3385 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTI FICAT P MI ER
BUILDING APPLICATION & PERT' Q C
ILDIN Q J
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
NER'S G,¢J,IEC / PLAN CHECK VALIDATION
"" (/ QTY-. ,2 ELECTRIC PERMIT FEE
PRONE /� !I
corvr Acrons GI�O UTLETS-SWITCHES-RECEP 5.00/1.00 (�
NA E �y
UC.No. 27S LIGHTING FIXTURES 5.00/1,00 0-0
CONTRACTORSONTRACTORs M/•y- /g (F`S PPLIANCES-RESIDENTIAL F4.00
ORES I D. NE 2 ANELS PAID 5.00 � DATE OF APPLICATION
ARCHITECT I SIGNS 600 PLAN CHECK FEE J P.C.NO.
OR
ENGINEER
uc,NO SIGNS TRANS. APR I I NdJ3.00
ARCH.OR ENG, SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR 0 u ertinol5.00 n
ADDRESS MOTORS SEE FEE SCH,
SERVICE CHANGE 10.00
Foo LICENSED CONTRACTORS DECLARATION 3 2 mp
1 u w I hereby affirm that 1 an licensed under pruviawo,of Chapter ISSUANCE DATE
H z vi lcommenemg with Section 70001 of Division 3 0(the Business d n r O ` BLDG. ELECT. PLG. MECH.
F y z Professions Ca de yn her,"
is a full fort s ❑
z o m - License C ass Lic.Nmnber ❑ ❑
9 H °w Dotc ��[�Contrucmr_
Q y E J
M xr OWNER-BUILDER DECLA A BUILDING PERMIT
w 1G INFORMATION
Is , MISC.- REFER TO ORD
Is u-y I hereby al firm tlm1 I am exempt from lire Contractor's License vALUAnON SIFT.
F u o a Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct.alter,
R Q Q improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- O u requires the applicant for such permit to file a signed statement that TOTAL/I� PERMIT TO
w whe is licensed pennant to the provisions of the Contractor's License
F z i Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe 6-r-77
PLUMBING
< Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT FEE
0 the basis for thealleged exemption.Any violation of Section 7031.5
STORIES TYPE CONSTR.
in
p3m by any applicant for a penot subjects the applicant In a civil PenaltyALTER-DRAIN& VENT-WATER (EA.) 4.00
of not per,than five hundred dollars(S500).).
❑ I,as owner of 0m property,or fry 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(See. 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 or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided thus such...... o-
intents are not intended or offered for sale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or Improvmnent is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or am- RES IND CON PB Omer
Prove for Purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
D I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code: Fhe Contractor's License Law docs 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 a contracmr(Q lieensell pursuant to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
lire Contrazmr's License Low.
❑ Ialn exempt under Sri,-,BAP.C.for this WATER HEATER W/VENT 4.00
on
' Dam Owner WATER SYSTEM 4.00 ACC.DATE ACC FILE NO.
WORK F-RS'COSIPENSATION DECLARA'MON WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certilieate of colsent to wil-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation,11 nce,or a evil it
V ' copy there) lr( �f10�pLob,S. /�.�.
Q ///"' ❑ Gcrtill, op try film red FIRE bPRINK ENERGY T-24
Z Z •Olicant ftel� y is 11itt tion MISC.- REFER TO ORD.
O �Applicanl-�/ y�! V ❑ N❑ V ❑ N❑
ir W CERTIFICATE OF XIi.MPTION FROM WORKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE AL.U.D.
W > COb1Pl--NSATION INSURANCF PLG.CONTR. LIC.NO. PLG.
4. O fI'hiS section need not be completed if the permit is for one TOTAL v❑ N❑ v ❑ N❑
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of tile work for which this Per OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL H mit is issued,I shall not employ any person in any nwnn,r s0 as to
0U become subject to the W'nrkcri Compensation Laws of California. BUILDING
Dale Applic'amt ALTER OR ADD TO MECH. 4.00
} tan NO'T'ICE '10 APPLICANT: If,after making this Certificate of[A
2 emption,you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
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 10=C.F.M.1 3.00 A
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10000C.F.M.) 5.00 SEISMIC FEE
I hereby al'tirnl that there is a construction lending agent for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work $or which this permit is issued(Sec. HEATING UNIT(TO 1OQ000-BT-U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.17.50 ELECTRIC ��0 Qa
Lenders Address
I eertily that lhaveread lhisapplieation and slate that the ubill' VENTILATION FAN (SINGLE) 3.00
fonnation is correct. I agree to comply with oil city and county PLUMBING
dd' ances and state laws rclming to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
by authariae representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)'SEE FEE SCH. MECHANICAL
bnove.mentloned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Iiahllitius,judgncnts, costs and expenses which CONST.TAX
may i any way accrue against Said City in consequence of tits PERMIT ISSUANCE 3.00
gr 6 of this pen MECH.CONT. LIC.NO. MECH.
DIAL TOTAL
Sib mturc o(Ap taunt/Conhacmr
OFFICECOPY ,
• GI'1'Y Op CVT'INO INSPECTION RECORD (Offic411ppy)
33gs
3229 11000 N. Wolfe Rd.
PI;PIIIT' 50, SANITARY DIST. 140. LOT N0. ADU[il`.S,ti
Const. Int. Anechoic Chamber Hewlett Packard
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Building ____ 3-10-83 Date Insp .
Electrical -O",3 Power Pole
Plumbing; Undorgrouncl
Qchanica1. Rough Hiring
'Temp. Gas/F.iect. Ila la.s _---
Solar Ccili.ng
Fire Sprinkler Fixtures int/Ext _
Sign Motors
Grounding
Ffisc. Temp.
Per
Other------
FINAL
ther _FINAL INSPECTIONS Not Approved _
Date Insp.
Ars —_ PLUMBING
Electric �� :7-_ Date Insp .
Ptnmbin , Backflow
Mchanical Underground -
Solar Underfloor
Pont _ Partial. Rough
Grading Rough Complete
Planning Solar Rough __—
Fire Dept. - 7-14( [dater & insulation
Health Dept. plain Drain
Building R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-hemhrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One Hour Shaft
Di.aphrams Condensate Drain
Seismic Bracing EquipmenC Anchorage _ _
Halls-Panels Flues & Comb. Air
Frame Other
Lath Jot Approved
Uallboards Int Ext .
Firewalls
Other
Not A2proved