6532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
F BU I LDING PROJECT IDENTIFICATION PERMIT NUMBER
aDILOING .Z.OAPPLICATION & PERMIT' ^��^
ADDRESS _ b G
it O BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S 0` - PLAN CHECK VA LIDA5
NAME
�L.x 1,. ���^x /� �- QTY. ELECTRIC PERMIT FEE
PAke ' as k S PHONE .
CONTRACTORS
NAMF UTLETS-SWITCHES-RECEP 5.00/1.00 -
aD LIGHTING IF 5.0017.00
` y
CONTRACTORS - APPLIANCES-RESIDENTIAL 4.00
ADDRESS 1 t� QA^
.too:). 4v� PHONE a J \� PANELS 5.00 DATE OF APPLICATION
ARCHITECT
OR p �p,� - - SIGNS 600 PLAN CHECK FEE P.C.NO.
vl
ENGINEER
LIC.NO SIGNS TRANS. 3.00
nuoa Ess ENG. SPECIAL CIRCUITK�A5.130 PERMIT VALIDATION
• zap TEMP.METER OR POLE I 15-00 PAID
• APPLICANT'$ MOTORS MAY ft fiH.
ADDRESS 2 5
• SERVICE CHANGE .00 of jJJ 84
CRY
oo LICI;NSI:DCONTRACI'ORS.DECLARA'IION 9 'J
of Cupeitino
S C♦ IfL//1/11U/�.{
<u coi I hereby affirm that lam licensed under provisions of Chapter 9 / �� a Ssf AN4 HpE+srt( /
H a y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. NIECE.
H m z . Professions Coand my license is in full here 1Of14y.Iz_ ❑ ^
Z O w _ License Ck s Lie.Number V 11 I'LA'fe'I
o � r O Date M1e}��gq/y(1 'Contractor ql,
a L 2 �C/)O/!/ -'I �STQ `�' BUILDING PERMIT
¢ , w.< WNER-BUILDER DECLARATION INFORMATION
A o a MISC.- REFER TO ORD
w3 u r 1 hereby affirm Nml I um exempt from the Contractors License VALUATION
H _ PERMIT ISSUANCE 5.00 �. S/FT.
.. O j haw for the following reason.(Sec 7031.5,Ilusiness and Professions lou
Code:Any city or county which requires permit to construct'alter.
u,a p ' improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTE. LIC.NO. ELEC.
iI]u requires tile'applicant for such permit to file a signed statement that TOTAL. / PERMIT TO
K
m he is licensed pure mot to the provisions(d the Contractor's License •yn
H z i
Law(Chapter 9(commencing with Section 7000)ofDivision 3 of the &-tacr ? A 0a
's Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE I`
F o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN -WATER (EA.) 4.00 of not mom then five hundred dolbrs(5500).).
r ❑ h as owner of tire property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 02 OCC.GROUP RES.UNITS
their sole compensation,will do the work.and the structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Lode:The Contractor's License Law does not 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
himsell or through his own employees,provided that such improve-
ments are not intended oroffered for sale.If.however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner- GAS-EASYSTEM'-OVER 4IEA) .1.00 BUILDING USE
builder will have the burden of proving that h . .
e did not build im- - RES IND CON PB Omer
prove for purpose of sale.): - INDUSTRIAL WASTE INTER. .20.00 ❑ ❑ ❑ ❑ '❑
❑ 1•as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. : 5.00 ASSESSORS PARCEL NO.
and'PmfeWmW Code a'I'he Contractor's License Law does not apply
1.ell owner or property who huilds or improves thereon,and Who LAWN SPRINKLER V 5IEA.) . 1.00
contracts for such projects with n contructons)licensed pursued to
the Conlractnh License Law. SEWER-SANITARY- O EA.200ft/8.00 TRACT NO, PARCEL NO.
❑ 1 am exempt under Sec. T&P,C.for this WATER HEAT V 4.00
on
Owner Dale - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION EdiCLARA IION WATERTREA IP. - 4.00
I 1 hereby affirm Ihat'1 have a certificate ofcurment to self-insure. ZONING
ur a certificate of Workers'Compensation Insurance,or a cerlilieA - ENG.SITE NO.
