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9270 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING APPLICATION & PERMIT 9270 ADORESSZ U Na m1aAw ING-ELECTRICAL-PLUMBING-MECHANICAL OWNER'S PLAN CHECK VALIDATION • ONE NAME / I' CITY. ELECTRIC PERMIT FEE r CONTR,ICTOR'B NAME ZOUTLETS-SWITCHES-RECEP 10.00/1.00 1IC.No. s/ L`-I I LIGHTING FIXTURES 10.00/1.0 /\ CONTRACTOR D's PPLIANCES-RESIDENTIAL 4.00 �x/ ADDRESS / 17-A l,Py P A, PHONE 2qb'-hg PANELS 10.06 DATE OF APPLICATION ARCHITECT kr - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO. OR ENGINEER &111AAAAI LIC.NO, SIGNS TRANS. 3.00 ADDRESS ENc. SPECIAL CIRCUIT 5.00 Itey�TtUIonnoN ADDRESS EM UTI yor 64,,> d4nj & zap '?iK4q TEMP.METER OR POLE INS. 20.00 APPLICANT'S MOTORS SEE FEE SCH. JUL '1 1985 ADDRESS Jr SERVICE CHANGE 20.00 r POLE 30.00 o n o LICENSED CONTRACTORS DECLARATIONTEMP. qq City of Cupertino a u U I hereby affirm that 1 inn licensed under provisions of Chapter9 NV •rp IS SUA E DATE y a commencing with Section 7000)of Division 3 of the Business and SLOG. E EC PLG. MECH. F w _ Professions CodL aidlny licmisc is in lull 1'uk fleet. (( ❑ ❑ 2 O.' License Class_" V Con ract r I N 0 0. w Date_I- IZ-fins-Lic N mo a x s BUILDING PERMIT ¢ ¢w OWNER-BUILDER DECLARATION INFORMATION oP. MISC.- REFER TO ORD X S u H Iahereby affirm that 1 am exempt from the Contractor's License VALUATION SIFT. H u 0 J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 0 Code:Any city or county which requires a permit to construct,alter, ¢ a p improve,demolish,Sr repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -O n requires life applicant for such permit to file a signed statement that TOTAL l` ERMI TO n w he is licensed Pursuant to the provisions of the Contractor's License H z i Law(Chapter 9(commencing with Section 7000)of Division 3ofthe Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE ¢r O the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR. i ; � by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.15.00 of not more than five hundred dollars($500f): ❑ I,as owner of the property,or my employees with wages as BACK F LOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS their sole compensation,will do the work,and the structure is not intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law docs not apply to an owner of Property who builds or improves thereon,and who docs such work F IXTUR ES-PER TRAP 5.00 BO,FT,FLOOR AREA TOTAL ACREAGE • himself re through his own employees,fors,provided that such improve, ments mselfo through not onemployeesn provided that suhebuilding GAS-EA.SVSTEM-11NC.40UTLETS 6.00 r improvement is sold within one year of completion, .the owner- GAS-EASYSTEM-OVER 4(EA.) 2.00 Bu DING BE builder will have the burden of proving that he did not build or int- RES IND PB Omar prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 O I,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. 6.00 ASSESSORS PARCEL NO. and Professions Co lr: The Contractor's Licensc Law does not apply to an owner of properly who builds or improves lhereom,and who LAWN SPRINKLERS-OVER 5 IEA.) 1.00 contracts for such projects with a contractors)licensed pursuant to SEWER-SANITARY-STORM EA.2001t/10.00 TRACT NO. PARCEL NO. the Contractor's License Law. ❑ Imnexemptmnder Sec. .B.