1544 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERM( N
'BUILDING ., APPLICATION & PERMIT 544
ADDRESS
BUILDING- ELECTRICAL-PLUMBING-MECHANICAL
0 ER'9 +- - PLAN CHECK VA LIGATION
NOME v ".ELECTRICPERMIT FEE�'-
E �
T...T. � ./1- OUTLETS-SWITCHES-RECEP 5.00/1.00
NAMf ,,,, ��TT z
7 O, 2A5 LIGHTING FIXTURES 5.00/1.00
.ONTRACTOR's PPLIANCES-RESIDENTIAL 4.00
DOREss
vH PANELS 5.00 DATE OF APPLICATION
A CN TELT 6 QO PLAN CHECK FEE P.C.NO.
OR SIGNS
ENGINEER •3 QQ
LIC.No. SIGNS TRANS.
ARCH,SS ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP EMP.METER OR POLE INS. 15.00 Q
APPLICANTS MOTOR SEE FEE SCH. �J
ADDRESS
SERVIC A G Uf 41(17 10.00
II o w o LICENSED CONTRACTORS DECLARATIONMAY
I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a "' (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLO MECH.
D i Professions Co aZ icense is in(sell(gFFC aISILW' -; �� ❑ ❑ ❑
`o Z h 0 License Class Lic.Numbs
M H w Dale Contractor f
H -- - '- j1BUiLDING P,ERMIT'n`+$i
`¢ a w OWNER-BUILDER DECLARATION !'_y{Cj%?INFORMATION "r}/A,
REFER TO ORD
v iC LL y 1 hereby affirm that I am exempt from the Contractor's License MISC.- VALUATION E/FT.,
HLLNj Law for the following reason.(Sec.703L5.Business and Professions PERMIT ISSUANCE 6.00
Code:Any city ar county which requiresa permit toconstrucq alter.
Qs > o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
- o M requires the applicant for such permit to Ole a signed statement that TOTAL PERMIT TO
Lu m w he is licensed pursuant to the provisions of the Contractor's License
> Law(Chapter 9(commencingwith Section 7000)of Division 3 olthe -7 c•1( - < "aa e K. wk° �'
a Business and Professions Code)or that he is exempt therefrom and CITY,,.' PLUMBING PERMIT ,� EE i
4 x 0 r F STORIES TYPE CONETR.
IS
r. g the basis for the alleged exemption.Any violation o(Section 7031 5 ..s+ _ u " .s 7` '3' "$kr •�+T-
a ; by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
or ow more than five hundred dollars 13500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 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. 4.00
Code:The Contractor's License law does not apply to an owner of
properly who builds or improves thereon,and who dues such work FIXTURES•PER TRAP 4.00 Sd FT.FL00RAREA TOTALACREAGE
himself re through his own employees.Provided that such improve-
limmearenotintended or employees,ffered for r If, that r.suhebudding GAS-EA.SVSTEM-11NC.40UTLETS 4,00
or improvement is Sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON Pe Chner
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project ISec.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
contracts for such projects with a contractors)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-.B.&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate ofconsent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
pY t er L C/1.
O ❑ Rifted copy is ereby furnished. FIRE SPRINK ENERGY T-24
Z Z Certified copy is fled with the city inspection division.O MISC. REFER TO ORD. y E] N❑ y C] N[]nt �^ -
� = CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C.
LU > COMPENSATION INSURANCE PLO.CONTR. LSC.NO, PLG. Y ❑ N❑
1 0 (This section need not be completed if the permit is for one ♦ TOTAL Y❑ N❑
D Z hundred doll..IS 100)or less.) °i. jc S'rI' �a4f aid'+tay �' tNY S(u (Y�u ai u+ 4+'
U O 1 certify that in the performance of the work for which this per. �lP.t fd j1 p• ryFEE SUMMARY 4•
CITY. lMECHANICAL;PERMIT yFEE ... �+.r.�- �+:�
IL H mil is issued,1 shall not employ any Person in any manner u as to 7,r Yt R a I 4 .: ; S d ;, 4 n• 1 F H
U become subject to the Workers'Compensation Laws of California.
wa Date Applicant ALTER OR ADD TO MECH. 4,00 BUILDING
> N NOTICE TO APPLICANT: If.after making this Certificate of Ex..
? emption,you should become subject to the Workers Compensation APPLIANCE 4.00 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.NL) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IOAOOC.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Civ.C.).
Lender's Name H EATI N G UN IT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct I agree to comply with all city and county PLUMBING
ordinances and Mate laws relating to building contraction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon the BOILER-COMP Over 100,0009TUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to mve, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence or the
gra gD(ih' pCrm' . MECH.CONT. LID.NO. MECH.
OTAL ''"✓�"'Y"���'-" ;
" TOTAL F O
t use of ApplicanUCanlructor U
OFFICE COPY
1_544 10238 Portal Ave.
SAIILI'AIj DISI. IJO. LOT
Plumbing Jue 257-6255
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Ru't._1_din�_ Date l.nsp.
l;lnctrical _ Power Pole-
Pl.nmhLng_ —_ _ 5-3-82 Llndcrc.round --- ---_—
llnchan i cn l _ R(Mu ,h Wiring — 7_7 3_ R 2 ��-
'I cmp. ( as/I:1ccL. Ila(.Ls _ --- —
S(ila
--Snlar Cci.linu
FLrc Sprinkler Fixtures Int/Ext _
Sign Motors
Grounding
Ili.sc. Temp. Power -
-'— Other
FINAL INSPECTIONS Not Approved
Date Insp.
PLUMBING
Electric Date Insp.
I'Lnmhin , Backflow
Mechanical UrtderP:round
Snlar Underfloor
I'001 _ Partial. Rough
Grading Rou ,lmplete
I'lanninr_ Solar Rough
Fire Deft. _ 'later F. insulation
Health Dept. `fain Drain
fuildin R/of/S Drain
Other Gas _
Other_
BUILDING Not Approved
Date Insp.
Pad CerLification MECHANICAL
Foundation Date Insp.
Pre-Min.Lte Underfloor S.M.
Sl.ah-Membrane Ducts & Insulation
Rond Beam _ Fire Danvers _ -
Underfloor Girders
Floor Steel Crease Duct & Hood
Tiedowns One (lour Shaft
Oiaphrams Condensate Drain
Seismic Bracing P.qui,pment Anchorage
I1a1I.s-Panels FIues & Comb. Air _
Ir.(me --- Other
Lath _ ___ IJot Approved
Ilal.lbnards Int/Ext.
firewalls
Other W 4 I f t
Not A=0ved