.00
H contracts forsuch projects with,contmctor1s)licensed pursuant to
t 3' the Commctois License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
'ems ❑ 1an xen tundra Qc. ,BAP.C.for this WATER HEATER W/VENT 4.00
"'fl rcaeon_
owner �, ,¢� Dere WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
14 ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
mfil'ni That 1 have a certificate of con end to self-insure. ZONING ENG.SITE NO.
or it certificate of Workers'Compe,saliou Insurance,or it certified
copy thereof(See 3800.Lab_CA
Policy No. Company
❑ Certil'iedcopyisherebyfprnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division.
O Applicant MISC- REFER TO ORD. y E] N❑ y ❑ NE]
?I N CERT[FICA"1'14Oil EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOODZONE A.L.U.C.
W > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG,
CL 0 CI'his si,tom need net be completed if rhe permit is for one TOTAL Y❑ N❑ Y E] N❑
hundred dollars is 160)or less
.0 O 1 certify that in the performance of the work for which Ons per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F- not s issued,1 shall not employ any person in any insurer so as to
U
become subject to(lie W rkers'Crmpesation Laws ofCalifornis, U (f-C
•�^� a [)are_Applicant ALTER OR ADD TO MECH. 4.00 BUILDING /
} W NOHCL 10 APPLICANT: If,after making this Certificate of I!x-
-� Z chip'on,you should become subject m the Workers'Compensalion APPLIANCE 4.00 PLAN CHECK
Provisions of tireLaborCode, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=11F.M.) 3.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PWC.F.M.) 5.00 SEISMIC FEE
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.C.), HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Addit H EATI NG UN IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC /
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct.1 agree to comply with all city and County PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby aatlmroc representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
abovenwnrioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cuperti against Habil' i",ju gmenls, costs and expenses which CONST.TAX
may i any ay ace SIC t If City in consequence of the PERMIT ISSUANCE' 3.00
gmnL gof SPerm' MELH.CONT. LIC.NO. MECH.
_ TOTAL TOTAL oZ/
S lure of Applican nlraetor Dare
INSPECTOR COPY
APPLICANT TO FILL IN INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY.
BU I LDING PROJECT IDENTIFICATION - '7 PERMIT NUMBER
, ,t.
aU""W"c APPLICATION& PERMIT - P
ADDRESS- ., 1
N Ra
De BUILDING-ELECTRICAL PLUMBING-MECHANICAL a 714'
;1 -
NAMEPHONE 'PLAN CHECK VALIDATION
n/E -/71d[OTV. ELECTRIC PERMIT FEE
CONTRACTORS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00 �;.GC' •
uc.ND. LIGHTING FIXTURES 1;5.00/1.00
CONTRACTORS
ADDRESS APPLIANCES-RESIDENTIAL 4.00 »s
� .
PHONE PANELS 5.00 DATE OF APPLICATION
ARCRITECT SIGNS 6.00 PLAN CHECK FEE PGNO.
OR a - .
.ENGINEER
LIC.No, SIGNSTRANS. 3.00
ARC H.OR ENG. SPECIAL CIRCUIT S.OG PERMIT,VALIDATION' L')
,ADDRESS ,
ZIP EMP:METER OR POLE I 15.00
APPLICANT'S F' '
ADDRESS MOTORS 'x SEE•FEE SCH. r -
t SERVICE CHANGE `L' 0 - J
W 0 Z
Foo LICENSED CONTRACTORS DECLARATION �,'
z1 hereby affirm that I am licensed under provisions of Chapter 9 1 tie IRO j O ,
C a, a (commencing with Section 7000)of Division 3 of the Business and P IBS NCE DATE
F H 2 Professions Code,and my license is in full,force and effect. ' BLDG. ELECT.' PLG: , MECH."
o i m o License Class Lie.Number OF4A�
m F w Date Contract., - A
A y IF I BUILDING PERMIT
X �w � OWNER-BUILDER DECLARATION -' '^
w ;n m 1 hereby affirm that 1 am exempt from the Contractor's License MISC.- - REFER TO ORO ,'
u_o j Law for the following reason.(Sec.703 t.5,Business and Professions PERMIT ISSUANCEVAL 4fier.
QF Code:Any city or county which requires a permit to construct,alter, 6.00 '},,� /1,.' 11
p Q 0 improve,dCInOIISh,Or repair any S[rnmure,prior to its Issuance,also ELEC.CONTR. LIC.NO. ' ELEC. ' F/ {jl a Q y R
i w m¢ requires the applicant for such permit t.file a signed statement that TOTAL �� ,.
he is licensed pursuant to the provisions of the Contractor's License - - PERMIT TO
p
FZQLaw(Chapter 9(ccmmencingwith Section 7000)ofDivision 3 ofthe7i;-• Pte•
E 4 O Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE -
mFm the basis for the alleged exemption.A Ry violation'of Sect ion 7031.$ STORIES, TYPE CONSTR.
i by any applicant fora permit subjects $500h.licant toacivil penalty ALTER-DRAIN VENT-WATER'(EA.) 4,00
of not more than five hundred dollars(my em):
❑ 1,as owner of the property,or my¢mployees•with'wages as BACK FLOW PROTECT. DEVICE 2.00 , OCC.GROUP RES.urvtTB
their sole compensation,will do the work,and:the structure is not
Code:Th• offered for sale (See7044,doe, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License thereon
not apply to an owner wof ork property who builds or improves[hereon,and who does such work FIXTURES-'PER TRAP a 4.00 P• ' •50.FT.FLOOR AREA -TOTAL ACREAGE
himself or through his own employees,provided that such improve- - - -
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1'INC.40UTLETS 400 -
or improvement is sold within one year of completion,the owner- _
builder will have the,bure en of proving that he did not buildor am- GAS-EA.SYSTEM-OVER 4,(EA.) 1.00 BUILDING USE
1s�oye for purpose of sale.). - RES', IND CON PB Other
' LY I,-as'owner of the property,am exclusively contracting with ' INDUSTRIAL WASTE INTER." -20.00 ,',.f-T•. `'El O' 1:1
;
licensed contractors to construct the project(Sec. 7044,Business LAWNSPRINKLERS-1 INC 5.V.8. 00 y gSSESsoRB PARCEL No.5.
and Professions Code:1'he Contractor's License Law does not apply - - r
to an'owncr of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.)' 1.00
contracts for such projects with a contracror(s)licensed pursuant to `
the Contrac or's License Law, SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO
❑ la xen pt under c. ,B.&P.C.for this WATER HEATER W/VENT -4.00 -
reason
Owner + Date WATER SYSTEM• , .. _ 4.00 ACC.DATE ACC.FILE NO.
„ WORKERS'COM PIINSATION DECLARATION WATER TREATING EQUIP.„ 4.00 s -
rereby affirm that I have a certificate of consent to self-insure,ora certificate of Workers'Compensation Insurance,or a certified ' ZONING ENG.�S ITE NO.
ropy thereof(Sec.3800,Lab C.). - -
Policy No Company
O • ❑ Certified copy is hereby furnished: ' FIRE SPRINK ENERGY T-Z4
Z Z O-Certified copy is fled with the city 'inspection division.
F, O ApPhnvnt' ` - MISC:- -REFER TO ORD. :YE] N� v0N '•N�.
W CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE I 6.00 FLOOD ZONE' A.LU.C.
LU COMPENSATION INSURANCE - PLG.CONTR. LIC.NO.' . PLG, '
Q' 0' " (This'Section need hot'b¢ completed if the permit'is for on¢ .•'I ' TOTAL V❑ -N� v Q" NE
•:) Z hundred dollars($100)or less.) .s
U O I'certify that in the performanceof the work For which this per. QTY MECHANICAL PERMIT FEE " FEE SUMMARY
LL F- mit is issued,I shall not employ any-peAon in any manner so as to ,
O'w become;subject to the Workers Compensation Laws of California. - - -
y Date' Applicant - -
' } or NOTICE. TO APPLICANT: lf,'eift¢r'makiog this Certificate of Ex- ALTER OR ADD TO MECH: 4.00 BUILDING
Z empton,yon should become suhjectgto the Workers'Compensation. APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith-comply„with U FEE 'such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=CF.M.) 3.00
• - CONSTRUCTION LENDING AGENCY' . AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 , SEISMIC,FEE ate:
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,CRU.). - - HEATING UNIT(TO 100,000 B.T.U.) 4.00 .
Lender's Name -
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 aELECTRIC,
`
-
I certify that i have read•thisappbcaton and state that the above ' VENTILATION FAN (SINGLE) ' 3.00 -:
� Information is correct I agree to comply with all city and county -
. ordinances and stale,laws relating to building construction, and BOILER-COMP,(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING ..
hereby authorize representatives of this city to en[or`upon the .BOILER-COMP'I Over 100,000 BTU)SEE FEE ITCH. MECHANICAL-
above;mentioned property for,inspect purposes. 4
(Wej agree to save, indemnify'ampkeep harmless the City of MISC.- - ^REFER TO ORD. -
Cuperd against liabih'ies,y4 grunts, costs'and expenses which -
may, any ay sec e a t aid City in consequence of:the PERMIT ISSUANCE 3.00 CONST.TAX
gran g of sperm' MECH:CONT $ LIC NO MECH. 9
r TOTAL TOTAL T/
aturoof Applican t ntractor Data
OFFICE COPY .' , _ • '
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
--- -AUDRE66 LOT O.
g C-1 R
PERMIT ISSITED DATE "ELECTRICAL DATE INSP.'
Electrical
Plumbing "Power Pole
Mechanical �rr„�un
e as ec oR Wiring
o
oar Malls -
ire rin c er ei in
Siixtures nt/Ext
tors
Misc. Grounding
e ower
uther
FINAL INSPECTIONS DATE INSP, Not .Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
.Mechanical
o ar Backflow
.'Solar
or un
r err r oor
Planning artaRough
N
a t. u c ete '—
ea t pt, ar nuEl
�uil3mg — Wa—ter-4 Insulation a—ter-4I
Other err aur .
o ain
Lias
Other
BUILDING DATE INSP. Not Approved
Pad Certification
oun anon ELECTRICAL DATE INSP.
Pre-Gunite
amain cane Underfloor S.M.
Beam Ducts & Insulation
LInderfloor Girders Fle ers
Floor tee ireree ace
ie ownsree ase Duct oo —`
is ramsnye our Sham –
eismecracin Condensate aur _
s- ane s _ ui ent orage --
rame Flues omb�Cir
.
37ewa s
lboa�r ss Int/Ext. '” Fat rove
�ir
Ne./ f
t� Approved _