^� copy thereof(Sec.3800.Lab,C.) /-_ .• ;7
_ Policy No ' Company m t,�F�s,y`h Is S .
Q ❑ i�rreeified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z r Certifie opy is filc� it, inspection division.
O Appli'lou ". MISC.- REFER 70 ORD. Y ❑ N❑ Y ❑ N❑
~ rn � �; PERMIT ISSUANCE 6.00 (p -- FLOOD ZONE A.L.u.c.
CC > CE A'I'Ii0 'XIiMRI'ION PROM WORKERS'
IL - COMPF-NSATION INSURANCE' PLG.CONTE. LIC.NO. PLG. q
d0 (This se,fimn nn one lived not be Completed if the permit is for o TOTAL OL Y F] No Y❑ N[30 Z hundred dollars IS 100)or less.) -
U O 1 evilly that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL E- mit is issued,I shall not employ any person in any manner so as to -
U become subject to the Workens Compensation Laws of C.1ifamia.•
ED Date ApplicantALTER OR ADD TO MECH. 4.00 BUILDING
} 'm NOTICE 10 APPLICANT': 11'•after making this Cc Howate of lis-
F Z
creation,you should become subject to lite Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mull lorthwilh comply with - FEE O
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,ODOC.F.NL) 3.00
-coNsrRUCTION1.EM)ING AGENCY AIRHANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
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(Sec. MICROFILM
3097,CivC.). HEATING UNIT LTO 100,000 B:T.U.) 4.00.
Lender's Name HEATING UNIT IO OOO B.T.U.)7.50
Lender i Address ELECTRIC
• ( certify tis corrvc readthisapplication and all c that the above VENTILAT FAN (SINGLE) 3.00 - y � =
information n correct. 1 agree to comply with oil city end county BOILER 0'10 , .T.U.) 4.00 PLUMBING O(
hereby au and stmt Taws relating to building enter ipon and
hereby mentioned
eopertyforicesec this city to enter upon the BOILER- OMP (Over 100,000 BTU)SEE FEE SCM. MECHANICAL '7
abovrmwLioned property for inspection'purpoxs. -
(We) agree to as, indemnify and keep hornless the City of ISC.- CI of RTO ORD. _
Cupertino against Iinhilitics,judgments, costs and expenses which ". CONST.TAX
y any way a against said Cily in consequence of the PERMIT ISSUANCE a . 3.00
gr ting of this pc MECH.CONT. LIF NO. MECH.
TOTAL -7 - TOTAL 9
gnalurn of Applicant/Contractor DatJ
OFFICECOPY r
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
co. ADDRESS � —�
�h row �`�uo�e� 2OWNER
��—�
PERMIT ISSUED DATE "ELECTRICAL DATE INSP.
ui ing
Electrical
turbin, Power Pole
Mchanicai underground
eas ec Rough� firing
�Iar Walls
Fire Sprinkler Ceiling
Sin 1-ixtures int/Ext
otors;
Misc. rotor ut
.1FT
Other
FINAL INSPECTIONS DATE INSP. Not .Approved
Gas
Electric
Pliunbing PLUMBING DATE INSP.
anica
•;o ar Backflow
Pool r tm
Grading r oor
angorPPartial Rough
ire t. Rouriete
Health et. oar u
ui�ut ater ' insulation
e� iter— Main Drain
7767Main
Gas _ y
.Other
BUILDING DATE INSP. Not ApproVed
Pad Certification
otmanon DATE INSP.
re- ire
Slab-Merbrane Underfloor S.M.
Bond Beam Ducts & Insulation
Undertloor Girclersers
loot tee1 "F1!5 ce
iT'edowns Grease Duct 4 Hood
is rams One Hour Shaft
eismecracist Condensate Drain
al s- anels to ent Anchorage
tame Flues 4 UOMb. Air
K1a ter – y'-
oar H7 Zxt. Not Approved
Firewa s
Other
Not kpproved
t � I
BUILDING
ELECTRICAL
PLUMBING
•
MECHANICAL
MISCELLANEOUS