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3908O Z P: O Cr — W > 0-0 z U o LL U OLLI aw } to U - • APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE"BALL POINT PEN ONLY_ BUI LDI NG PROJECT I DENT[ FICATION , APPLICATION & PERMIT BUILDING — ELECTRICAL -PLUMBING — MECHANICA P MIT NUMBER 390 -V BUILDING ADDRESS OWNER'S "AME.�S� L1�.,LU COJ PHONE CITY. ELECTRIC PERMIT FEE LAN CHECK VALIDATION CONTRACTOR'S NAf�E OUTLETS - SWITCHES - RECEP 5:00/1.00 LIGHTING FIXTURES . 5.00/1.00 J tLIc.N CONTRACTOR'S ADDRESS APPLIANCES - RESIDENTIAL -4.00' ' PANELS 5.00 PHONE'L DATE OF APPLICATION RC TCT OR ENGINEER LIC. NO. 'ARCH. SIGNS - 6.00 PLAN CHECK FEE - P.C. NO. - 9 - SIGNS TRANS. 3.00 OR ENG. ADDRESS - ZIP SPECIAL CIRCUIT 5.00 - P MIT ALID N / J TEMP. METER OR POLE (NS. .15.00 APPLICANT'S ADDRESS MOTORS SEE'FEE SCH. SERVICE'CHANGE 10.00 LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. icense Class Lie, Number - - ELECT. ❑ -PLG. ❑ MECH. ❑ Date Contractor J NG PERMIT OWNER -BUILDER DECLARATION I I � RMATION MISC. — REFER TO ORD 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5. Business and Professions Code: Any city or county which requires 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 VALUATION 0 C Ino' "o 'lJ $/,FT. -PERMIT ISSUANCE 6.00 ELEC. CONTR. LIC. NO. ELEC. TOTAL PER CITY. 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 STORIES TYPE CONSTR., 'the basis for the alleged exemption. Any violation -of Section 7031.5 by any applicant for a permit subjects the applicant toacivil 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 intended or offered for sale (Sec. 7044, Business and Professions BACK FLOW PROTECT. DEVICE 2.00 OCC. GROUP �� RES. UNITS �• DRAINS -FLOOR, ROOF, AREAXOND. 4.00. 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 F IXTUR ES'- PER TRAP 4.00 sO. 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 im- prove for purpose of sale.). ❑ 1, -as owner of the property,. am exclusively contracting with GAS EA. SYSTEM - OVER (EA.) 1.00 BUILDING USE RES IND CN PB Other ,E ❑ � ❑ INDUSTRIALWASTE INTER. 20.00 LAWN SPRINKLERS - 1 INC 5 V.B.' 5.00 ASSESSORS PA CEL NO. - di{ / licensed contractors to construct the project (Sec. 7044, Business to P ownei of grope The Contractor's License Law does not apply.A� to an owner of property who builds or improv thereon, and w LAWN SPRINKLERS -OVER 5• (EA.) .1.00 contracts for sucL�ee' ts with a cont actors Ice d purse t the Contras s l,aw. `Imc P.his reaGn 4 SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 4.00 Date � r WATER SYSTEM 4.00 ACC. DATE ACC. FILE NO, WATER TREATING EQUIP. 4.00 WORK ERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self -insure. or a certificate of Workers' Compensation Insurance• or a certified COPY thereof (Sec. 3800, Lab.C.). - ZONING ENG. SITE NO. Policy No. Company ❑ Certified copy is hereby furnished. copy is filed with the city inspection di:•ision. Applicant PP ' FIRE SPRINK Y 11 IJ ENERGY T-24 Y ❑ IX MISC. - REFER TO -ORD. CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE PLG. CONTR. LIC. NO. - PLG. TOTAL COMPENSATION INSURANCE (This section need not be completed if the permit is'for one v E] N 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, after making this,Certificate of Ex- - APPLIANCE 4.00 PLAN -CHECK 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. FEE AIR HANDLING UNIT (TO 10,000C.F.M.) 3.00 . AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00 SEISMIC FEE CONSTRUCTION LENDING -AGENCY 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 HEATING UNIT (OVER 100,000 B.T.U.P.50 EL ECTRI C I certify that I have read this application and slate that the above VENTILATION FAN (SINGLE) 3.00 information is correct. I agree to comply with all city'and county ordinancesand state laws relating to building construction, and PLUMBING BOILER-COMP(3.H.P, or 100,000 B.T.U.) .4.00 BOILER -COMP'lover 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 nd a penseS whi may, in any way accrue against said Ci . cons uence o f perm t. L n �✓ LL [SiS MISC. - REFER TO ORD.' CONST. TAX PERMIT ISSUANCE 3.00 -COCH.NT. LIC. NO. _ MECH., TOTAL' TOTAL I�LD nature of Applicant ontractor Date v 1 v 'OFFICE DOPY • J C I T Y O F C U P E R T I N 0 Building Division PROJECT CONTROL #-<c_7�� ADDRESS ZQ PEM1IT # hWNER G�/�{/(� PHONE5�� ADDRESS SAN. # REP. PHONE BLDG. TYPE ARCHITECT PHONE OCC. GROUP ADDRESS REP. PHONE CONTRACTOR � /t PHONE VAL. $ ADDRESS STRUCT.PLAN CK REP. PHONE BLDG.PLAN.CK J PLAN CHECK HOURS PERMIT FEE CAP FEE CONST. TAX ENERGY FEE PUBLIC WORKS 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. �� d ENG. DEPT. PLAN. DEPT. STRUCT. ENG. ENERGY HEALTH DEPT. SAN..DIST. CENTRAL FIRE DIST. HANDICAPPED * A. - APPROVED * N.A. - NOT APPROVED CYFY OF CUI'I,I"TI;lO I1;SPI.;GTIO1'. RECORD (Office Copy) 3908 10787 S. Blaney Avenue PI;MIT NO. SANITARY DIST. NO. LUT 110 ADDRESS Interior Remodel JA Moreing Co. PROJECT OWNER JOB SITE PI1014E NO. PERMIT ISSUED DateI ELECTRICAL Buildins Date � Insp. Plumhilir Mcchnnical Temp. Gas/I'.lcct. Solar DateInsp. T;lectric Plumbing Mechanical _ - Solar Pnn Grarlin 1'lannin fire Dept. — Health Dept. P,uildin -,1 Other BUILDING Date Insp. Pad Certification Foundation Pre-Gunite Slab-Ilembrane Bond Beam Underfloor Girders Floor Steel Tiedowns Diaphrams Seismic Bracing halls -Panels Frame Lath Uallboards nt Ext.l s.dc fx3 Firewalls Other Not Approved Underground P,auu,.h Wiring_ halls Ceiling Fixtures Int/Ext Notors Grounding Temp. Power Other _ Not Annroved PLUMBING Date Backflow Insp. Underground Underfloor Partial Rough Rough Complete Solar Rough _ Water & Insulation Main Drain R/of/S Drain Gas Other Not Approved 11ECIIAN I CAL Date Underfloor S.M. Insp. Ducts & Insulation Fire Dampers Fireplace Grease Duct & Hood _ One }lour Shaft Condensate Drain Equipment Anchorage Flues & Comb. Air Other Not Approved Ll BUILDING FT rrTPTrAT PLUMBING I TfrrUT ATJTr AT MISCELLANEOUS'' J ca v, o C i i u. I I' i I �v � I�` r c v .z ca v, o C i A'A WIK4 - `ij �vg 16, XM W.1 N"�' q - `ij �vg 16, XM