C7203 f APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI L61 NG PROJECT.1 DENTI FICATION PERMIT NUMBER
gO,LP,NG -, APPLICATION & PERMIT � n 2 O
wooREss
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL r
OWNER'$ — PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT . FEE
•rNE .
coN>ERACTORs UTLETS-SWITCHES-RECEP 5.00/1.00
iICNO, LIGHTING FIXTURES 5.00/1.00
CONTR
ACTORS 4.00
4� PPLIANCES-RESIDENTIAL 4.00
-1 oo
PHONE PANELS 5.00 DATE OF APPLICATION
SIGNS 600 PLAN CHECK FEE .NO.
ENGINEER
LIC:no. SIGNSTRANS:N 3.00
,Appq'Eu E"G' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
- ZIP TEMP.METER OR POLE INS. 15.00 /
APPLIc,wTs - MOTORS SEE SCH.
woGREss
SERVICE CHANGE 10.00
Woo LICENSED CON'RACTORS DECLARATION
a U. I hereby aftimu that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
v,Z a (commencing with Section 7000)of Division 3 of the Business and
¢ ME
H m i Pru fessiuns Cq�sa an my license u in full force and effect G. ELE T. PLG.
❑Z 0 w- LicenseCJ�ss—�1 LW.Numhe T
0 v,H 0 Dine Con tractor —
`¢ m E" BUILDING PERMIT
¢ 'm u OWNER-BUILDER DECLARATION i INFORMATION
W0 A I hereby affirm that I am exempt from the Contractor's License MISC.- - REFER TO ORD
�+c io y p VALUATION S/FT.
F ..o g Law for the following reawn.(Sec.7031.5.Businexsand Pmfessions PERMIT ISSUANCE 6.00 ,i
55y Code:Any cityorcounty which mr,iresa permit toconstruct vlleq
rt ¢¢ p improve,demolish,or repair any structure,prior to its LRuancc,aLw ELEC.CONTE. LIC.NO. ELEC.
u requires the applicant for such permit to File a signed xtuteincnl that TOTAL/• PER
w he is licem
ed pursuant to the provisions of the Contractor's License
H z a Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Bou nom and Professions Code)or that he isexempt therefrom and CITY. PLUMBING PERMIT F E a
¢ 10 the basis for the alleged exemption.Any violation ufSRlion 7031.5 STORIES .TYPE CONSTR.
n ; _ by any applicant fora permit subjects theappphcaut to a civil Penalty -
ofnot mom than fivehundred dollars(S5(0).): ALTER-DRAIN&VENT-WATER (EA.) 4.00
❑ 1,'as owner of the property,or my employees with wage as BACK FLOW PROTECT.DEVICE 2.WOCG GROUP RES.UNITS
their wit,compensation,will do the work,and the structure is nol .
Intended or offered for sal, (Sec. 7044, Bashiev and Professions DRAINS-FLOOR,ROOF,AR EA,COND. '
Code: 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 1 TOTAL ACREAGE
himself or through his own employees,provided that such improve-
meets am not intendd or offered'for sale.IL however,the building GAS-EA.SVSTEM-11NC.40UTL S 4.00
or improvement is sold within one year of completion,the owner- -
builder wdl have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (E 7,00 BUILDING USE
RES IND CON PB ,Omer
'prove for purpose ofstheJ. - INDUSTRIAL WASTE INTER 20.00 ❑
❑ [,as owner of the property,am exclusively coNracting with
licensed contractors m construct the project(Sec. 7044,Ilmines LAWN.SPRINKLERS- 1 IN)(5 V.B. 5.00 ASSESSORS PARCEL NO.
end Professions Axle:The Contractor's License Law does not apply _
to an owner of progeny who builds or improves thereon,and who LAWN SPRINKLERS-O R 5(EA.) 1.00 -
mntracls for such projects with a contmetods)licensed pursuant to -
the ContractorsLicmiseLaw, - SEWER-SANITARY-S RM EA:200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.' ',B.&P.C.for this-
teaser
his WATER HEATER ENT 4,00
teaser
OwncrUale WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO..
