0563APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLYIJ,"
P BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL -PLUMBING -MECHANICAL
PE NUMBER
0563
BUILDING -
AooREss
/
03� c 1N vu P. L
OWNER'S
J'SPLAN
N -1
Lam' l
PND
PTY. ELECTRIC PERMIT FEE
CHECK VALIDATION
CONT'I 3/ ' / CTDR' / O2�
NAME
I NAME n_
LNJIV1,110 Ie r uc. NO.'J
UTLETS-SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
ADo
ADDDRESSRESS �
APPLIANCES - RESIDENTIAL 4.00
PANELS 5.00
4530! NE 2,
DATE OF APPLICATION
ORCNITECT
ENGINEER
uc, NO.
SIGNS 6.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
AARCH. OR DDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
• ZIP
APPLICANTS
ADDRESS
MOTORS SEE FEE SCHP
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 70001 of Division 3 of the Bus ness and
Professions Cp1e.:ynd- y se is in full far •tl'e51%�
License Clas Lia Number 77
ISSUANCE DATE/
BLDG.
ELECT.
PLG. MECH.
Di Cmttmc
�y/
G -2y eUNER-BUILDERDECI. A
I hereby affirm (hal 1 Ian exempt from the Contractor's ficsoosu
Law for the following reason. (Sec. 703 L5, Business and Professions
Code: Any city or county which requires permit to construct, aIle"
BUILDING PERMIT
INFORMATION
MISC. - REFER TO ORD
-
PERMIT ISSUANCE 6.00
VALUATION
,
$/FT.
ELEC. CONTR, LIC. NO. ELEC.
TOTAL
n,,p
CITY. Po�j48 IT FEE
'Inn prove, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Low (Chapter 9 (commencing with Section ,70001 of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
PERMIT TO
D
/ L�
STORIES
TYPE CONSTR.
the basis for the alleged exemption.. Any violation of Section 7031.5
CITY
by any applicant for a permit subjects the applicant Ina civil penally
of not more than five hundred dollars ($500).):
ALTER -D V ER (EA.) 4.00 ,Ob
❑ I, as owner of the property, or 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
Code: The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, Imwever, the building
BACK FL T. DEVICE 2.00
OCC. GROUP
RES, UNITS
DRAINS-FLtQO NEA, COND. 4.00
FIXTURES - PE 4.00
siz
SO, FT. FLOOR AREA
TOTAL ACREAGE
GAS- EA. SYSTEM 1 .4 OUTLETS 4,00
or improvement is sold within one year of completion, (be owner
builder will have the burden of proving that he did not build or in.
provefor Purpose ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SVSTE E IEA.) 1.00
BUILDING USE
RES IND CON PB Omer
EJ 11 1:1 0 ❑
INDUSTRIAL STEIN. R. 2000
.
licensed contractors to construct the project (Sec. 7044, Business
and ProfessionsCode. The Contractor's License Luw does not apply
to an owner of property who builds or improves (hereon. and who
LAWN SP KLERS - 1 INC 5 V.B. 5.00
LAWN SP INKLERS - OV IEA.) 1,00
ASSESSORS PARCEL NO.
contracts for such projects with a contractors) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -ST EA. 200ft/B.00
TRACT No,
PARCEL NO.
❑ 1 am exempt under Sec. ,B.&P. C. for this
Nisson
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACO. FILE NO.
WATER TREATING EQUIP, 4.00
W(IRKF:RS'COMPENSATION UECLARATIOK
1 hereby affirm that 1 have a certificate of consent to sell' -insure,
rtlf '77yy ..,,ojj��''orkers' Compensat'sn Insurance, or a certified
ZONING
ENG. SITE NO.
c o4QIuk�3800, Iab.0
li o..//NN Company
❑ Certified Copy is hereby furnished.
the
pp Ceni'd copy is tiled web the city inspersion di�xnlm.
APPlicant �.L�p�-j.-S_1�t
FIRE SPRINK
v N
ENERGY T44
vF N
MISC.- REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS,
PERMIT ISSUANCE 6.00 (p
FLOOD zoNE
A, L.u.c.
COMPENSATION INSURANCE
(This section need nut he completed if the permit is for one
PLG. CONTR. - LIC. NO.
PLG.
TOTAL
Y ❑ N�
Y N�
hundred do11ars(S100) or Iess.)
I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any nimocr so as (o
DTV. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to the Workers' Connpensation Laws of Caliti rnia.
'Date ApplicantALTER
NOTICE. TO APPLICANT: If, after making this Certificate of lix-
OR ADD TO MECH. 4.00
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
PLAN CHECK
FEE
timptfon, you should become subject In the Workers'Compensation
provisions of the labor Code, you nwst forthwith comply with
such provisions or this penttft shall be decnned revoked.
AIR HANDLING UNIT(OVER 10=C.F.M.)5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction larding agmmy for
the performance, of the wok for which this permit is issued (Sec.
3097, CYC.).
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OV ER 100,000 B.T.U.P.50
ELECTRIC
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
0
BOILER-COMPI3 H.P. Df lOD,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
_
MISC. - REFER TO ORD,
CONST. TAX
(We) agree to save, fnrlemn' y keep/Ilxrmless (lie City of
Cupertino against. iuhil ics; j" B- ea -coStand expenses which
may in a y'`ay tic c e a ty/ con sueyce V
gr nlfrlL� r'Wpen
7_
PERMIT ISSUANCE 3.00
MECH. MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
. gra( re of APPIia on GiCtOl - Date
-
OFFICE COPY
•
0563
GI'fY OF CUPERTINO IIISPE:CTIOL' RECORD (Office Copy)
_ 10330 W. Wolf_ Vall_co_ Shopping Ctr.
PCPJIIT PIO. SANITARY DISI. N0. LOT NO. ADDRESS
Plumbing E1 Torito
PROJECT
OWNER JOB SITE PIIONE NO.
ELECTRICAL
FINAL INSPECTIONS
BtILDIIIG
Date I Insp.
Pad Certification
Foundation
Pre-Gunite
Slab -I lembrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
halls -Panels
Frame
Wallboards int/Ext.
Firewalls
Other
Not Approved
PLUMBING
Date
Backflow
Undergza4w,d
Underfloor
Insp.
Ducts & Insulation
Partial Rough
Fire Dampers
Rough Complete
Fireplace
Solar Rough
Crease Duct & flood
Water & Insulation
One Hour Shaft
Main Drain
Condensate Drain
R/of/S Drain
Equipment Anchorage
Gas
Flues & Comb. Air
Other
Other
Not Approved
Not Approved
MECHANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Crease Duct & flood
One Hour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS