5744 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
' $UI LDI NG PROJECT I DENT[FICAT10N I PERMIT NUMBER
ADILDIN APPLICATION & PERMIT
DDRESSn (�� C BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 5744
OWNER' V PLAN CHECK VALIDATION
NAME QTYELECTRIC PERMIT FEE
f) l PHONE �S�_71P .
CON
NAME �x UTLETS-SWITCHES-RECEP 5.00/1.00
/JIRL Bta2-1- LIC.No, yj ,5 LIGHTING FIXTURES 5.00/1.00
POOR
RESS PPLIANCES-RESIDENTIAL 4.00
CONTRACTOR
y7-99 PANELS 5.00 DATE OF APPLICATION
ARRCHITECT r SIGNS 6.00 PLAN CHECK FEEO
ENGINEER ^
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
AZIP EMP.METER OR POLE INS. 15.00
ADDRESS
MOTORS SEE FEE SCH.
.
SERVICE CHANGE 10.00
woo LICENSED CON'PRACPORS DECLARATION
Q U v I hereby al tion (hut I am licensed under provisions ol'Chaptcr 9 ISSUANCE DATE
N n (commencing with Section 7000)of Division 3 of the Business and
a BLDG. ELECT. PLG. MECH.
F w z Professions Code,yJld y license is in full for .. itt f ❑ ❑ ❑ ❑
o i y W Lot, Clus Lic.Numhcr x7V
Dam'7I2S_ Contractor-LCAN
a m BUILDING PERMIT
OWNER-BUILDER DECLARATION
A o a INFORMATION
PA
w g I hereby affirm that 1 am exempt from the Contractor's License MISC.- REFER TO ORD
F n o j Law for Gm following reason.(Sec.703 L5.Business and Professions PERMIT ISSUANCE 6.00
VALUATION $/FT.
PwwE Culls:Any city or county which requiresapermit In construct,alter, 0
SE ¢ ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIG N0. ELEC.• (f7lTt
O ¢ requires the applicant for such permit to file a signed statement Ilial TOTAL
6 w m he is licensed pursuant to the provisions of IIIc Contractors License
PERMIT TO
F,zQ Law(Chapter 9(camnmeneing with Section 7000)of Division 3 of the �(. �� '�
¢ o Business and Professions Code)or that he is exempt therefrom Slid OTY. PLUMBING PERMIT ItyC'E A01-41
¢F o the basis for the alleged exemption.Any violation of Sermon 7031.5 STORIES' TYPE CONSTR.
ems -
by any applicant for a permit subjects the applicant talz civil penalty ALTER-DRAIN (EA.14.00
of not more than five hundred dollars(S500).): _
Cl 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 occ.GRouP RES.UNITS
icir sole compensation,will do the work,and the stmeRne is not
immoded 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 or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
hin,sellor through his own umployces,provided that such improve-
mentsarenotintendedoroffered I.,sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS t EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or hit- FES IND CDN PB Omer
prove for purpose 0 sale). INDUSTRIAL WASTE INTER. 20.00 El El El ❑ E]❑ 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 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 conturem to licensed pursuant to
/ the Con trmtnri License Low. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sea ,B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date _ WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO,
WORK ERS'COMPENSA'I'ION DECLARATION WATER TREATING EQUIP_. 4.00
I hereby affirm (hal 1 have a certificate of consent to sell-insure, ZONING ENG.SITE NO.
or u certi Laatc ur Worker,'Compensation Insurance,or a ccitified
copy thereof(5.V411910,
0 b.CJ.
Pohey Nn.411j cMln
O ❑ erlili'd ',my is hereby fumisbcd. FIRE SPRINK ENERGY T]4
Z
2 C rlil' cr' 1�1� ny inapecllon division,
F F O nnplicala � MISC.- REFER TO ORD. y❑ N❑ Y ❑ N
- CIi R1'I FICA'1'1i 01'pXEMI'l'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.LLLC.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
CIL. 0 (This section need not he completed if the per...it is for one TOTAL - Y❑ N❑ Y ❑ N❑
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
bee mno subject to the Workcri Conlpcmuliun Lnws oPCuli
Cforniu.
1 Dale Applicant BUILDING
- N NOTICE '1'0 APPLICANT: If, He,making this Certificate of lis- ALTER OR ADD TO MECH. 4.00
F- ? emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions o1' the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10M0C.F.M.) 3.00
CONsTRUC'I'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE 6a
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT). 2.00
the performance of the work f which this permit is issued(Sec. MICROFILM
30'17.Civ.C.). _ H EATING UN IT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address 'Trt ELECTRIC
I cenity that I[,live read i1n,application and sane mal lire above VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and slate laws relating to building construction, and BOILER-COMP(3H.P.or100,000B.T.U.) 4.00
hereby, authorize representatives o1' this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCH. MECHANICAL
above.mentinnedPropert for inspection nmpows
(We) agree to sa mnnify a d keep harmless lire City of MISC.- REFER TO ORD.
Cupertino cs,jud• Its, coals and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
mu an c ug:f aid City in unsequee re of tlm
alliin• a MECH.CONT. LIC.NO. MECH.
d TOTAL TOTAL 3� /f
Signa ne plicant/Con raztor I Dah,
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
• 02 7 -S� /U� 26p oleo(?I NU. ADDRESS - -
F=7 7MR
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
ui in
e Pca
Plumbing Power Pole
Mec:hamcal er un
Tenp Gas/Elec u win
Solar a s
Fire Sprinkler ceiling
bign Fixtures nt xt
otors
Misc. Grounding
12�D Power
Uther
FINAL INSPECTIONS DATE INSP. NotApproved
Gas
Electric
gun ing PLUMBING DATE INSP.
anica
o ar Backflow
001 r im
gra in r ouo
GlnPartial ou
ire t, u o ete
ea t e t.
Solar u
m inWater ' ns ation
er in . a�n
oDrain
Gas
Other
BUILDING DATE INSP of Approved
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-NJembrane Underfloor S.M.
Bond cts nsu ation
Underfloor Girders Fire Damers
Floor Steel Fire lace
ie owns Urease JXlct & Hood
Diaphram One Hour Shaft
eismecracindensate ain
a s- anels m ment Anc ora e
tame Flues r
a Other
a oar Intxt. rove
7tFFirewa s of
er
Net Approved