3466 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
K. BU LDI NG PROJECT I DENTI FICATI ON PERMI MBER
APPLICATION & PERMIT B ��
II
DDRESS 1 LF
Y. 'r wLr f • II �Lf BUILDING.=ELECTRICAL-PLUMBING-MECHANICAL -'
OWNER'5 PLAN CHECK VALIDATION
�• NAME��G?L' �' �� QTY. ELECTRIC PERMIT FEE
NCCTCHS ONE
CONTRACTOnS
NAME OUTLETS-SWITCHES-RECEP 5.00/1.00
LIC.NO. LIGHTING FIXTURES 5.00/1.00 .,
CONTRACTOR'S -
- Y ADDREsgs - Brr-,E'r�r APPLIANCES-RESIDENTIAL 4.00
/\ / y-67 ,rr 'HONE /J' PANELS 5.00 DATE OF APPLICATION
ORRLHITECT SIGNS 6.00PLAN CHECK FEE P.O.NO.
PIV(IIRttT - '7
le,41 A'0. 1 1-,Le.,NO. SIGNS TRANS. 3.00
ADDRE55 E"GSPECIALCIRCUIT 5.00 PERMIT VALIOATIO
Is, 'Sf OD f'L CijV :vd �d L/' Cu, EMP.METER OR,POLE INS. 15.00
APPLICANTS IMOTORS SEE FEE SCH. c:J
ADDRESS
SERVICE CHANGE 10.00ca
O o LICCN that I a IBA used u DECLARATION / /W
I hereby affirm that I am licensed under provisions of Chapter A
'� (commencing with Section 7000)of Division 3 of the Business and
¢ n BLDG. ' ELECT. PLG. MECH.
w " Professions Co> and my license is in toll for c and efj G ❑ ❑ ❑
z.o v, - License CI. s I.Ie.Number
0 ZA F w IT Contractor
a m E BUILDING PERMIT
rc ¢ ¢ OWNER-BUILDER DECLARATION
o a" MISC.- REFER TO ORD INFORMATION
K
3 1 hereby affirm that I am exempt from the Contractor's Lirense VALUATION
LL
LL o 4 Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6 00
s $/FT.
Code Any city or county which requires.permit to construct,aIter,
0 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
PER T T
w m w he is licensed pursuanten the provisions of the )ofDivtor's License
F i >
Business
(Chapterand
Professions
nCodecing )or Section is exempt theref o and (VA
¢ Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
¢ = � the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
a3 _ by any applicant for a permit subiects the applicant to a civil penally ALTER-DRAIN& VENT-WATER (EA.) 4.00 r_
of nal more then five hundred dollars(5500).):
❑ I,as owner of the property,Ri my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and tine 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 dues not apply to an owner of
property who builds or improves thereon,and who does Such work FIXTURES-PER TRAP 4.00 SG.FT.FLOOR AREA TOTAL ACREAGE
himself us re through his own employees,provided that such improve-
himself a through dad oroffered for employeesale.lf,ed that r.Such
emprong GAS-EA,SYSTEM-1INC.4OUTLETS 4.00 �-
or improvement is sold within one year of completion, file owner- GAS-EA.SYSTEM-OVER 4(EA.)
builder will have the burden of proving that he did not build or im_ 1.00 BUILDING USE
RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑. ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWNSPRINKLERS-1 INC.5 V.B. 5.00 gssEssoas PABCEL No.
and Professions Code:The Contractor's License Law does not apply /
to an owner of property who builds Or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
Ccontracts for such projects with a contractor(s)licensed pursuant m
tale Contractor's License Law. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT NO. PARCEL NO.
the r
.❑ lam exempt under S..-,B&P.C.for this WATER HEATER'W/VENT - 4.00
reason
Date - Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00
I hereby affirm that I have a certificate of consent to SCII'-insure,
or a certificate of Workers'Compensation Insurance,or a certified -rtL(le�, p ZO fl ENG.SITE N0,
co
otl e�D ee QQyyyy C:). o� (,(/�/I SA4 3r ?7c*
O Certified.c Py is herebyfurnished. tF/R2'Gt!/)Ttl"'� Fw sPRwK EN ERCV r-24
Z
CC fit d o is Ci ith ih cieN
division.
