16505 ADDITIONAL, PERMIT FEES
` t
BUILDING PROJECT I DENTIFICATIOA!�_ "p
VALUATION
IIILDING
v � p O 3r iwBEss
o S
nxip FEE SUMMARY
riM Lai L`PN��
NO Nrnnc.ons BUILDING
fL��D�
uc.No PLAN CHECK
0 z FEE
Aoaaiss (` _
SEISMIC FEE
QTY. ELECTRIC PERMIT FEE
u�
57 UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES
—APPLIANCES-RESIDENTIAL PLUMBING
PANELS MECHANICAL
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
PERMIT VALIDATION
EMP.METER OR POLE INS: H LniIg
MOTORS _r SEEjFgE]_ HJ IV {
O SERVICE CHANGE IS I
Z2
F L2 ' tTOTA' I 16 ^ cf0
LUN
OTV. PLUMBING PERMIT FEE ISSUANCEDAT
W eLDa ELwr.
00
❑ECN
Q_ o
� 2ALTER DRAIN&
BACK FLOW PROTECT.DGJC—EOF UUi
O w DRAWS-FLOOR,ROOF,AREA,COND.
} y
FIXTURES PER TRAP
Z GAS-EA.SYSTEM-11NC.40UTLETS
() GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1INC 5 V.B.
LAWN SPRINKLERS-OVER 5 IEA.)
SEWER-SANITARY-STORM EA.20011/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP. J
dd/
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT LTO 1Q000CF.M)
AIRHANDLINGUNIT(OVER 10=C.F.M)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.T.U.)
VENTILATION FAN(SINGLE)
BOLLEN-COW(3 H.P.or 100,000 B.T.U.)
B01 LER COMP(0..1 IOD.ODO BTU)SEE ICE SCM.
TOTAL
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALfiL POINT PEN ONLY
' BU I LDING PROJECT I DENTIFI CATION PERMIT NUMBER _
MIRES, sS� .�M/p BIN
APPLICATION -T', " 1 UILDINI U�1 J
yAa G f✓� r BUILDING-.ELECTRICAL-PLUMG- C[ 0[
MECHANICAL G'
I)WNER'S� 2 Q 0 D nPLAN CHECK VALIDATION
NAME V L/sza-y' - OTY. ELECTRIC PERMIT FEE
oORS 1-1 C14A F 'HONE - A0
NAM,ACiUTLETS-SWITCHES-RECEP. 10 /1.00
TInlr 'LLZ LIC.NO. d'6`/73 LIGHTING FIXTURES 10.00/1.00 LJpyd/j7
ADDRESS ., PPLIANCES-RESIDENTIAL - -4.00
ADDRESS .J/r') SUSL
3 3 1?3 L' U vHON Y PANELS 10.00 DATE OF APPLICATION,
-0
aacHrrscT PANELS 200 AMP) 20.00 PLAN CHECK FEE .C.NO:
OR wAu�fu'PAfN naYL. Lrn c• r
ENGIN R
r T LIC.NO. ,?3 SIGNS TRANS. .3.00
AD ADCHESR ENG. SPECIAL CIRCUIT r ' 5,00 PERMIT VALIDATION
MiS G ZIP EMP.METER OR POLE INS. 20.00
APPLICANT
DDRE ens
AMOTORS SEE FEE SCH. 11
t
/ (,5-, SER, IC H, 20.00
ca
F o o LICENSED CON'I'RACI'ORS DECLARATION I ,
a v v I hereby affirm that 1 am liconsed under provisions of Chapter 9 t; ISSUANCE D TE
w [commencing with Section]000)of Uivisiun 3 of the Bminestend
BLDG. ELECT. PLG. MECH.
