0628 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT ONLY
P
• BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING - ELECTRICAL- PLUMBING - MECHANIC
PERMIT NUMBER
0628
PLAN CHECK VALIDATION
BUILDING
IlR S& Q� L ,L
OWNER'S
NA,MSE `T /
�.'1 96
- -
OTY. ;'ELECTRICPERMIT,;t.' FEE~''
PNDNE 133-
I- -
DATE OF APPLICATION
caNTRACTORs
�NAM�Ey. •�,
IrLI 1�: �. Ob LS LII:. NO. Z
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
ADNTRACTOR's P�Lu �Ll-�
•'JIL/ss" - igAID W PHONE 070
PPLIANCES-RESIDENTIAL 4,00
PANELS 5.00
ARCHITECT
OR
E GINEER
.No. -
SIGNS 6•00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR
ADDRESS ENG.
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 15.00
ZIP
APPUCANT'S
ADDRESS
MOTORS SCH.
bD
SERVICE CHA 10.00
LICENSED CONTRACTORS DECLARATION
I O 1.,A ov M1
I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
(commencing with Section 7000) of Division 3 of the Business and
Professions Co* 4 y license is in full fare def ct
'Licen lass` Lic.Number .�.e_Ppab.%
BLDG.
p�
ELECT. I PLG. MECH.
❑
Date '4� Contractor =i•4.6.Ci_
•i.ry<KBUILDING P.ERMITI�ar,,
'/--.�-•INFORM_ATION�r,,;,.ki
OWNER -BUILDER DECLARATION FOOLS
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason. (Sec. 7031.5, Business and Professions
Cade: Any city or county which requiresapermit to construct. alter,
Improve, demolish, Or repair any Structure, prior to Its Issuance. alio
requires the applicant for such permit to file a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
the basis for the alleged exemption. Any violation affection 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).):
MISC.- REFER TO ORD
VALUATIONS/FT.
// OoO
f0
"
PERMIT ISSUANCE 6.00 4P -
ELEC.41VCONTR. LIC. NO.
ELEC.
PERMIT TO
- •:,�f-'r `•- FY -' - i '
QTY. •• P.LUM., PERMIT 48. , rIgY r 'FEE
_ •3,r e. r a .°:P[ ,. �. 4r.•�; a.+r... '" °
STORIES
TYPE CONSTR.
ALTER -DRAIN -WATER (EA.) 4.00
❑ I, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure if not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA, COND. 4.00
intended or offered for sale (Sec. 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 dues such work
himself or through his own employees, provided that such improve-
-ments are not intended oroffered forsale. If, however, the building
FIXTURES - PER TRAP 4.00
S4 FT. FLOOR AREA
TOTAL ACREAGE
GAS -EA. SYSTEM- 11NC.40UTLETS 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-
for purpose ofsale.).
❑ I, as owner of the property, am exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
REB IND CON PB GO.,
❑ ❑ ❑ ❑ ❑
INDUSTRIAL WASTE INTER. 20.00
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
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 thereon, and who
contracts for such projects with a contractons) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec.-. BAP.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER SYSTEM 4.00
ACC. DATE
ACD. FILE NO,
WATER TREATING EQUIP. 4.00
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self-insure.r/
or a certificate of Workers Compensation Insurance, or a certified
L I'CC,)
ZONING
ENG. SITE NO.
copy thereof(Sec. 3HOO, Lab.C) ,1
Policy Na. Companyl� U E %, & f �bf �
❑ Certified Copy is hereby fufnlShCJ.
❑ Ceni copy Is fed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N❑
ENERGY R24
Y ❑ N❑
MISC. - REFER TO ORD.
CER �ICATE OF E%EMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG.CONTR. LIC. NO.
TOTAL (I?Y)
p.(O•
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one
Y N
❑ ❑
Y N
❑ ❑
,' vf::..',i-., N.^Y ,.°Yr,.l-lt".'aL;,/4?:.E.
: h L �^ Y1, a
DTV. a + MECHANICAL- PERMIT-, FEE"
3 Yx •` IA * " )" s `''k'v'` • ' "'' .STbu% •'' ,,,JTgrf,q
'i •••,W_-.-..,,..aay..wm
'N FEE SUMMARYI�'t;<;
". ro.. _A•a.:.<.....«-..
,-r,..yr,t
a -s
...,,.. a,N
hundred dollars 0100) or less.)
1 certifythat in the performance of the work for which this per.
mit is issud, I shall nt employ any person in any manner So ato
become subject to the Workers Compensation Laws of California.
Date Applicant
BUILDING
�� / / 4-0
ALTER OR ADO TO MECH. 4.00
NOTICE TO APPLICANT: If, after making this Certificate of Ex-
emption, you should become subject to the Workers Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
APPLIANCE 4.00
PLAN CHECK
FEE
%S
AIR HANDLING UNIT (TO IO pQOGF.M.) 3.00
AIR HANDLING UNIT(OVER 10=11F.M.) 5.00
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
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 ISec.
3097, Civ.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
HEATI NG UNIT (OVER 100,000 B.T.U.P.50
ELECTRIC
P
Lenders Name
Lender's Address
I certify that I have read this application and state that the above
-Iu�matmn is correct. I agree to comply with all city and county
miLmces and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
/
BOILER -COMP (3 H.P. or 100,000 B.T.U.) 4,00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
lin iDy authorize representatives of this city to enter upon the
above-mensinned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
gra ting of this permit.
c
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
;N. +'�•�?;']:;LS ,, ;,
Si aura of pplicant/Contractor Date
OFFICE COPY
r
0628
PI:PdII'r PIO.
. Pool
CIrY OF CUPEUINO INSPECTION RECORD (Office Copy)
SANITARY DIST. NO.
PROJECT
_ 19865 Portal Plaza
LOT N0. ADMIESS
llayco Const. 733-9693
01•INER JOB SITE P11014E NO.
II ELECTRICAL
FINAL INSPECTIONS
BUILDING
Date Insp.
1'ad Certification
Foundation
Pre -Gu
nite
Slab -I lembrane
Bond Beam
Underfloor Girders
Floor Steel
Uiaphrams
Seismic Bracing
halls -Panels
Frame
Lath
Wallboards Int/Ext.
Firewalls
Other
Not Approved
0
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
Partial Rough
Rough Complete
Solar Rough
I -later & Insulation
*lain Drain
R/of/S Drain
Gas
Other
Not Approved
HECUANICAL
Date
Underfloor S.N.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & Hood
One [lour Shaft
Condensate Drain
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved