2936Al
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE RQI_I._ POINT PEN ONLY
BUILDING PROJECT:I DENTI FI( N. -
•`' APPLICATION & Pr-wMIT
BUILDING =:ELECTRICAL- PLUMBING - MECHANICAL
PE Ir
J
9 3
BUILDING
ADDRESS
/
O ER'S '
_ ..
PLAN CHECK VALIDATION
NAME
�D PHONE
QTY. ELECTRIC PERMIT FEE
-
DATE OF APPLICATION
CONTRACTOR'S
NAM _'
E
/ l etre LIC.Na,V � giiA
,OUTLETS -SWITCHES- RECEP 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S/ S
ADDRESS - rI P -
e1,3 a f s vL PHONES t -k
- NES - RESIDENTIAL 4.00
APPLIANCES
PANELS -7, 5.00
ARCHITECT - -.
OR
ENGINEER -
LIC. No.
SIGNS-. 6.00
�
PLAN CHECK FEE
P& C. NO.
/� /►
JJ
WW
SIGNS TRANS. 3.00
ARCH. OR ENG.
ADDRESS
SPECIAL- CIRCUIT 5.00 -
PERMIT VALIDATION
'
TEMP. METER OR POLE INS. 15.00
ZIP
,
.,A
APPLICANTS ADDDRESDRESS _ -.
MOTORS" SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of.the Business and•
Professions Cod nd my license is in full f f
License CIa s Lic. Number!
ISSUANCE DATE
BLDG.
ELECT.
PLG.
MECH,
Date Contractor
I BUILDING PERMIT
OWNER:BUILDER DECLARATION
hereby affirm that Iam exempt from the Contractor's License
Law for the following reason. (Sec. 703 1.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to file a,signed statement that
he is licensed pursuant to the provisions of tHe'Contractor's License
INFORMATION
MISC. - REFER TO ORD
-
VALUATION $/FT.
PERMIT ISSUANCE `6.00
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
_ ERT�
yQfJ/R//ia
CITY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that lie is exempt therefrom and
IAIJM 4
the basis for the alleged exemption. Any violation of Section 7031.5.
STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to acivil penalty
of not more than five hundred dollars (5500).):
ALTER -DRAIN &VENT -WATER (EA.) 4.00
❑ I, as owner of the property, or'my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not app)y'to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for'sale. If, however, the building
FIXTURES- PER TRAP 4.00
SQ. FT. FLooR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 INC.4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that he did not build -or owner-
prove for purpose of sale.).
❑ I, as owner. of the property, am exclusively contracting with
- GAS EA. SYSTEM - OVER 4 (EA.) 1.00
BUILDING USE
RES', IND IN PB Omer
❑ ❑
INDUSTRIAL WASTE INTER. 20,00
licensed contractors to construct the project (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply
to an owner of property who builds or improves thereon. and who
_
LAWN SPRINKLERS - 1 INC 5 V.B. 5.00
ASSESSORS PARCEL NO.
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
❑ I am exempt under Sec. .B.&P.C. for this
WATER HEATER W/VENT 4.00--•
reason
Date Owner
WATER SYSTEM 4,00
ACC. DATE
ACC. FILE NO. '
WATER TREATING EQUIP, •- 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure,_
or a certificate of Workers' Compensation Insurance, or a certified
-,
ZONING
ENG. SITE NO.
copy thereof (Sec. 3800, Lab.C.).
^-
Policy No. Company
FIRE $PRINK
Y
ENERGY T-24
`
IWMI
❑ Certified copy is hereby furnished.
,� Certified p f wit Me city inspection division.
A p leant - �,/
MISC. - REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
8r7
. COMPENSATION INSURANCEPLG.
(This section need not be completed if,the permit is for one
Y ❑
CONTR. LIC. NO.
PLG.
TOTAL
hundred dollars (S 100) or less.)
1 certify that in the performance of the work for which this per-
mit is issued, I shall not employ any person in any manner so as to
CITY. MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
become subject to'the Workers' Compensation Laws of California.
Date • Applicant
ALTER OR ADD TO MECH. 4.00
NOTICE TO APPLICANT: If, aftermaking this Certificate -ofEx-
emption, you should become subject to the Workers' Compensation
APPLIANCE 4.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply -,with
such provisions or this permit shall be deemed revoked.
FEE
AIR HANDLING UNIT (TO 10)000C.F.M,) 3.00
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER IO)DDOC.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.
3097,Civ.C.).
MICROFILM
HEATING UNIT_ (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
H EATI NG UN IT (OV ER 100,000 B.T,U.)7.50
ELECTRIC
I certify that I have read this application and state that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to, comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER -COMP(3 H.P. or 100,000 B.T,U.) 4.00
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
MECHANICAL
hereby authorize -representatives of this 61y to enter upon the
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
may in any way acc a s said City in consequence of the
CONST,. TAX
PERMIT ISSUANCE 3.00
gran - of 's per -
MECH. CONT. LIC. NO,
MECH.
TOTAL
TOTAL
Ov
Signature of Applicant/Contractor Dide
OFFIC4 COPY
C I T Y O F C U P E R T I N 0
Building Division
PROJECT
CONTROL #c aT
ADDRESS D
PERP'IIT
OWNER PHONE
SAN. #
ADDRESS
BLDG. TYPE
REP. PHONE
OCC. GROUP
ARCHITECT PHONE
ADDRESS
REP. PHONE
CONTRACTOR aHONE
VAI. $ v�
ADDRESS
REP. �� / PHONE
S UCT.PLAN CK
Aw
BLDG -PLAN -CK
PLAN CHECK HOURS
PERMIT FEE.
CAP FEE
CONST. TAX
ENERGY FEE
TOTAL FEES
DATE REC. DATE RET.
C�
BLDG. DEPT.
---- -- -- --
ENG. DEPT.
PLAN. DEPT.
�.�- ::9Z
STRUCP. ENG.
CENTRAI, FIRE DIST.
-HEALTH DEPT.
-SAN. DIST.
-ENERGY
-
'HANDICAPPED
J
C.iTY OF l;l:T1P10 INS1'I.;CTIOV RECORD (Off: Copy)
2936 _ 10625 N. De Anza
Pi;RP1I'T PiO. SANITARY DIST. NO. LOT NO ADDRESS
Extend Island & Install 2 -Pumps Arco
PROJECT OWNER JOB SITE PIIONE NO.
PERMIT ISSUED Date ELECTRICAL
Buil di.nr _ 12-22-8 Date Insp.
Electrical Power Pole_
Plumbing, Under ,r.ound — ----
Mechanical Rough Wiring
Temp. Gas/Ilcct. [1a17s _
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Si ,n tlotors
Grounding
Hisc. Temp. Power _
Other
FINAL INSPECTIONS Not Approved
Date I Insp.
L•lectric
Plumbing
?techanical
Solar
Pool
Fire Dept
Health De
15UiL1Jif4u
Date Insp.
Vad Certification
Foundation
Pre-Cunite
Slab -Membrane
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
Halls -Panels
Frame
f,a th
Uallboards Int/Ext.
Firewalls
Other
Not Approved
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
_
Partial Roush
_
Rough Complete
Solar Rough
Water & Insulation
Main Drain
R/of/S Drain _
Gas
Other
Not Approved
_
HECIIAN ICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
_
Fircpla_ce
_
Grease Duct & hood
One flour_ Shaft
Condensate Drair.1
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
BUILDING
ELECTRICAL
MISCELLANEOUS
S
i
S
StA4'i Af 1 tIF L'f;3R K•.TO BE PER FO.9I U Location �O ,�` /V • D ,r • I V Date'
Pg.1�NS ®ALCH PETROLEUM
�iN
t ( PCT� } ' CONTRACTpaA� BUILDERS' INC: , ' '" y� l '-
i t gel -9 3 AMES AVENUE
MlLPITAS, A 95035 t'l+ts i �+
I —�
�:�'i�!��iyir jFT,�- �P.>'Xi3. • .. ... I.1.f..••_. -.. - _.._ - { r'!y-' "L"' i i
7'
AP
BDG DFT'
ED
r BUILDING
T y ci
-PLUMBING
a.. - .6,. �1%'�•!f �} M-' k
IA
fr
"_ j
N e
is -LA L"_
a
A'' 0 D� CE 'Htt"ODE iORQTNAI�CS-� -a _ -- — _. ._ _-� -- -- -t-- -
i�
t f1 G spe Iflca IVIS
kej�t ron the Lest
job at a+l•,tiriles-and it is un
�am� 4v ti lit-vi.-iltsn� permission from
�'lffi('Iri t lit. _QitY bf CUpeii'66
st8Mf);rYN cf �h-s p an 2nd specifications
ILt Iasi hb e -d uo permit or -to be -'an_-
wb
rOtt l cf the yiblahon of .any provisions tel' T _ COTSIt � .1"I L b�
my Vit;} d�ra�lcg
pr State--aw:-
�.,. :.,"�" j y"�*a.e'r-•r � 1 r•1 ! `y���— �� ��/ �Crri� 7 1 - _ . `- µ - - -^ ,� -14
' Wi aztd R'epIace BLACK -Sea; Coat
1 G4=Qwete GREEN -Overlay
^`A=1.":^~ ^~_ __ . . -- -_ , - . ` ' :
Name
DIAGRAM OF WORKTO BE PERFORMED U Location,
r
Date
el
/ .1 �_
0A.1—UH T U L F. 1i Ni
1
UH DERS, INC. A LT * ;7� S A.'Q D
DS" A'VE N U E
9:3'7, A M.
M
JilLi. CA 95033
-DATE- 2 0 -THE STAMPING- OF -THIS PLAN.
SUBJECT TO: SHALL NOT BE CONSTRUED'TOiAl
11 State Laws& -R gul ions PERMIT OR BE ANAPPROVAL
e a
El C unty Ordinances
OF THE VIOLATIONS OF ANY T.
aity Ordin-ances'
0 L tter dated,-. ITV ,COUNTY OR -STAT LAW
tations. hereon
Weld Inspect ons
e 8t. ests
GENTRAL PRE PROTEECTibW DISTRICT
".NOT PLAN CHECK 'DOES NOT
Santa Clara
3071 Driftwood Drive
•EVIEWSTRUCTURAL
EOUIREMIENT
S7 sm ime'. -C4
4
pm). 7. P,401 0
A
�0
r g�
to i4) ej.
VUUU
7X
NO
.. 7. z
—7
RED -Remove and Replace BLACK -Sea] Coat
YELLOW- Concrete GREEN - Overlay
.7
R
t
A
7—
L
RED -Remove and Replace BLACK -Sea] Coat
YELLOW- Concrete GREEN - Overlay
.7
R
c!
iit(f _
7
i l i
CM PLUG
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F .�l � pO 6 1
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asaGL� 1%5s
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