6680 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BA POINT PEN ONLY
r BUILDING PROJECT IDENTIFICATI PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADDRESS - C C 8 O
a �a s. ,N TN.A1�U Ayy�y. BUILDING-ELECTRICAL-PLUMBING-MECHANICAL UU
OWNER'S PLAN CHECK VALIDATION
"AM..E,MN 129 l� /��� /��J) DTV. ELECTRIC PERMIT FEE
AMP129 WKVXf'/7//�P"ONE
CONTRACTORSUTLETS'-SWITCHES-RECEP 5.00/1.00
NAME
ACACNCo!<3S7X[JGTf41� Cha LIGHTING FIXTURES 5.00/1.00
uc.No.
'n^D'DP.�ESs TDRs D�OY q+.5ce7r �Laj s'S.7AVN PPLIANCES-RESIDENTIAL 4.00 ,
PHONE r- PANELS 5.00 DATE OF APPLICATION
ARCHITEC SIGNS 8.00 PLAN CHECK FEE P.C.NO.
ENGINEER,
LIc.No. SIGNS TRANS. 3.00
ARCH.OR ENG. rp y
rWl,- L, e!. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS T\O.JN
APPLICANT Yl1�7 LA zIP EMP. METER OR POLE INS. 15.00 (;^'� ,/
DDREs MOTORS - SEE FEE SCH. i�///j, l
AooREss ,(iZIFf1{ u7UL�s24 C.7/OU GO,
3�0+ 9u BLRd -5# f7N C[.H?q S SERVICE CHANGE 10.00
moo LICENSED CONTRACTORS DECLARATION Py O
¢ Lt u ' 'I hereby affirm that I am hcensid under'provisions of ChaphN 9. ISSUANCE
G w (commencing with Section 7000)of Division 3 of the Business and - EILDIftl ELECT PLG. I MUCH.
DO i Professions Code and my license u in full fort�agit IT L ❑9 a ,❑
z 0 m- License C ass f Lic.Number
��.G_y_'_I O_ -
0 2 H Date fiJ(.���Contract 1,0
`t¢ a w OWNER-BUILDS RATION. - CIt) IN�,usse.y ERMIT
REFER TO ORD N
R
;LL m I hereby affirm that I am exempt from the Coalractoh License MISC.- VALUATION SIFT.
LL
04 Inw for the following reaum.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6,00
L W Cock:Any city or county which requirssa Iscrmit to construct,alter, _7
¢ ¢ a Q improve,demolish,or repair any structure,prior to its issuance,also . U
ELEC.CONTE. NO. ELEC. O
is
-m¢ rcyuirrs the applicant for such permit to file a signed statement that TOTAL PERMIT TO
¢ Be m LL he is licensed At to the provisions of the Contractor's Lievow
tris
Law(Chapter 9(commencingwilh Section 7000)of Division 3 of the �N T�4/OzC PCE/ay0
a Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
IC r the basis for the alleged exemption.Any violation of S,ctim 7031.5 STORIES TYPE CONSTR.
d ; _ by any applicant for apermit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
of nor more than list hundred Jallars(5500).):
❑ [,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(Sic. 7044, Business end Pmfessrons DRAINS-FLOOR,ROOF,AREA,COND. 4.D0
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thaseon,and who does such work FIXTURES-PER TRAP 4.00 M FT,FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsare But intended oroffered for sale.If,howesoq the building GAS-EA.SYSTEM-11 NC.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 ml build nr im- . . .
RES IND CON PB Omer
prove for purpose of sae.). INDUSTRIALWASTE INTER. 20.00 ❑ [D E] [3 E]❑ I,as owner of the Property,am ixChxOcly contracting with
licensed contractors to construes the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Conrmaor's License Law does not apply
to an owner of pri+edy wpm builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
mmmcts for such nLaw.
ec with acolicensedor(sl licensed pursuant to
the Contractors License LSEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO. PARCEL NO.
