7088 / APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -,USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER BUILDING -
APPLICATION & PERMIT
y J
ADDRESS /,
D r 0 /. 1 r BUILDING -ELECTRICAL-PLUMBING-MECHANICAL1 1, 7088
JeQN ER'S !!!//NVV " PLAN CHECK VALIDATION
fiAME ELECTRIC PERMIT FEE
.i 4PHONE �J'�
ActRORsOUTLETS'-SWITCHES-RECEP 5.00/1.00
LIC,NO. LIGHTING FIXTURES 5.00/1.00
f.DNTRACTOR'S _ APPLIANCES-RESIDENTIAL 4.00 -
ADDRESS
PHONE PANELS 5.00 DATE OF APPLICATION
AROHTECT• SIGNS - 6.OU PLAN CHECK FEE P.C.NO.
OR
ENGINEER
uc.rv0. SIGNS TRANS. '3.00 '
ARCH.OR ENG. $PEDIAL CIRCUIT S.DD - 'PERMIT VALIDATION
ADDRESS
ZIP rrEMP.METER OR POLE INS. 15.00 9
APPLICANTS MOTORS SEE FEE SCH. /�Jl
AODREIns ' SERVICE CHANGE 10.00 /
oa O LICENSIi1)CONTRACTORS DECLARATION
¢ o e~) I hereby affirm (hal I am licensed under provisions of Chapter 9 ISSUANCE DATE
,o a is
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H m z Professions Code,and my license is in full force and effect ❑ ❑ ❑ ❑
Z 0 License Class Lie.'Nwnber
Datc Contractor _
< r s - BUILDING PERMIT
¢ ¢w a OWNER-BUILDER DECLARATION INFORMATION''
oa " MISC. REFER TO ORD
w w w I hereby affirm that I am exempt from the Contractor's License _HLVAL'UATION $/FT.
F LLoa Law for the following reason.(Sec.7031.5.Businessand Professions PERMIT ISSUANCE 6.00
Code:Any city or county which requiresa permit toconstiuct alter,
¢ ¢ ¢Q improve,demolish,or repair any structure,prim,to its issuance;also ELEC.CONTR. LIC.NO. ELEC. El
aS, requires the applicant for such permit to file a signed statement that TOTALj I I 1 - t PER TO
a w m he is licensed pursuant to the provisions of 0he Conmmt.r's Licenu
Fzi Law,(Chapter 9(commencingw'ith Section 7000)ofl)ivision 3 of the e.STl74cv 'S'w/tel�'
E i o Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE}}
a, m the basis for the alleged exemption.Any violation of Section 7031.5 ' t7 til UI STORIES-- TYPE CONSTR.
d. ; _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
of not more than five hundred dollars($5001.):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 DCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does asst apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 So.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
locals are not intended or offered for sale.If,however,the buildingGA$-EA.SYSTEM-I INC.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 tile - . . .
int- GAS burden of proving that he did not build or - RES' IND CON PB Omer
prove for purpose ofsale:). INDUSTRIAL WASTE INTER. '20.00
❑ I,as owner,of the property.am exclusively contracting will; ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5,00 ASSESSORS PARCEL NO.
aid Professions Cate:The Contract.,',License Law loci 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 contractor(s)licensed pursuant to
the CSEWER-SANITARY-STORM EA.200ft/5.00 TRACT NO. PARCEL NO.
pplIvmctmr icense Law.
ou
❑+I;u exmn unA•r See' ,B.&P.C.Os,Ibis WATER HEATER W/VENT 4.00
rcallalns10
Owner Date WATER SYSTEM., 4.00 ACC.DATE ACC.FILE NO.
ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I leave a certificate of consent to self-insure ZONING ENG.SITE NO.
oracertificate of Worker;Compensation Insurance,or a cerlified
copy thereof(Sec.3800.Lab.C.).,
Policy No. Company
O ❑ Ceitified copy is hereby l umished. FIRESPRINK ENERGYT-24
ZZ a Certified copy is file(] with the city inspection division. MISC.-. REFER TO ORD. v Q ❑ [:]" Nv No
O Applicant
y CERTIFICAI'Ii OF EXEMPTION FROM WORKERS' - PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
Ul > COMPENSATION INSURANCE PLG.CONTR. LIC:NO. PLG.
LL'c' (This section need not be completed if the permit is far one TOTAL Y❑ N❑ Y ❑ No'
-2) Z, hundred dollars IS 100)or less.)
U O I certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL I- mit is issued,1 shall not employ any person in any manner m as to
U become subject to the Workers'Compensation Laws of California.
O w Date Applicant BUILDING 1�
a ALTER OR ADD TO MECH. 4.00 /7
} W NOTICH TO APPLICANT: If,after making this Certificate of FX-_
F Z crop firm,you should become subject to the Worker;Compensation APPLIANCE 4.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shallbe deemed revoked AIR HANDLING UNIT(TO 10,000C.F.M.) 3.00
/ CONSTRUCTIONS LENDING AGENCY AIR HANDLING UNIT(OVER 10A000.F.M.),5.00 SEISMIC FEE �7J
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2-00
the peNisrmanec of tire work for which this pennil is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
3097,Cis,CJ.Lend"
Name HEATINGUNIT[OVER 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
' I certify that I ba ,ad.❑I: ppl' 't mn and stem(Bat he above VENTILATION FAN (SINGLE)- 3.00
information is correct.1 agree to comply with all my andtcountyPLUMBING
ordinances and state I relating R building construction, and BOILER-COIvP13 H.P.or 100,000 B.T.U.14.00
hereby authorize representatives of this city I') enter upon the BOILER-COMP (Over I00.000 BTU(SEE FEE SCH. MECHANICAL
above nhentianed property bar inspection phrpme,. _
(We) agree to save, indenhnify and keep harmless the City of MISQ.- 'REFER TO ORD.
Cuperlino against liabilities,judgments,costs and expenses which - CONST.TAX
ay in any way aceme against Said City in consequence of the PERMIT ISSUANCE . 3.00
g'u ing of is PcnniL MECH.CONT. LIC.NO. MECH, r
rorAl TOTAL /J7- c�'a
Sig Store of Applicant Contracmr Dale4 f _
OFFICECOPY a
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
OPER4Ir— Nom_ � `�
AUDELW LOT NO.
P=CT
_ LPi»U ER
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.'
ui in
--
ctricaa
Plurrbing Power Pole
mechanical Under un
e as ec u wiring
o la=r Wails
Fire Sp-rinkler Ceiling
bi i ixtures nt xt
otors
Misc. Grounding
e ower
Other
FINAL INSPECTIONS DATE INSP. Not ,Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
mechanical
Solar Backflow
ooh r un
brading oor
Planning Partial oul
iret. lete
u
ea t u e t. ar gh
u1jaing Water'F insulation
erin ain
oDrain
Gas
Other
BUILDING DATE INS,P Not rove
Pad Certification
oun ation _ ELECTRICAL DATE INSP.
Pre-Gunite _
a - rane Underfloor 'S.M.
Bond eam Ducts & Insulation _
Underfloor Girders ire ampers
loor Leel Fireplace
ie owns - rease Duct 4 Hood
Dma rams a our t --
eismec rapn n ensate Drain _
Walls-Panelu t Anc orT a
Frame Flues 4 Comb. Air
a�tmi _ er
.glMl'rarTboar Int/Ext. ' �� of Aprove3—
t1wirewalls —
Other
Net proved•—
BUILDING
Awl
ELECTRICAL
PLUMBING
e
MIEMANICAL
TUSCELLANEOUS
e