&P.C.for this WATER HEATER W/VENT 6.00 eason Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERSCOMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified rA Y�thereof(Sec.3800,La b.G. LP_pq-212-11p cylNo. Company�J D•'I D ert62A r reJ. FIRE SPRINK ENERGY L2< Z Z etlw 11c city ins lio'ylii V❑ NV ❑ N❑ OG'mt - G - MISC.- REFER TO ORD.F-' y PERMIT ISSUANCE 10.00 FL000 zoNE A.L.u.c. Cli IPTION FROM WORKERS' 111 _ ION INSURANCE PLG.CONTR. LIC.N0. PLG. 1 (This section need not be completed if the permit is for one TOTAL Y❑ N❑ V❑ N❑ Z to fired dollars($100)or less.) U O '�certify that in Zile puNormanee of Ile work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL H mit is issued,I shall not employ any person in any manner so as to U become subject to the Workers'Compensation Laws of California. BUILDING U w Data Applicant ALTER OR ADD TO MECH. 5.00 } N NO'rICF."rO APPLICANT: If,after making this Certificate of Ex- 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=C.F.M.) 4.00 CONSTROCI'ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE I 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM 3097,Civ.C.). Lender's Name HEATING UN IT(OVER 100,000 B.T.U.)9.50 ELECTRIC Lender Address I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00 into nsunion is correct. I agree to Comply with all city and county BOILER-OOMP(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING ordinances and slate laws relating to building constructionand hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL above mentioned properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX may in any way accrue ag'' st id City in consequence of the gr of is permit MECH.CONT. LIC.NO. MECH. J` J 12- TOTAL TOTAL rSignatur of Appl or Date OFFICE COPY ELECTRIC SERVICE NOTICE OFFICE COPY BUILDING INSPECTOR'S NOTICE t CITY OF CUPERTINO • �/{.�} �) �/� k: To YY ••s' You are hereby authorized to Connect electrical service for u ' l 'Owner or Tenant a � At 62/4/90 77l (� No,of Wires $'ixe of Wires Site of Switch Motor Load Voltage Phase Heating Load K W Voltage / Light I10 New Service Reconnect No.of Meters rye,t 120__Th,ee Wire More Service No.of Add.Meters Power Three hose Move Meter PM ELECTRICAL INSPECTOR y l CERTIFICATE OF COMPLETION BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO DATE n�3n �9r BLDG. PERMIT NO. 2- TT HE BLDG. LOCATED AT OWNED BY /I Ian COMPLETED) FOR USE AS I> (� HAS BEEN -TAL'TEREDi'-'-"' P• � / BI�1LDING INSPECTOR ' OFFICE CITY OF CUPERTINO.` copy GAS SERVICE NOTICE r 19 IF TOW+ You are hereby au•tthoorized to connect the GAS service for . Owner or Tenant' `�'+'"' �^J "�I• �'h'`"•' ' . At New Service No. of Meters . .�� ' LLReconnect. ''. Mo3e•Service No.of Add:Meters Move Meter I' •PLUMBING INSPECTOR.-­ BUIL NSPECTOR:"� " .. BUILDING INSPECTOR'S OFFICE 91dg.Dep. CITY OF CUPERTINO Olfice copy ` • �'h Sanitary Permit No. pNo 7( ElBdckflow•Device: ,,�,•� ' ',;3 t •.• , •r.;,,' , ; • ,.. , Plumbing Permit No. '©, Sewer Connection Plumbing Final• t;, Lot No. Owner or Tenani 5 1yr rW At Tracy �, h 19d Date Connected V.-- ./f`— ;9!Y Date'Final F,• PLUMBIN 'INSPECTOR r ELECTRIC SERVICE NOTICE OFFICE COPY BUILDING INSPECTOR'S NOTICE 1 ` � CITY OF CUPERTINO ` 19 To You are hereby authorized to Connect electrical service for " e e\�iOwner or tenant r/ ql" e. G� At '0 No.of Wires Size of Wires Size of Switch Motor Load ' Voltage Phase i Heating Load K.W. Voltage / x light I10_New Service Rewnnect , No.of Meters Heor i20 /_\ Three Wire More Service No.of Add.Meters Power Three Phase Move Mater ®• ELECTRICAL INSPECTOR ,/