6365 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDINGPROJECT I DENTIFICATION _ PERMIT NUMBER.
BNl0140 APPLICATION & PERMIT-
ADDRESS _ 6365
00HE r BUILDING =ELECTRICAL—PLUMBING—MECHANICAL
NAME S (hr/'� OI Cj M / RO Q(1 PLAN CHECK VALIDATION
�• ` �J9F QTY. ELECTRIC PERMIT FEE
OU✓ G V: PHONE
,CONTRACTORS OUTLETS SWITCHES-RECEP 5.00/1.00
NA
LID.NO, 313W4-
LIGHTING FIXTURES 5.00/1.00
ronrRAcroRs GJ,rs PPLIANCES-RESIDENTIAL 4.00
AODREss
e edekPHONE -4 PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS B PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC,NO. SIGNS.TRANS. 3.00
ARCH.OR R ENO SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
• ZIP EMP.METER,OR POLE INS. 15.00
:APPLICANTSs
ADDRESS MOTORS SEE FEE SCH.
SERVICE-CHANGE 10.00
Oo LICENSED CONTRACTORS DECLARAf ION
a u u I hereby affirm that I am licensed under provisions of Chapter 1), C J4.,� ' ISSUANCE DATE
y< w (rnmmenCing with Section 7000)Of Division 3 o(thc Business and BLDG. ELECT. PLG. MECH,
o z Pnmfessiom Cadc iyyf liccnx is in full ft n:�-,v'� ,Ii t
z o B - License CI _ _ _y�Lic.Nwnber_�_I J.]4_�
ow Date— —/ Curatao., MAY — 9 M4
¢ x BUILDING PERMIT
a: ¢w ¢ )WNER.BUILDF-R DECLARATION - INFOfiM TION
o A ca MISC.—' ORD
X
Y. u I hereby affirm that I son exempt from the Contractors License VALUATI S/FT.
r- .. oa. bow for the following reason.(See.7031.5,Businessand Professions PERMIT ISSUANCE' 6,00
Code:Any city or county which requiresx permit reconstruct.alter,
gal improve,demolish,or repairany stmetum,prior to its issuance,also ELEC.CONTE. - LIC.NO. ELEC. (!•o
- o ¢ rectums the applicant for such permit to file a signed statement that .- TOTAL d•am ` EMIT
w$" he is licensed pursuant In the provisions of the Contractor's License
F z i I.aw(Chapter 9(commmrcingwith Section 7000)of Division 3 ofthe G
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE �'"
at _o the basis for the alleged exemption.Any violation of Section 7031.5 STOB R.
a ;? by any applicant for a permit objects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not carom than five hundred dollars(5500).): 11
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is nut
intended or offered far sale (Sec. 7044, Business and Professions DRAINS-FLOOR;ROOF,AREA,COND. 4.00
Code: The Contractor's License law does not apply In an owner of -
property wlto builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 sa IT.FLC011 AREA TOTAL wweAGE
himself or through his own employees,provided that such improve-
menMarenot intended or offered for sale.If,howeveq the building GAS-EA.SVSTEM-11NC.40UTLETS 4-00
or improvement is sold within 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 an-
Proveforpurposeofsvk.). ' INDUSTRIAL WASTE INTER. 2000 RES IND eoN . PB oma
❑ 1,as owner of the pmpertcting y,am exclusively contrawith ❑ ❑ ❑ -❑ ❑
l evou'd contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:l'he Contractor's License Law does nor apply '
to an owner of property who builds or improve(hereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contmelnds)licensed purwant to
the Contractor's Licensc Law. SEWER-SANITARY-STORM EA.200f1/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sea ,B.AP.C.(or the WATER HEATER WNENT 4.00
reason
Owner Dole WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate ofconsent to xIf-insure. ZONING ENG.SITE N0.
ora certificate of Workers'Compensation Insuren`e,or ceaifcd
copy there.f(Sec.3800,Lsb.C.I Q I
Policy No. Company
O- ❑ Cerlified Y
l eJ. FIRE SPRINK ENERGY T-24
z Z ❑ Cert ifi �t�he�� .��yalK•cf�'�rvnslon. MISC. REFER TO ORD.Applicant, 2-'LILG . . . y❑ N❑ V❑ N❑CERTIIRTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
N IPLG.CONTE. LIC.NO.d ' 1'fhisction mpklcJ if the permit efor one TOTAL Y❑ N❑ Y❑ N❑
2 hundred dollars(Sl00)or leas.) '
0 1 certify that in the performance of the work for which this per. OTY MECHANICAL PERMIT FEE FEE SUMMARY
l- mit is'smed,I shall not employ any person in any manner so as to
0 become object to the Wnrkms'Compensation Laws of Celifnmw. pry.
Is.
Datc Applicant ALTER OR ADD TO MECH. ,q,OO BUILDING
} W NOTICE TO API'LICANC If,after making(his Ccrlifiam of Ex. s
f" Z empliou,you should become subject to the Wudreri Compcmariom APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most lorthwitb comply with FEE
U such provisions or this permit shall be,deemed revoked. AIR HANDLING UNIT(TO 10=CF.M-) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,0WC.EM) 5.00 SEISMIC FEE
I hereby of ttrm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the performance of the work for which this permit is issunl(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50 02�
Lem er's Add,5, ELECTRIC
I certify that I have read this appliation and state that the aboVENTILATION NTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and 'BO ILER-COMPI3 H.P.or 100,0008.T.U.) 4.00
hereby authori/c representatives of this city,to enter upon the BOILER-COMP(Over IOQODO 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 agahlst liabidi ,judgments, costs and expenses which CONST.TAX
may a way accm gvnsl said City m conte 'enc of the PERMIT ISSUANCE 3.00
i g this permit. MECH.CONT. LIC.NO. MECH. Q-O
�( TOTAL
igmaturcuf Ap i a/Contractor Da[
If OFFICE COPY '
r CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
ADDRESS j
•- Wirg "
k'FWf L:1 OWNER
PERMIT ISSUED DATE / "ELECTRICAL DATE INSP.'
AMIui in fTL
ectric
in "Power Pole
e anica r un
as ec u irin
o ar Walls
Fire Sprinkler i ink
Sign Fixtures Int xt
tors
Misc. Grounding
Power
er
FINAL INSPECTIONS DATE INSP, Not Approved
Gas
Electric
Flu—m
kPING DATE INSP.
,dmkxbchPLUMBING
i
o
lar
Backflow
0 — r un
Grading oor.
Planning arti
ire t. u ete
eat e t. ar KOUR5
building B.a Water '& Insulation
Other Main Drain
[ cTTtn i v P ct o am
s e Other
BUILDING DATE INSP. Not ApproVed
Pad Certification
oun anon ELECTRICAL DATE INSP.
Pre-Gunite
cane Underfloor S.M.
Ream cts n ation
Undertlo,or Girders Fire Darrpers
Floor Steel Fireplace
ieclowns Grease ct 4 mood
rams a our t
eismecraci.n condensate ain
Ts ane s ui ment Ancora e
rame —I ues 4 UM. Air
a ' Other
lqwJa. oar Int/Ext. of rove
I-Tirewa s
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
•
DECHANICAL
•
WSCELLANEOUS