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.APPLICANT TO FILL -IN INFORMATION WITHIN RED LINES-, USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FII )N
BUILDING - APPLICATION& PI IT
ADDRESS
2 C �O(Jf7'� Cr ' BUILDING -ELECTRICAL- PLUMBING -MECHANICAL3545
ko MIT UMBER
OWNER'S -'
NAME. -
/r�'I �[[���,, QTY. ELECTRIC PERMIT FEE
407-41 PHONgS--� 7
PLAN CC -Kr VALIDATION
)))
_ ,Ai !" V �/
M " Q O 1J
.City of. Cupertino
DATE OF APPLICATION
CONTRACTOR'S
LI ?. NT1B
OUTLETS - SWITCHES - RECEP 5.00/1.00NAME
LIGHTING FIXTURES 5.00/1.00
CONTRACTOR'S
ADDRESS -A
eQ eow7 - P-ONE272-403
'APPLIANCES - RESIDENTIAL 4.00
PANELS' - 5.0.0
AARRCHITECT - .:
O
ENGINEER
u c.No.
SIGNS 6.00
PLAN CHECK FEE
-.
P.C. NO.
_
SIGNS TRANS. 3.00
ARCH E55 ENG
4111Dpo*L Zip
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
�c
0 '
TEMP. METER OR POLE=INS. 15.00
AS
ADDREDDRESSS
., MOTORS -^ SEE FEE SCH.
72 e-P#W, A'wA-T_ •S
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under, provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, and my license is in full (or a and effect.
License Class �jr"�" Lic. NumberFz
Da 0 Contractor
ISSUANCE DATE
BLDG. -
ELECT.
PLG.
MECH.
BUILDING ERMIT
{. j
OWNER -BUILDER DECLARATljI
• I hereby affirm that I am exempt from the Con lractor's:License
Law for the following reason. (Sec. 703 1.5, Business and 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
I INFORMATION
REFER TO O
MISC. = RD
VALUATION $/FT.
O/t✓
PERMIT ISSUANCE 6.00
,
ELEC. CONTR. LIC. NO.
ELEC.
TOTAL
PERMIT TO
QTY. PLUMBING PERMIT FEE
Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and'Professions Code) or that he is exempt therefrom and
TYPE CONSTR.
the basis for the alleged exemption. Any violation of Section 7031.5DRIES
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 apply 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
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM - 1 INCA 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 im-
prove for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with
GAS EA. SYSTEM OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Other
❑ ❑ ❑. ❑ ❑ ,
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.
❑ 1 am exempt under Sec. B.&P.C. for this
reason
WATER HEATER W/VENT 4.00
Date Owner
WATER -SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP, 4.00
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure,
r a certificate of Wo ke s' Compensation Insurance. or a certified
ab.C.)
ZONING
ENG. SITE NO.
..
panyd.��A►.Ca!
❑ ed copy Is hefUrnlshed.
erti(ied c y is filed with the city inspection division.
Applicant
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N.❑
MISC. - -REFER TO ORD.
CERTIFICATE OF EXEMPTION FROM WORKERS'.
PERMIT ISSUANCE 6.00 aw
FLOOD ZONE
A.L.U.C.
COMPENSATION INSURANCE'
(This section need not be completed if the permit is for one
Y ❑ N❑
Y ❑ - N❑
PLG.CONTR. LIC. NO.
PLG. oa
TOTAL d,,
hundred dollars (S 100) or less.)
I certify that in the performance of the work for which this per-
mitis issued, I shall not employ'any person in any manner so as to
.
QTYMECHANICAL PERMIT FEE
,
FEE SUMMARY
BUILDING
become subject to the Workers' Compensation Laws of California.
Date Applicant
-NOTICE TO APPLICANT: If, after making this Certificate of Ex-
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
FEE
emption, you should become subject to the Workers' Compensation
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked.
AIR HANDLING UNIT (TO 10=C.F.M.) 3.00
AIR HANDLING.UNIT(OVER 10=C.F.M.) 5.00-
SEISMIC FEE
lO
CONSTRUCTION LENDING AGENCY'
I hereby affirm that there is a construction lending agency for.
the performance of the work for which this permit is issued (Sec.
3097,Civ.C.).
EXHAUST HOOD,(WITH'DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
VENTILATION FAN (SINGLE) 3.00
PLUMBING
y
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 city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City. of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in consequence of the
granting of this permit.
MISC. - REFER TO ORD.
CONST. TAX
PERMIT ISSUANCE 3.00
MECH. CONT. LIC. NO.
MECH.
TOTAL
TOTAL
gnature o . pphcanl/Contractor ate
OFFICE COPY
CITY OF CUPERTINO I11SPI;GTIOV RECORD (Office.Copy)
3545 22391 Carnoustie Court
PERPLI'T PIO. SANITARY DIST. 110. LOT NO. ADDRI:SS
Solar Furuta
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date
Bu:i1 dins 5/19/83
Electr Leal
Plumhiny 5/19/83
Mcchanical
Temp. Gas/Elect.
Solar
Fire Sprinkler
Sign
Mise.
FINAL. INSPECTIONS
Date I Insp.
C,r.s
Flectric
Plumbing
Mechanical
Solar S- -23
Gradin
Planning
Fire Dept.
Health Dept.
P,uildin
Other
BU ILD Ii1G
Date
Pad Certification
Insp.
Foundation
Pre-Gunite
_
Slab -Membrane
_
Bond Beam
Underfloor Girders
Floor Steel
Tiedowns
_
Diaphrams
Seismic Bracing
!falls -Panels
Frame
Lath
11allboards Int/1;xt.
Firewalls
Other
Not Approved
Date j Insp.
Power Pole
Under ,round
Rough Wiring
!Ta-* s --
Ceiling I
Fixtures Int/Ext
Motors
Grounding
Temp. Power _
Other
Not Approved
PLUMBING
Date
Backflow
Insp.
Underground
Underfloor
_
Partial Rough
_
Rough Complete
Solar Rough
[dater & Insulation
Main Drain
_
R/of/S Drain
Gas
Other
Not Approved
1LECLiANICAL
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire .Dampers
_
Fireplace
_
Grease Duct & hood
One }lour Shaf t
Condensate Drain
Equipment Anchorage
_
Flues & Comb. Air
Other
Not Approved
bU1L1)1NU
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
C I T Y O F C U P E R T I N 0
Building Division
PROJFCTQ�_
ADDRESS��� /,
OWNER �. 1 /e
ADDRESS
REP.
ARCHITECT
ADDRESS
REP.
CONTRACTOR ��%� i11
ADDRESS
REP.
PLAN CHECK HOURS
�
PHONE
PHONE
PHONE
PHONE
..,�. D ; _ PHONE'3353
PHONE
CONTROL N��'8
PEF1IT # dc5-5E5—
A.P.N. #
SAN. #
BLDG. TYPE
OCC. GROUP
VAL. .$
STRUCT.PLAN
Pd PLAN
BLDG.PLAN.CKCK
PERMIT FEE
CAP FEE cJ a
CONST. TAX
ENERGY FEE
PUBLIC UORKS
MICRO FILM FEE
TOTAL FEES
1st. Submittal
2nd. Submittal
3rd. Submittal
DATE REC.
DATE REC.
*
.DATE REC.
DATE REC. *
DATE REC.
DATE REC.
BLDG. DEPT.
3i.
13
ENG. DEPT.
PLAN. DEPT.
STRUCT — ENG.
ENERGY
HEALTH DEPT.
-
SAN. DIST.
-
CENTRAL FIRE DIST.
HANDICAPPED
A. - APPROVED
* N.A. - NOT APPROVED
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