-�p� Applicant MISC,L 20 J"Jdi2 REFER TO ORD. /p v N❑ v ❑ N❑
~ rn PERMIT ISSUANCE 6.00
O: CIi RTIFICA'IT OF EXEMPTI FRS' FLOOD ZONE
IU - COMPENSATION INSU PLG.CONTR. - LIC.NO. PLG. -�R.
(This section need not be completed if the permit Is for ono TOTAL 7` V❑ LJ i.L❑
hundred dollars IS 100)or less.)
U O 1 certify that in,Nle performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
IL F mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
Date Applicant BUILDING
a ALTER OR ADO TO MECH. 4.00
} W NOTICE TO APPLICANT: If,after making this Certificate of im
♦- Z Er visions of
should become
e, you most
Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. ' AIR HANDLING UNIT(TO 10/100 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY - AIR HANDLING UNIT(OVER 10=C.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 Name H EATI NG UN IT(OVER 100,000 S.T.U.)7.50
Lender's Names ELECTRIC
I certify that['have read this application and State that the above VENTILATION FAN (SINGLE) 3.00
information n correct. I agree to comply with all city and county BOILER (3 H.P.or 100,000 B.T.U.), 4.00 PLUMBING
t ordinances and correct.
State . I a relating to comply
will) construction, and -
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE F EE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.'- REFER TO ORD.
Cuperti must liabilities,judgments, costs and expenses whicll PERMIT ISSUANCE 3.00. CONST.TAX
maY an ay .care against 'i City in consequenc of(b
gran(ng spermil MECH.CONT. LIC NO. MECH.
l L TOTAL tp
TOTAL aaa
gnafimvof Applicant/Contra IT&IE -
�� OFFICE COPY
CITY 01' CUPERTLNO INSPECTIOV RECORD (Office Copy)
1'1;P�lo. SANITARY DISI. NO. 1. A�� ���A )RI•;5 � ---
PROJECT
OWNER JOB SITE PHONE N0.
PERMIT ISSUED Date ELECTRICAL
Buildi.ne _ Date Insp.
III ectrical Power Pule
I'Lumhing Underground — --
ilechani.cal Rough Wiring _
Temp. Gas/l;lcct. I1a11.s _
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext _
Sign Motors
Grounding
Hi.sc. Temp. Power _
Other
FINAL INSPECTIONS NoL Approved _
Date Insp.
r„s
PLUPIBING
Electric Date Insp.
Plumbing Backflow _
Mechanical Underground 3
Solar Underfloor
Pool
Partial I;ou;;i /
Gradin , Rough Complete --
I'Lnnni.ng Solar
Rough
Fire De t. Water & Insulation-* ;� _
Health Ie t. "lain Drain('0
Building R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp. to.,..." G T3
Pad Certification m a'
Foundation pWa�ow�A-mT"ML� p�
Pre-Ganite �D�� Iat Insp.
Underfloor s.PI.
Slab-Hembrane Ducts & Insulation
Bond Beam Fire Dampers _
Underfloor Girders Fireplace _
Floor Steel Grease Duct & flood
Tiedowns One flour Shaft
Diaphrams Condensate Drain
_
Seismic BracingEquipment Anchorage"
I1al..ls-1'ancls
Flues & Comb. Air
Frame Other
Lath Not Approved
Ilallboards Int/Ext . .�7 �1
Firewalls // oC�M Oki yyye f -/1-b3
Other
Not Approved 73
BUILDING
ELECTRICAL
PLUMBING
/ wa.� P. �W c�,n.�.en . r..Qoe w�v N i✓cw».a.� G 'y P�-
WTAX �y
MECHANICAL
MISCELLANEOUS