-
❑ 1 um exempt under Sec.-.B&P.C.for this WATER HEATER W/VENT .4.00
reason
Owner Dutra WATER SYSTEM 4.00 ACC.DATE ACO.FILE NO.
WORKERS'COMPENSAI ION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of comsat to self-insure, - - ZONING ENG.SITE NO.
or a certificate of Workers'Compuuwtion Insurance,u u certified
copy thereof(SecC. Ip.RYLabC)r_hgF aQ/✓ �•
Policy No. Company
O ❑ Certiticd copy is hereby furoished. - � � FIRE SPRINK ENERGY T44
Z Z G/Ceitifed py is Bled with the it inspcetion.division. -
O Applicant_- Eic4' G,N LI>� �a, MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
ILL CUT1-V rEOa?N OM WORKERS. PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.UC.
W
> COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PEG. y N - Y N
CL (This section used not be complete) if the permit i for one. TOTAL ❑ ❑ ❑ ❑
0Z hundmJfythatIlarx(SI the orless) '
U F- I is issued,
I h the to employ
of the work for which anoe,So
per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 1- mit is issuede I shall not employ any person in any manner su us m
betaine subject to the Workers'Comprnvliun Wws of Californw. -17
O w BUILDING J
NDateOT Applicant ALTER OR ADD TO MECH. 4.00
} y
NOTICE TO should
become
IL after to the
Ibis ns Compo.le of E.-
emptier,you should become subject to phi Workers'Compensation with APPLIANCE 4.00 PLAN CHECK
provisions io the Libor mit Shall
you most forthwith comply with FEE
CJ such provisions or this permit shall Irc deemed revoked. AIR HANDLING UNIT(TO 10100GF.M.) 3.00
'CONSTRUCTION LENDING AGENCY " AIR HANDLING UNTT(OVER 10)(MQEIvI) 5.00 SEISMIC FEE'
1 hereby affirm that there is e construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this perout is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's NameHEATING UNIT(OV ER 100,000 B.T.U.)7.50 ELECTRIC
Lender's Address
I cenify that 1 have read this application and state that me above VENTILATION FAN (SINGLE) 3.DO
s m o in.tiois is correct 1 agree to comply with.II city and county BOILER-CONP 13 H.P.or 100,1X10 B.T.U.) 4.00 PLUMBING
4 ordinances and state laws relating to building construction, and
hereby authorise representatives of this city to enter upon the I BOILER-COMP IOxer 100,000 BTU)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 CONST.TAX
may in any way accrue against said ❑ty'in Consequence of the PERMIT ISSUANCE 3.00
gee ing this pminit. MECH.CONT, LIC.NO. MECH.
7 E TOTAL TOTAL
a(mem'Applicant melmctor Date 4 -
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICES COPY)
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
ui m: /
ctri
Plumbing Power Pole
Mechamcal Underground
7emp Gas/Elec xough wiring
o ar Fulls
Fire Sprinkler Ceiling
bip Fixtures Int/Ext
tors
Misc. Grounding
Te ower
Other
FINAL INSPECTIONS DATE INSP. NotApproved
Gas
ectric
um 3n - PLUMBING DATE INSP.
anica �
• o a�'!r Backflow
00l r un
6rading oor
PiaM3-ng Partialu
Fire t. u ete
eat Dept. Solar Rough
j1ding Water ', lnsulation
LYther in ain
oDrain
Gas
Uther
BUILDING DATE IIP. NotAppr—oVFff—
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-Mernbrane Underfloor S.M.
Bond earn TJ cts n ation
Underfloor-7-r3Fr—s --- Fire ers
Floor SteerFireplace
ie owns urease ct oo
rams ee ur Shatt
eismec bracing Condensate Drain
s- an s ui ment Anchorage
Tame X-f, Piues r
ath UETer
oar t at. Tot XFpr6ved
irewa s
er
9E rove
BUILDING
ELECPRICAL
PLUMBING
•
MECHANICAL
TIISCELLANEOUS