0 tR - Prolcssiom Calc unit my licence u in full for$,c a_ ofLrcjj � - ❑ ❑ ❑
0O'U' - License Class t'/� I.ic.Numbir�{yJ'(z'/_/y -
o w r ° Date /4 a-'a!'�td Cc nImctor_t ,<,Ajt Ey aZ r-, '
a x BUILDING PERMIT
e, a OWNI'R-BUILDER DECI-ARATION
s i; " �N ORD INFORMATION
w 3 LL I'hemby affirm that I em,seems! from the Contractor's Liceme qp�� . ' VALUATION
F e- O a Law for the following reason.(Sec.7031.5,Business and Professions PERMI Yf'1" UPERIINQ 10.00 a� f/FT.
ee Code:Any city or county which mquiresa permit toeonstmet.alur, -
CIG
rtso ¢ p improve,demolish,or repair any structure,prior to its issuarim,also ELEC.CONTR. LIC.NO. EIEC. -
C¢ requires the applicant for such permit t0 file a Signed Statement that ��6 TOTAL` P MIT 0
a w$ he is licemed pursuant to the provisions of the Contractors License nEp
r- za Law(Chap ter 9(commencing wit h Sec l ion 7000)of D ivision 3 o f t he ~�i I'✓rKf
Ixo
Business and Profession,Calc)or that he is exempt themfrum and OTY. PLUMBING PERMIT FEE
¢ r$ the basis for the alleged rail subjects
Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subieers the applicant to
civil penalty ALTERDRAIN&VENT.-WATER IEA.15.00 '
of not more than live hundred dollars($SOO)J -
: _
❑ I,as owner of the property,or my.employns with wages as BACK FLOW PROTECT. DEVICE 4.00 OCC.GROUP RES.UNITS
their Sole compensation,will do lite work,and the-st nmlum is not
intended or offered for Sale(Sec. 7144, Busirim and Profccaorm DRAINS-FLOOR,ROOF,AREA,COND. 5100
Code:The ConGactor's License law does not apply to an owner of -
properly who builds or improves thereon,unit who Jus such work FIXTURES-PER TRAP 6.00 5p.F ,FL°oR AREA TOTALACREA°E
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-1 6.00
men!,are not intended oroffered for salt.If,howeseq the building
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im.
-_ prose for purpose of Sala). INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ 1,as owner of the property,ant exclusively contracting with ❑, ❑ ❑
licensed contractors to construct the project(Sec.71414,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL No.
and Professions Code:The Contractors License law docs nor amply -
l°.n owner of progeny who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
cont mels for such projects with a contractuds)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10.1X1
the Contractor's License Low. TRACT NO. PARCEL NO.
❑ lam exempt under Sec. ,B.&P.C.for lfiis WATER HEATER W/VENT 6.00 -
reason
Owner Det, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
ORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. - 5.00
W
I hereby.(firm that I have a certifrcale of consent to sel Linsum, ZONING ENG.SITE NO.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(Sce.3800,Lub.C.). - -
Policy No. Company -
O ❑ Cenifiedcopyisucoebyfrumshed. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is tiled with the city inspection division.
O Applicant misc.- REFER TO ORD. - Y C NE] -v C]' NQ.
fLy CER1'WICA'I'E OF ExEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C. -
LU > I COMPENSATIONINSURANCE PLG.CONTR. LIC.NO. PLG.
CL ❑ If:his section decd not be completed if the permit is for one TOTAL 'Y N� v C] NE.
Z) Z hundred dollars IS 100)Orlscl
U O 1 certify that in 17m performance of the work tsar which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL F- mit is issued. I shall not employ any Person in any manner so as to
O W become subject to the Workers'Compensation laws of California.
Is. Dain nppliou"l ALTER OR ADD TO MECH. 5.00 BUILDING
} rn NO'T'ICE 'I'O APPLICANT: If,after making this Certificate of Fx- _
(— 2 emption,you should become subject to the Workers Co iNnsation APPLIANCE 5.00 ' PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked: - AIR HANDLING UNIT(TO 10=CF.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10,000QFM.) 6.00 SEISMIC FEE
1 hereby affirri that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work I.,which this permit is issued(Sec MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,0008.T.U.)9.50
Lender's Address - ELECTRIC L�
1 certify that 1 have read this application and stole that the above VENTILATION FAN (SINGLE) 4.00
information is correct, 1 agree to comply with all city and countyPLUMBING
lLn
I)� urdinarand state laws relating to building construction. and BOILER-CONP(3 H.P.or 1b0,000B.T.U.) 6.00
hereby authorise roperty r.tIves of o is'eity es enter upon the BOILER-COMP (Over,100,000 BTU)SEE FEE SCH. MECHANICAL
breby ;nth nes property for inspection purposes.
