2320 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
rRMIT ER
BUILD
BUILDING PROJECT IDENTIFICATION ING APPLICATION & PERMIT 2320
PDD C$g
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
019NER'a PLAN CHECK VALIDATION
NAME - QTV. ELECTRIC PERMIT FEE
LON TRAC0'S /�•
NAME C OUTLETS-SWITCHES-RECEP 5.00/1.00
Gor� �7✓/edl a/ uc.No.(/O-11- /q R LIGHTING FIXTURES 5.00/1.00 s je!L
r.DNT'ACT R's j! APPLIANCES-RESIDENTIAL 4.00
AJDDRESS�jh.[C IrrpI5-Z Ste• F [� _
- LOA /(/'05 CP, 9yo 2 PHONE/]y�'S��-/ PANELS 5.00 DA TE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
x DR
ENGOLENGINEERI.G.NO. SIGNS TRANS. 3.00'
ARCH,OR ENG. - PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
'
ZIP TEMP,METER OR POLE INS. 15.00
APPLIcarvr's MOTORS SEE FEE SCH. a E
aooREss
1' SERVICE CHANxGyE 10.00
o o LICENSED CONTRACTORS DECLARATION -
< uI hereby affirm that I am licensed under provisions of Chapter 9 vISSUANCE DATE
H rt i (commencing with Sermon 7000)of Division 3 of the Business and s LJ BLOC. LECT. PLG. MECH.
D H 7 i r Professions Cod'ssions Cod-E+ nse is in full for effe r ❑
- License ass Lia Number
F H H w' Date Contractor EY
ID - BUILDING PERMIT
Lr a w ¢ OWNER-BUILDER DECLARATION INFORMATION
A.
;A N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
vAy � 5/FT.
r u O a Luw for the following reasVALUATION on.(Sue.7031.5,Business and Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requires a permit to construct,alter, i
2 IN¢ improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH. LIC.NO. ELEC. a*
O¢ requires the applicant for such permit to file a signed statement that TOTA
PERMIT TO
e w m y he is licensed pursuant to the provisions of the )of
fDivision License
f 2 fle
4 Lsw(Chand Procosions Codeng )orth that
is exempt
fttheref o and
f i o Business and Professions Code)or,tAn he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ H $ the any
a for the alleged ermit subjects
Any violation of Section malty STORIES' TYPE CONSTR.
by any applicant fora permit subjects theepplicam toa civil penalty ALTER-DRAIN&VENT•WATER (EA.) q.00 4
of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RE;UNITS
their sole compensation,will do the work,and the structure is not �p �g /
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 �!w`
Code The Contractor's License,Law docs not apply'to an owner of
property'who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOORAREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11 NC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im-
provcforpurposeofsale.). INDUSTRIAL WASTE INTER. ' 20,00 RES o CON PB Omer
❑ 1,as owner of tile 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 does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 /r
•contracts for such projects with a contractors)licensed pursuant to v
.. the Contractor's License Law. SEWER-SANITARY-STORM EA,200ft/8.00 TRACT No. PAR/CEL No,
. IamexemptunderSec, ,BP.C.lot this WATER HEATERW/VENT 4,00 p/ 3h
a❑ .&
son v r
Dale Owner WATER SYSTEM 4.00 ACG DATE ACC.FILE NO.
WORKERS'COMPF-NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. - ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
copy the f ec 6 0, C.). - Jnr
Policy N, �� "y�fd'{C FNisd
❑ Ce imdc ylsh reby furnished. FIRESPRINK ENERGY T-24
Z Z ❑ Certified opy Miley it [Ile cit impeclion division. MISC.- REFER TO ORD.
O Applicant i./ afiy3^-1 V❑ No
~ to PERMIT ISSUANCE 6.00
O: - CIiRTIPICATEEEXEMPTION PROMWORKf:RS' FLOOD ZONE �L�
U7 > COMPENSATION INSURANCE PLG.CONTR. LIC.No. PLG.
IL O (This section need not be completed if the permit is for one IOTA Y❑ �,••t J
:) Z hundred dollars(E100)or less.) -
•U O 1 certify that in the performance of the work for which this per, QTV. MECHANICAL PERMIT FEE FEE SUMMARY
r� tmit is issued,1 shall not employ any person in any mamser so as to
U become subject to the Workers'Compensation Laws of California.
LOU Datc ApplicantALTER OR ADD TO MECH. 4.00 BUILDING d/C
} W NOTICE TO APPLICANT: If,after making this Certificate of fix-
f" ? emplion,you should become subject to the Workers Compensation APPLIANCE 4.00 RLAN.CHECK-
provisions of the Labor Code, you must forthwith comply with -FEE-
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT IOVER 10MC.F.M.) 5.00 SEISMIC FEE L?
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
Om performance O,f AAP
work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). AAPKe, HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
ELECTRIC
I C
Lender's Addre
I certify that ICave read this application and state that ore Shove VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING -
oNinances.and state laws relating to building construction, and BOILER-COMP I3 H.P.or 100,000 B.T.U.) 4.00 ��•
hereby 'authorize representatives of this city to enter upon theo a�
above-mentioned property for inspection purposes. 801 LER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. G
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 C TA
may in any way accrue against said City in consequence of the
gmtilin flhis crmil. MECH.CONT. LIC.NO. MECH.
X Z _a. TOTAL TOTAL
ignatumof Applicant Contractor Date
OFFICE COPY -
LCOPY OF CUPERTINO INSPECTIOC R1-GORD (Office Copy)
2320 _ 10692 Pebble P1.
PDpdfl'I MO. SANITARY DIST. 110. LOT NO. ADDRESS
Addition Stephenson
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildine -7--2-7--F2- Date Insp.
Electrical 8-2T-72 Power Pole
plumbing -7--2-7-72 Underground
Mochanical 8-24-62 Rou h Wiring
Temp. Gas/lilect. [tails
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign Motors
Grounding
Misc. Temp. Power _
Other
FINAL. INSPECTIONS Not Appiroved
Date Insp.
("'Ps _
Electric / .2 - 23 Z PLUMBING
Z Date Insp-
plumbing
Backflow
Mechanical Underground
Solar Underfloor
Pool Partial Rough l -
Grading Rough Complete
I .Lannin Solar Rough
Fire Dept. [-later & Insulation
Health Dept. Main Drain
Duildin R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
Pad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-Membrane Ducts & Insulation _
Bond Beam Fire Dampers _
Underfloor Girders Fireplace
Floor Steel Grease Duct & hood
Tiedowns One ![our Shaft
Diaphrams --'—
Condensate Drain
Seismic Bracing ui )ment Ancharage
halls-Panelsu
Flus & Comb. Ai
Frame /6_
OTTF—er
Lath Not Approved
Wallboards(j !?xt. 0
Firewalls , �— 2'',rw.Go- iSTf_j� S S' • �( I6 -$z
Other
Not Approved
i
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS