2076CITY OF C!IPERTINO
APPLIGII,'[ION FOR COMMERCIAL BUILDING PERMIT
AND
CERTIFICATE OF OCCUPANCY
13UILOING INSPECTION DIV1810N
0. ° -
MOO Us
Pian* Received By Date
REGI. Plans. survey Calca- Struc. Energy Elect. Meph.
Plans Checked By Date
Application Approved By ... s*. Date ,. �•,� .
Validatett By Date
Compensation Certificate Verified By Date
Permit Fee (plus penalty If applicable) S• � `�
Plan Check Fee (less deposit of ;. Rat.
Entergy Plan Check Fee (011p• of S. Rat. i#
Strong Motion Fee S. '
Plumbing Permit Fee S
Fteeitricat Permit Fee s
!.tech 1,110,/C0019 Permit $
Construction Tax $
sorer Conn. Fee Water Conn. Fee S-
LaindfIC0e Fed Street Tree Fee S•
M144, Fee S.
Type Canal. Group. Div. Opc. Load. No. Exits.
flow Loads. 1st. 2r.d. Other Sprinklered, Arta Sep. Walls.
EmAronmentai status: Exempt Other
DeOpr+ Review Approval: Bldg, Site Sign
Use Zene P.D. Conditions
Cond. Use. permit a Variance # Parking Spaces Load. Sp.
Approvad By Date
s
Encroachment Permit. Grant of Easement.
'Curb, Gutter, Sidewalk, Driveway Replace Repair
sewer. Conn. Fee S. Water. Meter $.
Agreement for Completion of Public Works Improvements
Plans Chtrked By Date. Approved By Date.
PERMIT INSTALLATION i NO. E':ChiFEE
Light Outlets, Switches.
Fixtures Receptacle*
TOTALNUMBE14(lessthan1000watW) $tio
Range Cooking Unit. Oven. 2.00 .
"or Garb. Disp. Dishwasher 2.00 . .
SERVICE OR TEMPORARY FOvli[R to 2.00 .
too amp/0.0"', 200/$7.00, 500/$0.00
000%;20.00, t00/$10.00
MOTORS, Gansiators, Welders, Heaters,
20riti,80, 60Tr/to.00,r HP—KW—KVA to 1 0/5112 3.80.
.00
500/5t6.Q4
Signis with I XFIAR 2.00
Each additional XFMFI/Time Clock so - -
Annual ewtocal iv'tifintename 25.00 . .
Jth#r fu", Ordinerlcc Curftrntl
psmolt Fes $ 6.00
TOTAL ELECTRICAL PERMIT FEE (plus penalty if app. 0) 3
Fnrrn* / f 01100*curt By' Date:
f+Itittt" evouRd Work
asEkitQriclli
- Pkirrt" and Heating
sulatten / E.nordy
Bye! list
T'rmpWary Power dfaa / elect
�'irNet < #iilaairicat
ffbtl� ' �luNtlMlp ! Itiea#gtnicai -
!wW - tri Review / Landscaping . .
Puttfic we(". ,..,..
0
PERMIT NUMBER
STREET ADDRESS OF PAOJF-CT _
Legal Description: Tract Block. Lot.
Descriptlon of Work
is% Struet. improvement on Parcel: Yes, No. A.,ea of Bldg.
Separate Structure or Addition/ Alteration to Exist. Bldg.
No. of Stories. Use of Building
Value In t: S. f d,. ;j , _,.,,p ./.l. H
Owner t Sf Phone -2
Contractor, City Bus. Lic.
Address: Phone:
Contractor - Eliectncal
City Business License + Phone:
Plumbing:
City Business License Phone:
Heating and tooling
Oily Business i.icenee N Phone:
Arcii itect/ Designer' Phone -
Engineer, Phone:.. 'IJ69niswii
Lender- Q- .. ... ..
'i csrtify that in the performr.nce of the work far which this Perak its
Issued I shall nqt emptoy any person in arty manner so as to become eubleat
to the workman krapmpenralfon.iaw>rof Callfornia."
St"ATU112 OF Ft k s ) ��'� � �J
APPLICANTaOWN1t1t- t•
I certify that as the applicant I am licensed under the provisions 04 the
contractor$ License Law and luttho that my Lieenae No.
In Clasalfeatlon is in full forceandeffect: or
I certify that 1 am exempt from the "Llceneed Y0q. •ed" provielmh M the
contractors License Law. (State beefs of exemption.,
I hereby acknowledge that t have road this spptioallon and state that ft -*b*" 44
correct and $L+rsa 10 comply war sit city Otorwim. .. and State Larrs m Wmfnp
building.
i (We-) agree 10 save indemnify and keep harmless the City of Cugortino
against liabilities, judgments, coats and expenses which may In any way
accure against said City in r.onaequenee of the granting of this permit.
SIGNATURE OF DATA
.#MICANT/CONTRACTOR
NO—TV.. When Property vaildabd fMa neat eoetetl: wise • lultdfrte Rsrm& This
permit exptrert and baeunme nU f err Mold gmukl ~it net be 09"IsMatd WOW
M days cram validirti" deb, or ah*M auMtorfxad oongi eoMan be 60@01011etS er
ebYcdaitsd tm a period of 120 days after walk te cWwAeoed.
Gas Sytem with up to 5 outlets
$ 4 .-0o '
Each additional outlet
1.00
Water System (installation, Alt, or Repair)
4.00
Water Closet. Water Heater Ld. Tray,
4.00..
3.00
Lavatory Shower Pan. Bathtub Sink.
Wash. Mach. Dishwasher Garb. Disp.
3.00
Sewer
8.00
Lawn Sprinkler Sys $6.00 .Ea, add sys $2.00.
3.44 '
3'00
Vacuam Breakers
4•SO
Stop Sink. Floor Sink. Floor Drain
4.00
Urinat. Interceptor water Softener
4.00 .
4.00
Plumbing Piping without fixtures
Misc.
f x.00
Permit Few
TOTAL PLUMBING PERMIT FEE (plus panal ty ifagtp. tom]} It....�..
Forced A(r Unit to loom
.$0.00
4.000
over loom
Comfort Cooling Unit to 3 ton/HP
6.00 .
9.s0
to 15 ton/HP
1:0 30 ton/HP
to 50 ton/HP
17.00 .
Space Heater Wali Heater
8.00
Flues - other than above
3.44 '
3'00
Vent Fan: Kitchen. teeth
6.00.
commercial Rarle Hood
misc.
; 9,00
Permit Fee
TOTAL Htg./ Coolg. Permit Fee (plus PsnrrltY if ap(a. 0) E
Sheet 2 t
A
OF CUPERTINO BUILDINf".
PEP141T
Permit No: �
Date: r
BU1Lt)INC PROJECT IDENTIFICATION.
WORKERS, COMPE\SATIOX DECLARATION
Appltcznt's Slailing Address
I hereby affirm that I havi a certificate of consent to self-insure,
or a certificate of Workeri' Compensation insurance. or a certified
Address of Building _Z i3G+�& rZ. ! %i�-1
copy thereof (Set 8W.1.,alb.C.r:
Policy No, ..,•,_ Company
Owners name - r
[] Certified copy is hereby furnished.
[] Certified copy is filed with the county building inspection.
Telephone No.� P ..
department or county — department.
Date .—__. Applicant
Contractor's tame
Contractor's Mading Address — -
CERTIFICATE OF EXEMPTION FROM WORKERS' .
CO:MPFMATION IRSURANCE
Lie: No,
(This section need not be completed if the permit is for one
Architect or Engineer - -- —
hundred dollars ($100) or less.)
Architect's or Engineer's Address
I certify_that in the performance of the work for which this permit
Lie. No. --
is issued, l shall not. empioyany personin any manner sots to become
subject to the Workers' Compensation Laws of California.
LICENSED CONTRACTORS DECLARATION
Date- _ Applicant--
NOTICE TO APPLICANT: if, after making this Certificate of
I hereby affirm that f am licensed under provisions of Chapter 9
Exemption, you. should become subject to the Workem'
(commencing 3+-ith Section 1000) of Division 3 of the Business and...
Compensation Provisions of the Labor Code, you must forthwith
Professions Code, and my license is in full force and effect•
comply with such proviiions or this.permit shall be deemed revoked,
Licansc.Clus Lic_ `umber
Hata .�._ Contractor _
CONSTRUCTION LENDINC ACE .Cy
I hereby affirm that there Is a construction lending agency for tha .
performance of the work for which this Wasit•is:issued ,Sec. 3M,
ON"'FER•BUILDER DECLARATION
Lender's Name
Lender's Address
hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Sec. 7031.5, Business and Professions
I certify that I have read this application and state that the above
Code: Any city or county which requires a permit to construct. alter*
snformatioa is correct. I agree to comply with all city and county.
Improve, iiemolish, or repair any structure, prior to its issuance, also . ,
ordinances and stats laws relatinif to building construetfon, orad'
..,
requires the applicant such permit to file signed statement that
hereby authorize representatives of this county to enter. upon the
he is licensed pursuant to the provisions of the Contractor's License
aboye•mentfoned property for inspection purposes.,
Law (Chapter 9(commencingwith Section 7000)ofDivision 3ofthe
..
Business and Professions Code) or that he is ezempt therefrom and
the basis for the alleged exemption. Any violation of Seetion-70.31.5
aistulum d Apptiewis or Agnes Gate
by any applicant for a permit subjects the applicant to,a civil penalty
of net more than five hundred dollars (5500).):
as owner of the property or my employees with wages of
-OW1VF R.BtJIb.DEil VERIFICATION
their sole compensation will do the work, and this structure is not.
or offered for sale (Sac 7044, Business and Professions
"Attention Properly Owner,
'owner•builder
Code: The Contractors License Law does not apply to an owner of
"An building permit. hes been applied for in
your nadte and beottns your signature.
pproperty who builds or improves thereon, and who does such work
himself or through his .own employees. provided that such
"Please complete and return this Information In the envelope
n e
improvements are ctrl intended or however, the
on for sale.
nethe
provided at your earliest opportunity to avoid y delay
in processing and issuing your building perztir No builditeg permit
buiiding or improvement it sold within one >ear of completion, the
thin c
will be issued until thea verification is'racetved.
owner-build e r will have the burden of proving that he did not build
1. I personally plan to provide the major labor and materials inti I
or improve for the }purpose of solo.}•
i, as owner.of the property ant espluspvely contracting wsth '
Construction of the proposed. property improvement (yes or no)
licensed contractors to construct the project (Sec. 7044, Siusiness and
; (hare/kava not) signedan application for •
Professions Code: The Contractors License Law does not apply to
Iowner
building permit for the proposed work
an of properly who builds ar improves thereon, and who
;L 1 have contracted with the following person (firm) io provide
contracts for such projects with.a co_ntractor(s) licensed pursuant to
the proposed construction
the Contractor's Licome Ltw.). -
blame
[j I am exempt under Sec. ,., _.: ,-B..&P.C. for this
Address City z . v_ .
reason
Date `" �� Ow or
-0 t. - ..
Phone..__ . Contractors Lh1ense Na— --
4 1 plan (o provide, portions of the work but i have hired the
following to coordinate, supervise, and else malor.
person provide .
week:
Name_
dhoi
Pne_...�_
.,,._... Contractors ractors License No.
S I will provide some of the work but i have contracted ihired)
the following persons to p-041 the work indicated:
Name Addram Phone Type of tirork .
Signet!
iropertyownar
Social Security number ,r........ ,
C I TY --OF CUP.ERTI N 0
zuiicung iJayaslqu
PROj-isC _ T� 13 1 -.B -M 67
ADDRESS/Gad .N �y`otF jC�c,y�G_
OWNER Ile 4�,z'L T "'ZZ
ADDRESS
RAF'. GU -f Vo a c
ARCHITECT
FET.
CO :^P�LASTfi)R
REP.
SUPT"
DATE FEC. DA
_
PHONE
PHONi Zigy
PHOKE
PHONE
PHONE
F
RET.
FILE.
slu:t .
Y
BLDG. TYPE
OCC. GROUP.
p
VALUATION $'
FEE =0 STEM, EFTS �t' !
BLDG. PL91 CY.`: F_.'
BLDG. Pr MIT "iE
CAP_VEE
. TOTAL FEES
REt"Ac�5
..
BLDG. DEPT.
f
Mil
i
,PidamiNG DEPT.
d�
COUNTY HEALTH,
COUNTY FIRE MARSHAL
_
INDUSTRIAL WASTE
STRUCTURAL ENG.
SANITARY DISTRICT
SOLS INVESTIGATION .
SOILS COM2ACTIOti
i'