1078 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONOT�
BUI LDI NG PROJECT I DE CATION
eBDILDING
-
APPLICATIO ERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
P N MBER
_ 1078 Q
v
ADDRESS
O
OWNER'S
NAME`j �y �'
QTY, ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
C NO E
_
NAME A°°Rs
OUTLETS - SWITCHES - PIECED 5.00/1.00
'' LIGHTING FIXTURES 5.00/1.00
LIC. NO,
CONTRACTORADOR Ess
- PPLIANCES- RESIDENTIAL 4.00
. PANELS, 5.00
'HONE
DATE OF APPLICATION
ARCHITECTcity, I
OR
ENGINEER
SIGNS $.00
PLAN CHECK FEE P.C. NO.
'
SIGNS TRANS. 3.00
AARCDDRK OR ESS ENG
1 ZIP'
SPECIALCIRCUIT $,QO
PERMIT VALIDATION
/
.I EMP. METER OR POLE INS. 15.00
aPADDRESS PucANrs
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
•
!/
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full force and effect.
Class I Lic: Number-
umber
ISSUANCE DATE
BLDG.
ELECT.
❑
PLG. MECH.
❑ El
--
Date -
Date Contractor
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION
I hereby affirm that I ant exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
Improve, demolish, Or repair any structure, prior to its Issuance, also
requires the applicant for Such permit to file a signed statement that
DivContractor's License
of the) of
to the with Section
ha Is licensed 9 (commencing
Law (Chapterand theron 3 eland
Business and Professions Code) or Dlal he is exempt therefrom and
Professions Code) or Section is exempt
MISC. - REFER TO ORD
PERMIT ISSUANCE6.00 a'
VALUATION
/O V
31
$/FT.
ELEG. CONTR. LIC. NO.
/�
ELEC. W
TOTAL
PERMIT TO
Iwir �� •. �,,,,_,
`/
DTV. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
a for the alleged exemption. Any violation of$ection malty
the any subjects thcapplicant loo civil penalty
by any applicant fore hundred :
of not more than five h dollars (my
ALTER -DRAIN VENT -WATER (EA.) 0..00
-
❑ I, asompowner naf the property, or my employees with wages as
e prop em
their sole compensation, will do the work, and the structure rs not
intended or offered for sale (Sea 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve.
mentsarenot intended or offered for sale. If, however, the building
BACKFLOW PROTECT. DEVICE 2.00
OCC. GROUP
�}�
P -le
RES. UNITS
/
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
FIXTURES - PER TRAP 4.00
SO FT, FLOOR AREA
TOTAL ACREAGE
-
GAS-EA.SVSTEM-11NC.4OUTLETS 4.00
or improvement is Sold within one year of completion, the owner-
.builder will have the burden of proving that he did not build or im-
prove for purpose of sale.).
❑ I, as owner ol', the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 (EA.) 1.00
BUILDING USE
HEyS �MI-q-I CON PB Other
PU El' 0 .❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS- 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OV ER 5 (EA.) 1.00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves (hereon, and who
ASSESSORS PARCEL NO.
contracts for such projects with7a contractons) licensed pursuant 10
oy.j'ontmemrs License Luw.
JL lam a to de Sec. ,tl.&P.C. Inr Ibis
rwson
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
Date
v
WATER SYSTEM 4.00
ACG. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
woRKERscQMPENsnn D: Ln n oN
I 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 _
❑ Certified copyis h urehy furnished'
❑ Certified copy is fled with the city inspection division.
icant
FIRE SPRINK
v N�
ENERGY T.24
v No
MISC. - - REFER TO ORD.
CERTIFICATE OP EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLooOZONE
at.. u.c.
C�PIThiS SeClldn ne0ed n1aN be completed R'If thcl-permit is for ane
PLG. CONTR. LI0. NO.
TOTAL
Y N
V N
hundred dollars IS 100) or less.)
- I certify that in the performance of the work for which this per-
mil is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws of California.
Date Applicant-
QTY MECHANICAL PERMIT FEE
-
FEE SUMMARY
BUILDING
Q SO
Y
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of F;x-
-0,
emption, you should become subject to the Workers' Compensation
srovisions of the Labor Code, you must forthwith comply with
uch provisions or thiq permit shall be deemed revoked
APPLIANCE 4.00
AIR HANDLING UNIT (TO 10,000CF.M.) 3.00
PLAN CHECK
FEE
.24
/
AIR HANDLING UNIT (OVER 10=1C.F.M.) 5.00
SEISMIC FEE
•,70
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this pennit is issued (Sec.
3097, Civ.C.L
EXHAUST HOOD (WITH DUCT) 2.00
H EATING UN IT (TO 100,000 B.T.U.) 4.00
MICROFILM
Lender's Name
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
0
Lender's Address
I certify that I have read this application and state that the above
VENTILATION FAN. (SINGLE) - 3.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100.000 BTU) SEE FEE SCH.
MECHANICAL
herebyrepresentatives ins ec this city to enter upon the
above mentioned
actio rR property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of
MISC. • REFER TO ORD.
Cupertino against liabilities• judgments, costsand expenses which
may in gainst said City in Consequence of the
PERMIT ISSUANCE' 3.00
CONST. TAX
grand i
Pro
MECH. CONT. LIC. NO.
MECH.
TOTA1
TOTAL
but ore of ApFrueksr
OFFICE COPY
:r -
�.J✓r3
1078
PERMIT NO.
Z�x-lesysibn /{'- 6""O -
CITY OF CUPERTINO INSPECTION RECORD (Office Copy) -1",7
/e7fer 7At-ebeW.
SANITARY DIST. NO. LOT NO.
19980 Peartree Lane
Additon Arlo Gilpatrick
PROJECT 0I4NER
Date
Building
Electrical 11-5-81
Plumbing- 9 _ J 7-f.7
Mechanical A 1y_r"L
Temp. Gas/Elect.
Solar
Fire Sprinkler
Sign
Misc.
FINAL INSPECTIONS
Date Insp.
Gas
Electric
Plumbing
Mechanical
Solar
Pool
Grading
Planning
Fire Dept.
Health Dept.
Building ¢ Z /_ 8 Z
Other_ Al P/G'
STRUCTURAL
Date Insp.
Pad Certification
Foundation I _9� I
Pre-Gunite F.
Slab-Hembrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
[Malls -Panels
Frame
Lath
Wallboards<ZZOXExt. 'L►
Firewalls
Other
Not Approved
ADDRESS
253-8711
Kk
JOB SITE PHONE N0.
ELECTRICAL
Date Insp.
vrounaing
Tem Power
Other
Not Approved
PLUMBING
Date Insp.
R/of/S Drain
Gas _ p_
Other
Not Approved
MECHANICAL
Date Insp.
Underfloor S.M.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & Hood
One Hour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
ELECTRICAL
PLUMBING
.i
MECHANICAL
MISCELLANEOUS