WORKERS'COMPENSATION DECLARATION WATER,TREA NG EQUIP: 4.00
I hereby affirm that I have a certificate of consent to sell-insure. _ ZONING ENG:SITE NO.
or a certificate of Workers'Compcosation Insurance,or a certified
f cagy lherlof(Scc. oC
copy
No. Comp,n,.
QAJ �
O ❑ CrRifed copy .-
is hereby furnished. FIRESPRINK ENERGY T-24
❑ Ceri d � PIs,, ah the city inspection div
Z ision.
- ( AppfcCeni �q-eC Icsger MISC - REFER TO ORD. Y EJ NY CD No
M N CERI'IF]CA'fli OF FXEMPI'ION FROM WORKERS' PE IT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU > COb1PENSATION INSURANCE PLG.CONTIR. LIC.NO. PLG. v N Y N�
Z ITh , section need not he completed if the Permit 'Is for one TOTAL
hundred,dollars IS 100)"or lea.) -
U O I certify that in the:perfomlance of the work for which this tier- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner w ce to
Q w become subject to the Workers'Compeomlion Laws of California
Dale As heaut BUILDING �s -
O_ 1 P ALTER OR ADD TO MECH. 4.00
to NOTICE TO.APPLICANT: If,after making this Certificate of Ex- - '
F-. ? cmPlion,you should hecomc subject❑u Due Workers'Coml+cnsation APPLIANCE '4.00 PLAN CHECK G�
provisions of the Labor Cade, you must forthwith comply with FEE a
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M) 3.00
CONSTRUCTION LENDING AGENCY. AIR HANDLING UNIT(OVER 10=C.EM) 5.00 SEISMIC FEE l of
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,CN.C.). HEATING UNIT(TO 100,000B.T.U.) 4.00 '
Lender',Address
H EATI NG U N IT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
1 certify that 1 have read this application and slate that the above - VENTILATION FAN (SINGLE) 3.00
information es correct. 1 agree to comply with all city and county PLUMBING
ordinances and state-laws relating to building construction, and .BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
hereby authorize reposcmalives of this city to'enter'IN" the BOILER-COMP (Quer IWODOBTU)SEE FEE SCH. MECHANICAL
above-mentioned property fcr,inspectipo
on Purses..
(We) agree to seos, indemnify and keep harmless the City of MISC., REFER TO ORD.
Cupertino against liabilities,judgments, cosh and expenses whichCONST.TAX
may in any way accrue against said City in consequence,of the PERMIT ISSUANCE 3.00 _
'n of this Permit MECH.CONT. LIC.NO. MECH. /
TOTAL /j TOTAL.
Si lure of Alicam Contractor -Date
OFFICE COPY
M
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
k�2&//91/m
AIWRE�ib -7=77--
�� auocl 4 .
PERMIT ISSUED /r ELECTRICAL DATE INSP.'
Building J
Electrical
PlurrbinE Power Pole
ani r un
T2 as ec ug %ring s-
o ar Walls
Fire Sprinkler e% in
Sign ixtures Int/Ext
tors
Misc, Grounding
12n32 Power
Other
FINAL INSPECTIONS DATE INSP, Not rove
Gas
ectr%c 3_
PlumbingPLTMING DATE INSP.
-mechanical
Solar Backflow,
Pool Underground
Grading oor
ann%n Partialou
%re t. u ete
eth Dept. ar o
% %n o e Water ' insulation
Fer Drain
76777-5m—in
Gas
Other
BUILDING DATE INSP of Approved
Pad Certification
1�oundation ELECTRICAL DATE INSP.
re- unite
Slab- rane Underfloor S.M.
bond Beam M—ETTT7nsulation
Underfloor Girders Fireers
Floor tee ace
%e owns Grease Duct & Hood
Diapftrams One Hour Shaft
e%smec rac%n on ensate Drain
s- ane s ul ment Anchorage
rFame ues Lomb. Air
Lath er
va oar Int/Ext. of rove
trees s
Other
Not rove
BUILDING
ELECTRICAL
PLUMBING
•
MECHANICAL
AIISCELLANEOUS