(We).agun, to save, Indemnify and keep harmless lhe•Clly of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE10,00 CONST.TAX
may in any way accrue against taint y in consequence of the -
gratiLm,,et this pemriLMECH.CONT. LIG NO. MECH. �U
l/ ,616 OTAL
TOTAL
Signature of Applicant/Con[ tar Date
OFFICE COPY
r
POST THIS CARD NEAR FRONT OF BUILDING
PERMIT Nu mETi"
CITY OF CUPERTINO 16505
INSPECTION DIVISION
JOB INSPECTION RECORD
L /!� IT f
PERME)(PI RATION
JOB ADORESS94a0V CK#�ZL /—YY —UNIT# LOT# �. i! ,1-/-�
PERMI''I[EXPIRES IF WORK
OWNER j I` LIQ?I 'CONTRACTOR IS NOT STARTED WITHIN
INSPECT19DATE INSPECTOR INSPECTION RECORD 180DAYS OFPERMIT ISSU-
ANCE OR 180-DAYS FROM
NOTE: -LAST CALLED I NSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VALIDATION
CUPERTINO STANDARDS. p GARAGE SLABS - '.-•;���.- 1 G� , .�
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED—
UNDERGROUND /SLAB
IGNEDUNDERGROUND /SLAB
PLUMBING
ELECTRICAL
ISSUANCE unrE
MECHANICAL - BLuc ecEci , PLG. - mECR.
❑ o ❑ : .
AO NOT POUR FLOOR UNTIL ABGVE HAS BEEN SIGNED - BUILDING PERMIT -
INFORMAT
• WOOD FLOOR • VALUATION TFT.
PLUMBING `
MECHANICAL
ELECTRICAL rt- PERMIT U
FRAMING .. /� . 7 TL 'i`�`✓1 1�p'i�/�. i
- srowes / TAPE CONSTR.
INSULATION 70
OCC,CROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF' NOTE:NO FINAL'INSP.SHALL BE MADE BEFORE SO FT'FLOO1'Alice TUTAL AC PEACE
DIAPHRAGM _ THE CONSTRUCTION TAX IS PAID" -
BUILDING USE
ROOF SHEATHING- - F ' T NIPS IND❑ ❑ ❑N ❑ Of
APPLYAO ROOFING UNTIL ABOVE HAS BEEN SIGNED- FINALS DATE INSP. ASSESSORS PARCEL NO
'ROUGH SAN.k
PLUMBING - ELECT-ENERGY
TRACT NO. PARCEL NO
_
TUBS&.SHOWER PAN PLUMBING ENERGY - '
MECHANICAL - - MECH.ENERGY ACC DATE ACC,PILE No
ELECTRICAL. - BUILDING ENERGY -
FRAMING ELECT.FINAL TEST zoNlNc
INSULATION - PLUMBING ENG SITE NO,
GAS TEST' - - GAS
'- MECHANICAL•/ - RE SPRIrvK - ENERG�r.aa
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING 0 ' "� ` ❑ "�
FI,000)CNF A.L U.L.
EXTERIOR SHEAR ' ELECTRICAL RELEASE I
. INTERIOR SHEAR . FIRE DEPT. P�'' '"� ` ❑ "
SHEETROCK GRADE . FEE SUMMARY '
EXTERIOR LATH •� _ BUILDING ' -
'TEMPORARY APPROVALS BUILDING ;: p
- INTERIOR LATH • '
SCRATCH COAT - ELECTRIC _ 'PLAN CHECK
GAS j - 'FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY 'SEISMIC FEE
- OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILM '
ARRANGE FOR INSPECTION BY PHONING'252-4505, - ELECTRIC
�� ONE WORKING,DAY BEFORE REQUIRED INSPECTION. PLUMBING
. z PLEASE GIVE JOB ADDRESS WHEN PHONING. :.
— SEE PERMIT FOR EXPIRATIONDATE — 'MECHANICAL
IMPORTANT!
CONST.TAX
• PLEASE READ REVERSE SIDE'BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE,CDP,Y
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bultdim Proeet Identification PERMITNO.
B°Bdbg Addmu: 21992 "'1,
am one
__r__jA&_ f a, CITY OF CUPERTIN0.BUILDING DIVISION p -
Contraet«+Nam Lk.Net APPLICATION / PERMIT Z
C'�o~ BUILDING-ELECTRICAI PLUMBING-MECHAMCAL CATEGORY CONTROL If
Archlba/Fsgleer. Llc No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddrcaK PERh0TI56UANCE " ❑ 19 F-1 F-1LICENSED CONTRACTOR'S DECLARATION
I hertby+Hbm l9)of ivson3edheunder Bundrtraand ro Chapter
salons9(mrvnrnc AF'P[.IANCFSRFS(OEN7IAL O DESCRI]'I'ION
Ingwith Smbn JOW)ofd effc Division 8udvaand I'rofeWonaCode,and my
If¢nx Is in full form and dfcd. PANELS �
Lkeve Cbm_`_LieY_4—L(�J_ _$�j4��
D1Ty. 1
a
ae CnruuRor - 37 �1 \ I
ARCHITECPS DECLARATION AMT'S 111
x]. I understand my plans W 8 be used u public record& OVER 1000 AMPS SQ.FC.FLOOR AREA f/SQ.FT.
WO
Licensed Prdmlonal 9CN5ELDCTRICAL LED IN
6 OWNER-BUILDER DECLARATION
E, 7 (herebyafRrmtlutlamezemptfmm1lmCo..r`a[J¢�Lwfwthe SPECIALCIRCU1T/M79C p U T E F�
R,MZ E folbyl hg an.(SMIon7 t.HuntressM.1t Pr p.e , Code Any city or TEMP.ME-CFE OR POLE INST.K� C7J munrywhlch requlresa pemdt In mvtruR,a11¢r,lmprwe.aemolah.orrepalr
�[ a nyarudumprbrtoits msu aborequimiheappU¢ tfmsuchpemdtto POWER DEVICESK FIN a signed statement that he as e¢nsed pursuant to the provbbru of the
Oµ Cmrxeh,r'e Lkeroslaw(Chapte9(..rnaogwWSectbn9000)ofDIA-
�OS don3olthe Bupneu+nd Prdeabv Code)orthat heb eumptlhercfrom+M SWIMMING POOL FJ.ECCRIC VALUATION
Y.'•-t the basis for the alleged eeemptbn. Any violation of SeGbn 90315 by any
dad
applicant fora pemdt subjedathe+pplicanl Ina doll penalty of not rmrcth-n OUTLET&SWITCFESFIXTURES
6 .. five hundred ddlara(5Mf.
F1I,uowrer of the pmperty,or my empleyee with wages a their wk NEW RESIDENTIAL ELECCR SQF7. SCOWIS TYPECONSIRUCT)ON
�7� mmperuaHan,will dotlew Prom snhestmdumbroormucted oronoe Lar
O uk fnot apply
eurbmandfprombv code:TFs buildht orJmpdo/a LI¢veI.w 7 Q• O
I{S don ho oeapply torn ower orpropertywhonemporimproveslh!that and - OCC.GROUP RIS UNITS
0.0. wpmeocmerduam kMmreBmthmugh hlaowne.Ithown,er,thele thetauch Oa
Improvememis not lnterdedoarofcompIMale.ILhowev ionised U g¢ TOTAL 7 1
improvemerd bedd wkhinoeyerofcompleibn,thowner-bu8derwlllhave
t"rdenof provingthat he db not build or lmproee f¢prposeofsale.). QTY. PLUMBING PERMIT FEE
LI[u owner of the Property,am eacluntvely contracting with li¢vM FLOOD ZONE wPN
mntractontomvimet the projea(See.901l,Buainemard Profeulov Code: PERMCCISSUANCE .
