6232 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT ^^ ^
nD RESs '30 QN _ _ b G G
`� BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
osv 5 - PLAN CHECK VALIDATION
NAME nn OTY. ELECTRIC PERMIT FEE J^
V
Ll
Lli
CONTRACTORS
t`()/ /yy''�1 U
' TC PRO NE /
-
nME UTLETS-SWITCHES-RECEP 5:00/1.00 8
QC. LIC.No. 6 LIGHTING FIXTURES - 5.00/1.00 -
roNTRAc.ors APPLIANCES-RESIDENTIAL 4.00
CONTRACTORS
J PRONE PANELS 5.00 DATE'OF APPLICATION EL
A I SIGNS • 600 .PLAN CHECK FEE P.O.NO.
on �a
ENGINEER L'�"� `7�"'' LIC No, SIGNS TRANS. 3.00
ARCH,OR ENG. PERMIT VALIDATION
ADD
RC.ESS , SPECIAL CIRCUIT 5,00 -.
` ZIP TEMP.METER OR POLE-INS. 15.00
APPLICANTS MOTORS ' SEE FEE SCH. -
ADDRESS
SERVICE CHANGE 10.00 1
wo o i/S4 LICENSIiD CONTRACTOR$DECLARATION• -
¢ u I hereby,iffC thain
t I n licensed under provisions of Chapter 9 - ISSUANCE GATE
y Q.w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
0 vs z Pm(essions C an my,li¢nsc is in full fpr and cff
0 o m- Limn las Co Num ❑ ❑ ❑
� m F ° nate - Contractar
OCT r 0 19 BUILDING PERMIT
¢ ¢w¢ OWNER-BUILDER DECLARATION , INFORMATION
F. o a- U - - MISC.- REFER TO ORD
U.V, 1 hereby alfinn that 1 am exempt from the Conlmctor's'License VALUATION S/FT.
RLLof law for the following reason.(Sec.703 1.5,Busin-uand Professions PERMIT ISSUANCE 'Ci o0f Q I
CWe:Any airy or county which requires a permit to construct,alter,
ac 2 Q improve,demolish,or repair any structure,prior to its n,mance,also ELEC.CONTE.- LIG N0. ELEC.
¢ tepuirts the applicant for such pOnIn to file a Signed statement that TOTAL ,PERMIT TO -
st " he is licemod pursuant to the provisions of the Contractor's License I
rzi Law(Chapter 9(conimencing with Section 7000)of Division 3o fine �('/�v�riG /�✓jEQJ
< Business and Professions CWe)or that he is exempt therefrom anA DTV. PLUMBING PERMIT FEE
re r O the basis for he ullegcd exemption.Aoy violation of Section 7031.5 STORIES TYPE CONSTR.
n ;$ by any applicant fora permit subjects the apylicanl loacivil penally ALTER-DRAIN&VENT-WATER (EA.) 4,00.
of not mom than fisc hundred dollars(S500).):
Cl 1,as owner of the properly,or my employees with wages es BACKFLOW PROTECT:DEVICE '�2.00 OCC.GROUP RES.UNITS
their mole compenmlion,will On the work,and the Uroctme is not -
intended or offered for sale (Sec. 7044, BUsm.and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law dols not apply to an owncr of.
property who builds or improves thereon,and who docs seen work FIXTURES-PER TRAP 4.00 50.FT,FLCOR AREA TOTALACREAGE
himself or through.his own employees,provided that such improve-
memsarenotintended or offered for sale lL however,the building GAS-EA.SYSTEM-1INC.4 OUTLETS 4.00
or improvement is sold within one year of completion,the owner. GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 aulLOlrvG USE
builder will have the burden of Arming thin he did not buil)or im' RES IND CON PB Other
prove for Perlis.of.la). INDUSTRIAL WASTE INTER. 20-00 •+
❑ I;as owner of the property,am exclusively contracting with ❑ - ❑ ❑ ❑ ❑
licensed contractors to construd the project(See.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSOHS PARCEL NO.
and Professions Code:The Convucnlh.License Law does not apply
to an owner of pmpl'rty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such Projects with a annreclotls)licensed pursuant to
the Contractor's License law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT No. PARCEL NO.
- ❑ 1 am exempt Tinder Sec. .B.&P.C.tot this WATER HEATER W/VENT 4,00
reason
owncr Date WATER SYSTEM - " _4.00 ACC.DATE ACC,FILE N0.
W'ORKGRS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby.(firm that l have a cell)hcale Of cumct"to self-insure, ZONING ENG.SITE NO.
or a certiticate of Workers'Cmrpen.tion Insurance,or a certified -
copy theme f(See.3800,Lab.Cy�
Policy Noy- CompanS�i--''�l r
O ❑ Ceaifiedcopy'isherebyfumishal((JCZ5�EM FIRESPRINK ENERGY T24
Z Z. ❑ CcHillc�cnt r e� w h tnc cityinspl'cmvsion. MISC,- REFER TO ORD. -
O, Applicant-/�. - Y.❑ N❑ v E] N[]
cc w CERI'IF[CAT Ii OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE- 6.00 FLOOD ZONE AL.U.L.
LU > COMPF-NSWION INSURANCE PLG.CONTR. LIC NO. PLG: Y❑ N❑ Y ❑ N❑
CL O - ffhis section deed Not be completed if the permit is for one TOTAL
D Z hundred J.11...($1000011..)
L) O I terrify that in the performance of the work for which On.per OTY. MECHANICAL.PERMIT FEE FEE SUMMARY
LL U out is issued,I 'hall not employ any person in any manner so as to
been`ny'sub,JFyl�1y the Workers'Com a Icon La u. )�
U UmcJLJ y}�_7tt_Applicam� ALTER OR ADD TO MECH. 4_00 BUILDING /
} to 'NOT C'9f?TOA I [C-ANT: IL a to making this C rti tate sl'Ex-
t Z .option,you should become subject to the Workers'Compensation - APPLIANCE. 4.00 - PLAN CHECK
provisions of the Labor Calc, you must forthwith comply with ,FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOCF.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE '
I hereby affirm that there u IT construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work fur which this Permit is ixiued(Sec: MICROFILM
3097,yv.C.). ,. HEATING UNIT(TO 100,000 B.T.U.) 4.00
N
Lender's ame��u 1LAYC.� I�Yc�-7�LA HEATING UNIT(OVER 100,000 B.T-U.)7.50 ELECTRIC
Lender's Address
I earthy that I have read[Misapplication and slate that the above VENTILATION FAN (SINGLE) 3.00 -
• information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating In building constructio -COMP(3 H.P.or 100,000 B.T.U.1 4.00
n, and BOILER
hereby mutt seize repasentatis" of9hu city to enter upon the BOILER-COMP loser 100,000 BTU)SEE FEE SCH. MECHANICAL
•above menf red properly to inspection purposes.
(We) age to w.¢, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino a Inst liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX
may in any way accrue against said City in consequence of the
MMT oft 's permit. MECH.CONT. LIC.NO. MECH. '
_ TOTAL TOTAL
S' re of p icanl/Contra or - Date
OFFICE COPY
4• .
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COM1
FL 0?07 it _7777—
MctTttG ) ( 4:L GlYrL
PROJECT —" �
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'n
In
ectrica /
Plumbing ower Pole
anica er un
e as ec u thin 7 e -
o Ea FNaiis
Fire Sprinkler Ceiling
i i Pixtures Int/Ext
otors
Misc. roan 1n
e ower
Other
FINAL INSPECTIONS DATE INSP, Not Approved
Gas
Electric
Plumbing PLUMBING DATE INSP.
mechanicai
Solar Backflow
ool Under un
'qWoradmg UndertRoor
Partial Rough
it. ou ete
ea t e t. o ar ou
ui in fir -g Water ' , Insulation
er in ain
T777-77-ram
Gas
Other
BUILDING DATE INS.p Not rove
Pad Certification
Foundation . ELECTRICAL DATE INSP.
re- unite
Slab-Nbmbrane Underfloor S.M.
Bond earn rYETT7nsulation
Undertloor Girders Fire Dampers
Floor Steel Fireplace
ie owns brease Duct 4 Hood
is rams e our Shaft
eismecracin Condensate Drain
l s-
Vaane s ui ment Anchorage
Frame ues 4 Comb. r
Lath t er
allboards Int/Ext. of rove
irewa s
—Other
Net rove