7159 APPLICANT TO-FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEWONLY
BUILDING PROJECT IDENTIFICATION '
PERMIT NUMBER
HDLLDING. - . _ . � `APPLICATION & PERMIT
/. ADDRESS. ^ 7 1 C Q
'tel p.3 ) y J �at�/J -,.. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 'r I JJ
i- olr y1,l.: _ _
OWNER'S '.I PLAN CHECK VALIDATION
�L NAME. L/ OTY. ELECTRIC PERMIT FEE
GA) - Sir./i Fr Col<•L "PHONE 4''2
NAM[RAcrons OUTLETS 5.00/1.00
' T 110111ph I )WOE("OFT$ (, AT`C�C,No.6 61Lr15rx4 LIGHTING FIXTURES 5.00/1.00
J CONTRACTOR'S ADDRESSt - - PPLIANCES-RESIDENTIAL 4.00
Q'',LP PHONE Z'T7^r�'///.. PANELS. 5.00 DATE OF APPLICATION
ARCHITECTSIGN$ 6.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER - '
c.�rvd•. SIGNS TRANS "3.00
ARCH� LIC.
ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT '5.00
. ZIP EMP.METER OR POLE INS. ' 15.00
APPLICANT S t: MOTORS SEE FEE SCH.
ADDRESS '
SERVICE CHANGE 10.00
o o LICENSED CONTRACTORS DECLARATION �s%y
a o u 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
yz a (commencing with Section 7000)of Division 3 of the Business and
¢ H BLDG. ELECT. PLG. MECH.
. 0 w z P t sibns Cor1a,T�pd Iyy liccnLi i.Is full(mc ansJ yll t1, ❑ ❑ '
z o"� License Cl Lie JJ C N bcr - �
oy r w Det -x'1.75 1' Contra for {"•-v1-
¢ :[¢ a OWNER-IIUILUER DECLARATION' v BUILDING PERMIT
E
; m I hereby affirm that I an exempt from the Contractor's License MISC.!- REFER TO ORD I F MATION
u 00¢ haw for the billowing reason.(See.7031,5,Businessand Profusion, PERMIT ISSUANCE VALUATION g/FT.
� - Code Any city or county which requiresa permit reconstruct,alter, 6'DD
re Q > improve,demolish or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. IV•Ii V`4 C (IrQ
o LL requires the applicant for such permit to Ole a signed statement Bur TOTAL ��
P. w m he is licensed pursuant to rhe provisions of the Contractors License PERMIT TO ^� ,
r z a om
[.aw(Chapter I(cmencing with Section 7000).f Division 3 of the ja/t/R Lf.Z97g4�9i-/
Business and Professions Code)or tial he is exempt therefrom and QTY. ,PLUMBING PERMIT FEE
¢ o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
aiT by any applicant for a permit subjects The applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than Ove hundred dollars(SS00)J:
❑ 1,asowner of the property,or my employees with Mugu as ggCK'F LOW PROTECT.DEVICE 2.00 OCC.Group BEs.uNITs
their Sole canprensation,will du tire work,and the structure is noC
intended or offered for sale'(Sec. 7044, Business and'Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00 -
Code:The Contractor's License Law dos not apply to an owner of
property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 4.00 •sa FT FLOOR AREA rorwt ACREAGE
. himulf or.through his own employees,provided that such improve-
ntsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11 NC. OUTLETS 4.00
trn
or improvement is sold witrin 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 on. alis IND CON PB Osier
prove for purpose of sale.). - IN DUSTRIAL WASTE INTER. 20.00
❑ 1,as owner of.the property,am exclusively contracting with ❑ ❑ ❑ ❑.- ❑
licensed contractors to construen'the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
'amt Professions Code:Tire C....R er',Lieense Law Hires not apply -
to an owner of property who builds or improves thaeon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Cont for sw:hcenjeLwdhacommnor(s)liccnud prirsuam to SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
the Contractor's h projects
Law.
