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5649 (2) :INT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY 'R vmR 1tlUl LDING PROJECT IDEN%III CATION PERMIT NUMBER BUILDINGAPPLICATION & PERMIT 5649 ADDd5o BUILDING-ELECTRICAL-PLUMBING-MECHANICAL OWNER - - - PLAtE�II(Y&LIDATION �• NAME QTY. ELECTRIC PERMIT FEE r/'IL,u 1 `,O PE pp CONTRACTORSUTLETS-SWITCHES-RECEP 5.00/1.00 JUL 13 19V4 e�uNAME , 7 LIGHTING FIXTURES 5.00/1.00 11 �/ O, CONTR TORSPPLIANCES-RESIDENTIAL 4.00 City of Cupertino Eve4yi Ave ADOnfSa E - QO PANELS 5.00 DATE OF APPLICATION ARCHITECTS' AjkQ IG Gs M-(f / SIGNS 6.00 PLAN CHECK FEE P.0 NO. OP V ENGINEER3.D0 LIC. o. SIGNS TRANS. ARCH,OR ENG, 5.00 PERMIT VALIDATION, ADDRfssSPECIAL CIRCUIT ZIv EMP.METER OR POLE INS. 15.00 APPLICANT'SMOTORS SEE FEE SCH. ADDRESSay I/ SERVICE CHANGE /n+ 10.00 4l6 e-o D LICENSED CONTRACTORS DARATION �OI hereby afGru that I am licensed undvisions Of Cliapl cr 9 Q Ori ISSUANCE DAv, Qy (commencing with Section 7000)Of Divi3 of the Busine55 and BLDG. ELECT. LG. MECH. Protessions Code,and my license is in full •rot f c£'try-7 0 ,- License Cls Lic.Nmnbzw DatC' �$/Z-_Cotruwor ` .!_-ii.r3_- Y ` t/ec a�tG BUILDING ERMITAOWNER-BUILDER DECLTION INFORM TION oA MISC.- REFER TO ORD X 3 u y 1 hereby affair,that I :un exempt from, the Contractor's License VALUATION $/FT. F .. 0 a Law for the following reason.(Sec.703 L5,Business and Professions ,PERMIT ISSUANCE 6.00 .QQ Code:Any city or county which requires a Permit to construct alter, u,a p improve,demolish,or repair any structure,prior 10 its issuance,also ^EL�E.C.CONTR. LIC.NO. ELEC. O ¢ requires lire applicant for such permit to file a signed statement that �x Txp �Ptf�'1e 7" TOTAL rOQ ERMIT TO e w m u he is licensed pursuant to the provisions of the Contractor's License xr ria Law(Chapter 9(comnencing with Section 7000)of Division 3 ofthe a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE T the basis for the alleged exemption.Any violation of Section 703 L5 STD IES /Y E CONSTR. La T byany'applicantforapermit subjeotr Gmapplicanl toacivilpcnalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 of not more than five hundred dollars(5500).): ❑ I,as owner of the properly,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.GROUP RES,UNITS their sole compensation,will an 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 docs not apply t0 an owner of I property who builds'or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE himself or through his own employees,provided that such improve- mentsare Hot intended oroffered for sale.ll',however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00 or improvement is sold within one year of Completion,the owner. GAS-EASYSTEM-OVER 4(EA) 100 BUILDING USE builder will have the burden of proving that he did not build or an. . . . RES IND N PB Otue. prove for purpose of sale.). INOUSTRIALWASTE INTER. 20.00 El El13 ❑ ❑ 1,as owner of the property,am exclusively contracting with licensed contractors to cored ruel the project(Sec, 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSOR PAHCELNO. and Professions Code:The Contractors License Law does not applyto an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 contracts for such projects with a conlraetons)licensed pursuant In the Contmdor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO. ❑ I am exempt under Sri.-,B&P.C.for this WATER HEATER W/VENT 4.00 ecavm Owner Data WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO. WORK ERS'CONIPENSATION DI'CLARATION WATER TREATING EQUIP. 4.00 I hereby ulllnn that I have a certuicale(31 consent to sellains rc. ZONING ENG.SITE NO. or a certificate of Workers'Compensation Insurance,or a certified copy OereRt c.380 110 b1, .yC-.l2V/r Lt:£ Q ❑ - Certified copy is hereby furnished FIRE SPRINK ENERGY T 24 Z Z `IZ_ :nv Certified copy is tiled with the city inspection division. nphcMISC.- REFER TO ORD. Y F] N[3Y [:] N❑ O CC CERTIFICATE 017 EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.U.C. LU >_ COMPFNSATION INSURANCE PLG.CONTR, ❑C.NO. PLG. CIL 0 (Thin section need not be completed if the permit is for one 1TOTAL Y❑ N[3Y❑ N❑ 0 Z hundred dollafs(SIOO)or less,) U O 1 ceHiry tied in G,c performance of the work for winch this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY LL P mit is issued.I shall not employ any person in any manner In as to Uw beeURIC subject to the Workers'Compensation Laws Of California. BUILDING ELDatc Appueant ALTER OR ADD TO MECH. 4.00 } to NOTICE TO APPLICANT': If,after making this Certificate Of IN- F Z_ Cutption,you should become object 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 slmll he deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00 CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0,O00GFM.)'5.00 SEISMIC FEE 1 hereby atl'irm that there is a construction lending agency far EXHAUST HOOD(WITH DUCT) 2.00 the performance of the work I'or which this permit is issued(Sia MICROFILM 3097,Civ.0.). HEATING UNIT(TO 100,000 B.T.U.) 4.00 Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC Lender's Address r i I certify that l have read this application and state that lire above VENTILATION FAN (SINGLE) 3A0 infonndion is correct I agree to comply with all city andcounty PLUMBING Ordinances and state lows relating to building construction, and BOILER-COMPI3 H.P.Cr 100,000 B.T.U,) 4.00 hereby authorize representatives Of ties city to enter upon the BOILER-COMP(Over 100,000BTU)SEE FEE SCH. MECHANICAL above mentioned property 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 3.00 CONST.TAX 'pg any way accrue against said City in consequence of the 'hnpermit MECH.CONT. LIC.NO. MECH.TOTALTOTAL 10rc of ApplicantjC n[md r Date/ OFFICE COPY CITY OF CUPERTINO INSPECTION RECORD (OFFICES COPY) PERMIT NO. AW)FESS Alwonkp'G -15 11— Ric oc� Y PERMIT ISSUED DATE "ELECTRICAL DATE INSP.' F- i'Td n�� ectrl Plumbing Power Pole ' anica r un e as ec uwing bolar halls Fire. prin c ereZ i in Sign 1=res int/Ext otors Misc. Grounding Other Otear FINAL INSPECTIONS DATE INSP. Not .Approved Gas Electric Plumbing PLUMBING DATE INSP. �fe-�aziica� .,o ar Backflow 'oo r un Urading oor Planning artaRough Fire lei— u i ete He t. oar u _ in ater ' Insulation Other in aui 775779-Main Gas Other BUILDING DATE INSP. Not rove Pad Certification 7o—un—Ta—tion ELECTRICAL DATE INSP. re- unF to Slab-Membrane Underfloor S.M. Som DYcts nsu ation Undertloor Girders Fire Damperg Floor Steel _Fireplace Tied-owns reuse Duct 6 Hood is rams One Hour Shaft eismec racin Condensate a3.n a s- ane s ui ment Anchorage Frame y ues oMb. Air .I:ath Other Ei lboards Int/Zxt. of Approved �ftrewalls Other Ret Approved