13085 (3) APPLICANT TO FILL IN'.INFORMATION WITHIN 1ED Lr,NES - USE BALL POINT PEN'ONLY:'
-'
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BULLmNG -.--APPLICATION & PERMIT
;$�iSµC I•.V� DoT aasoT 13085
ARL
BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S
NAME 4M
PLAN CHECK VALIDATION
OTY. ELECTRIC PERMIT FEE 367
R d DNE
NAMFRacraas UTLETS-SWITCHES-RECEP 10.00/1.00 ('Z Z"3�
Uc.NO.Z4o46 LIGHTING FIXTURES 10.00/1.00
ADO ass TOR's /1 APPLIANCES-RESIDENTIAL .4.00
P40N T'� • f PANELS . 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20.00 - PLAN CHECK FEE" P.C.NO.
ENGINEE
' uc.No C646% SIGNS TRANS. 300 '
ARCH.OR ENG.14w�+9/ SPECIAL CIRCUIT S.00
ADDRESS M� PERMIT VALIDATION
«t EMP.METER OR POLE INS. 20.00 �.,�tr�
APPLICANTS
MOTORS SEE'FEE SCH.
ADODRESSDRESS �1TT MK''���+ - /
SERVICE CHANGE ROD
X00 LICENSED CONTRACTORS DECLARATION {, /pZL3�p
<u v 1 hereby affirm that 1 am licensed Division 3 of the Business and under provisions of Chapter 9 t (!'ISS/U/U/ANCE'DATE�
z w (commencing with
< Section 7000)of BLDG. ELECT. PttL�r..M MECH.
r N i Professions Code,and my license is in full force and effect. ® �
o i,n W License Class Lic.Number
Date Contractor s
at x s BUILDING PERMIT
E 0 i U OWNER-BUILDER DECLARATION INFORMATION
F 3:,� w 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO'.ORD
w VALUATION $/FT.
F w 0 at Law l'or the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
iw Code:Any cityorcounty which requires a permit to construct,alter,
q � Go
p ¢Q D improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC. �C O
ec D u requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
w$ he is licensed pursuant to the provisions of the Contractor's License S f—D �
r2T
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe U L
sic Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
ILHthe basis for the alleged exemption.Any violation of8eclion 7031.5 STORIES TYPE CONSTR.
m
ec ;.� by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN IEA.) 5.00 ��11
of not more than five hundred dollars($500)): y, 1�/V/J/�—
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 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 ProfessionsDRAINS-FLOOR,ROOF,AREA,COND. 5.00 r. �, /
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 5.00 SOL FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve
OL N
mems are not intended or offered for sale.If,however,the buildingG,AS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or ml- BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE INTER. 30.00 IND CON PB Omer
-' ❑ 1,as owner of the property,am exclusively contracting with ES ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7046,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 .ASSESSORS PARCEL 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 3xS'� —� 7_Q
contracts for such projects with a contraclons)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT'NO. PARCEL NO.
❑ I am exempt under Sec.- ,B.&P.C.for this WATER HEATER W/VENT 6.00 6-11
/
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Workers'Compensation Insurance,or a certified / ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C).
Policy No. Company ,
0 Cl Certified Copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z2 ❑ Certified copy is filed with the city inspection division.
MISC.- REFER TO ORD.
O Applicant V❑ N❑ Y ❑ N❑
� y CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU .2 COMPENSATION INSURANCE PLG.CONTR. LIC.NO. - PLG. y o IN❑ Y ❑ N❑
EL Z
(This section need not be completed if the permit Is (of one TOTAL _
hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this Per- OTY MECHANICAL PERMIT FEE FEE SUMMARY
LL h 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 'S' I
a ALTER OR ADD TO MECH. 5.00 -�
W NOTICE TO APPLICANT: If,after making this Certificate of Ex- _
Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 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 10,000C.F.M.) 4,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.PM) 6.00 SEISMIC FEE
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5,00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and state that Ithe above VENTILATION FAN (SINGLE) 4,00
information is correct. I 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.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(we) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino ago' st liabilities,judgments, costs and expenses which CONST.TAX
may any ay accrueinst aid City in sequence of the PERMIT ISSUANCE 10.00
gof spermit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signa e f pelican n ractor Date U✓�G�7
OFFICE COPY
- — .v . . r ,.}..':' ,".!cvir - • . .'era
CITY OF CUPERTINO'
CERTIFICATE=r 'OF _ COMPLETION
BUILDING INSPECTOR'S OFFICE
t
Date . __�.: .... q...............1 19...........
Building Permit No.
� - The Building Located at -..... .r? ............L.L1Fl /......L.N:........................... ....
Owned by ....3F....�\//....�}�'G(lti)......... .. . .
_ ......:.................................................
4
(Completer .
Has Been Altered)For Use As: .�l•Fl......................_.........................: .
j
..................................................................................................................................................
..................................................................................................................................................
PD-7 BUILDING INSPECTOR
--- - -----•--••—�----- ------•._..---- __.._...�
* ' -'•'* a PG.BE
- vp CITY OF CUPERT ANO 4 copy
^ CAS SERVICE NOTICE
j Y `7 N 19 d y-- 1
To J
You ore hereby authorized to connect the GAS service for 1
•- " Owner or Tenant - .P_'rz Y' r-'7iF•'rJc-,�.' i
1' /J
� New Service
v^ i
No. of Meters t Reconnect
�,! Mole-Service
No. of Add. Meters - i
Move Meter j
i PLUMBING INSP,�ECTORj—'-A`4-'ems+ -'r'ai k5'A-1V6L-� OO
t