❑ Iamexemptunder See B,4P.C.for tris WATER HEATER W/VENT 4.00 -'
reason
Owner Date - WATER SYSTEM ,4.00 ACC.DATE ACC.FILENo.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that I have a certificate of consent to self-insure; ZONING•' ENG.SITE NO. '
or a certificate of Workers'Compensation Insurance,ser a Leri l ied
pupy OreSkof(Sec.3800,Lah.C.). .
olicy lsl(. ' . Company -5,r.47r rs' .y -
O UT Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z ❑ Cerlifiel(,.I:op s led with tm city inspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
per¢. App licunt_Y�y V N V N
� m CERT 119 CATE 017 I:XIiM?I'ION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE' A.L.U,C.
Lu COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL 0 (Phis action need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z) Z hundred dollars IS 100)or less.) -
U O 1 certify that in the performance of the work for which this Per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
. LL H mh is issued;I shall not employ any person in any manner so as to
U become subject to the W'orkcrs'Compensatiuri Laws of California.
LU ' Data Applicant ALTER OR ADD TO MECH. 4.00 BUILDING 6 c/
} to NOI'ICIi TO APPLICANT': If,after making this Certificate of li x-
Z engrtion,you should become subject to the Workers'Compensation APPLIANCE _ 4.00 PLAN CHECK
Provisions of the Lab... Code„You must forthwith ctnr ply with FEE
U such provisions or this permit shall be deemed revoked. ' AIR HANDLING UNIT(TO 10,000CF-M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 - SEISMIC FEE a"i
I hereby alfion that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) '2.00
the perfnruwn¢ of the work for which this'porrin is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) ' 4.00
I.e adeh Name- HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I certify that l have ad this application and state that the above VENTILATION FAN (SINGLE) 3.00 '
rI rr nation is correct. 1 agree to comply with all city and county PLUMBING
t BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.o0
i. r Ninances and state laws relating t I building-construction, and
hereby authorize representatives of this city to enter upon (lie BOILER-COMP,(Over 100,000 BTUIS EE FEE SO IT MECHANICAL
above-mentioned property for Inspection purposes.
(We) agree to save, indemnlf and keep harmless the City of MISC.- REFER TO ORD. .
Cupertino against liabilities,jud cots, costs and expenses which CONST.TAX
may n way acct agai said City in conscyuence nl tiro PERMIT ISSUANCE 3.00
grapg tthis perlgii MECH,CONT. LIC!NO. MECH.
! -3. 3�, TOTAL TOTAL i8i7/00
7k, Signature of Applicant/Contractor Date
VVV OFFICE COPY _ •.
► CITY OF CUPERTINO INSPECTION RECORD
(OFFFICCE COP/Y)
R t� s ��
F tKUjt I�� a O ? .et�t ett
QDWNtK
PERMIT ISSUED DATE "ELECTRICAL DATE INSP:
crinin
R�trica
Plumbing Power Pole
Mechanicalr oun
Temp as ec u lirin
bolar Wails
Fire Sprinkler ein
�ign
Fixtures Int/Ext
Wo—forsMisc, Grounding
Temp ower
Other
FINAL INSPECTIONS DATE INSP, Not Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
-Mechanical
golar Backflow
• oo r un
Grading r oor'
Planning
PartialEh
tire t. ou uee
Health Dept. r u
m
gn
er in Water '& ns ation
- – --- o rain
Gas
.Other
BUILDING DATE INSP, Not rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
re- unite
Slab-MRibrane Underfloor S.M.
Bond Beam Ducts & Insulation
Undertloor Girders Fire Dampers
Floor Steel Fireplace
ie owns Grease Duct 4 Flood
i.a rams a our t
eismec bracing Condensate Drain
al s- anels Equipment An ora e
r�ame -� ues o r
Lat ter
a oar Int/Ext. of rove
irewal s
�-
Not rove ? - 2 S �r>
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
1.