The Codudari Liven a Law don no apply to an owner d property who ALTER-DItAQJ4 VEM-WATER k!N '
build. or Improves thereon,and wb mrNacs for avis Ptojem with a
ll¢n�d par.,ranttolhe Centrsdnr.LkeeeLaw. Bwac FLOW PROTECT.DEVICE FEE SUMMARY '
LJ I int e� mpt under S B Is P C for this reawn
nUTSIDEFEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
• Owner a Date RECE97 i
W RICM C .)PEN ATION DECLARAT ONS pT)cNgEq pEg TRAP SQTOOL TAX Y_ N
1 hereby+ffbm Ihrt I have a eertl0ote of consent to seB-trsurc,or
¢WlRote o(Worken'Cornpewaon Insurance m•¢Willed mPY thereof Tec RECEIPT Y
3BOO,Fab C.) _ GAS FA.SYSTEM-1 INC,4 OUTLETS PARK FEE Y_ N_
RUCEPdiryY !!�� l GASEA.SYSCEM-OVFR4(FA) DING IV
Cert lib a u�nLh�edu/tl � BUILDING DIVISION FEES
P - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�certlnea copy b riles with tit diy wpedbn alwwon. ..� -
CERTIFICATE OF EXU,IPIMON FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE gEWFR-SANCCARY-STORM FA X/ET Date Remi tit
(Chis.edlon need na.becorr,plrxN ifthe permit bforore hundred dollars ENERGYFEE Y N
(fl m)orles..) WATER HEATER W/VENT/ELECTR
I certify that b the pernernffoin nym work so as to It Fhb pemdt c loved,
1 shall not employ any perwn f any mannersou to become subject to the WATTFSYS IN/TREATING'
Wwken'Compewtlnn levo of California.Date PAID
O Z Appll¢nt NEW RE9DINIIAL PLMB. 5QFC. Date RCOeI t#
_Z O NOTICE TO APPLICANT.IL after making this Certificate of Faemption,you
should become subject to the Wor,eri Compevabn provisions of the Labor TOTAL:
~ N Code,you could forthwith comply wish such podebro or this permit shelf be
L¢ ] deemed revoked. BUILDING
d 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
]hereby! =Thatthe¢bamvtsudlwkMl gagencyforthepedorm ELECTRIC FEE
7 Z ah¢ofthe workforwhkhlhb permN 4bsued(Sec?IN/,CW.CJ TOTAL
U O Fencer-Name - PLUMBING FEE
LL F Lenders Aaamas QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfylhal have read this appllcatlnnand state thatthe abovelnformatlan
bmrted.lagreelocomplyw hWdiy&Mm ntyor ik nma detalelaws PERMIT E3SUANCE FEES PAID:
>. in relating to building mvivdion,and hereby autha repuvu,uthcs ofthb
Zcity to enter upon the above_menlbned property for Wpeiion purpoen. ALTIIt OR ADD TO METH.
(We)agree to uve,indemnify an d keep harnaess the City of Cu Wion - Date Receipt#
1) .8.1 11-618 ,/rdgmerrb,catsa dezpevew meylnan amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Wt ui 4mnseyuen¢ he colo+ permit. AIR HANDLING UNIT(OVER 10,(00CFM) CONSTRUCTION TAX
1grawroof ppRam ser#, 1- e — EXHAUSTHOOO(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappecant or future building arvpant store or handle harardous HEATING UNIT(TO 100,0008M Date Recei t#
material as defied by the Cupertino Muoldpal Code,Chapter 9.11,and the �--/�
Hea hh a rd Safety Cade,Seetion 255314)7 HEATING UNIT(OVER I W,,000 BTU) - TOTAL: y
Ye
dl the a ppInam or future build ing a pant use equipment ordevcm VENTILATION FAN 61NGTR RESID) ISSJJWATE
whkh cent harardo us air contaminants as defined by the Bay Area Air rpRp
()ualByhUnagement rlW-.trltl7/. BOILER MP PHP OR 100,f1(A BTU) ���V Q,
4h.�¢.dlhehevrdous materlab requirements under Chapter 6.95 of S08-ER�COMP(OVFR I(ID,000 B71n APR 3 19�7f1
the CAlJomie Health k SafetyCode,SMbv 25505,25533 and 15534.I
understand that if the building dm wt currently have,tenant,that It is my NEW RESIDENTIAL h1EOI SQFf
Lo�
"t" 0na8y the orcupM em ke awhkh must be met
beua fa CeWlfieste0
authur -gen Qre�� ISSUED BY:
rornL
OFFICE COPY