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8851 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BU LDI NG PROJECT I DENT]FIC l PERMIT NUMBER BUTLOING "� APPLICATION & PEOT ADDRESS O O 5 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 885 DINNER'S • PLAN CHECK VALIDATION QTY- ELECTRIC PERMIT FEE ON NOMERAc]oRs OUTLETS-SWITCHES-RECEP 10.00/1.00 /.7,, ' Q. uc.No LIGHTING FIXTURES 10.00/1.00 ,2� ADORRES Tonse aZ APPLIANCES-RESIDENTIAL 4.00 AQ f PHON 8 3 PANELS 10.00 O DATE OF APPLICATION ARCHITECT p� PLAN CHECK FEE P.C.NO. 0RN �.Y�-- q I PANELS (OVER 200 AMP) 20.00 ENGINEER LIC.No. � SIGNS TRANS. 3.00 ARCH. DD ESS ENG' SPECIAL CIRCUIT - 5.00 / PERMIT VALIDATION ➢P _ EMP.METER OR POLE INS. 20.00 AMOTORS SEE FEE SCH. ADDRESS GS "•" -' SERVICE CHANGE 20.00 �� o ¢ z Foo LICI3NSIiU CON"fRACT(1R$DECLARATION TEMP.POLE PAID 30.00 < u I hereby affirm [fill I am licensed under provisions of Chapter 9 ISSUANCE DATE N a N (commencing with Section]000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH. H N i Professions Co a I(.[1y license is in full(or d I. O C) iJi w o LicensCla ass V hie.Number O ,,,�_ Dam -DQ--pU' cnmraaor a r s BUILDING PERMIT ¢ ¢ w OWNER-BUILDER DECLARATION Cupertino INFORMATION w ; LL H 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO OR g reason.(Sec.703 LS.Business and Professions VALUATION H a.o a Law for the following PERMIT ISSUANCE /FT. Code:Any city or county which requires a permit to construct,alter, ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. O ¢ requires Ore applic:ml for such permit to file a sighed stateire,A that TOTALp•Z/S PERMIT TO he is licensed pursuant to the provisions of the Contractor's License F z i Law(Chapter 9 fcommencing with Section 7000)of Division 3 ofthe ¢ o Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE ¢ F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. ta u ;m by any applicant for a permit subjects the applicant to a civil penally of no,nmm than five hundred dollars(S50O.): ALTER-DRAIN& VENT-WATER IEA.) 5.00 O I,as owner of the properly,of my employees with wage,as BACK FLOW PROTECTDEVICE 400 their sole compensation,will do lire work,and the structure is not . . OCC.GROUP RES.UNITS intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00 Code:The Contractor's License Law docs not apply to an owner of property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTALACREAGE himselforof rote his own em ed I..s,provided that such ingsrovo - himsearrthroulmWeJoneriircdforsulc.Ii.howeveq lhenpro,g GAS-EA.SYSTEM-1INC.4OUTLETS 6.00 or improvement is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 IEA,1 2.00 builder will have the burden of proving that he did not build or im- BUILDING USE prove for purpose of sale). INDUSTRIAL WASTE INTER3000 RES wO CON PB Omer ❑ I,as owner of the property,am exclusively contracting with . . ❑ lie lII eJ eontraelon 10 <onslmcl the project(Src. 7044,liusincss LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO. and Professions Codr:'fhc C,m Uaclor's License Law Unca not apply D, an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00 comracts for such projects with a contruclom s)licensed pursuant to the Con tractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO. 0 I am exempt under Sec. ,B.&P.C.lie thislicalWATER HEATER W/VENT 6.00 Owner [)ate WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO. WORKERS'COMPF.NSATION DECLARATION WATER TREATING EQUIP. 5.00 1 hereby affirm that I have a certificate ofematenl to self-insure, or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO. copy lherc*'j�ee ,;:T ab.C.).�` r_6?_6 �''7Q Policy No Mlts areb Y-4rshad. J1�_I__I_ ❑ Certified copy ish�reby limluhed. I FIRE SPRINK ENERGY T-Z4 Z 2 `yR Cerll�d ropy is bled wyh t sly 'nspnctioN division. Alfplican✓�L.d.� C I a VCS.! /� MISC.- REFER TO ORD. YE] NE] YE] NE] F to /'" A's' FROMPERMIT ISSUANCE 10.00 LU - CISRTI PIGOI OF SA1IO FINS NC17 WORKERS' FLOODZONE A.L.U.C. W � COMPF.NSAI'ION INSURANCIi PLG.CONTR. LIC.NO. PLG. Cl- 0 (Phis section need not be o.moeled if the permit is for one TOTAL Y N Y N hundred dollars IS 100)or less.) U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY LL 1- mil is issued,I shall not employ any person in any manor,or as to U becumesubject to the Workers'Comperisalion Laws of California. U y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING . } rn NOl'ICE TO APPLICANT. If,after making this Certificate of Ex F ? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK U provisions of the labor Code, you must forthwith comply with FEE such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 CONS'T'RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.RM.) 6.00 SEISMIC FEE I hereby affirm that mere is u construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 the performance of the work for which this permit is issued(Sec. MICROFILM 3097,Civ.C.), HEATING UNIT(TO 100,000 B.T.U.) 8.00 lender's Name Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC d(S I cerlify that l have read this application and slate mal the above VENTILATION FAN (SINGLE) 4.00 information is correct I agree to comply with all city and crnmly PLUMBING ordinances and slate laws relating to building construction, and BOILER-COMP(3 H.Por-100,000B.T.U.) 6.00 hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,0006TU)SEE FEE SCH. above-mentioned property for inspection purposes. MECHANICAL (We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX may is y way accrue against said City in co Seyuen C of the PERMIT ISSUANCE 10.00 nntin of this permit / MECH.CONT. LIC.NO. MECH. 1y1 TOTAL TOTAL Signature of Appl¢unt/Contractor Uate OFFICE COPY I I �. FINAL GRADE ROUTE SLIP ' File No. Date Location _—} S Z"7 t�a t\J e-G cT- Subject _ I Ipproved Date Inspector 4 CERTIFICATE OF COMPLETION p� (6 BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO DATE- I 179r� BLDG. PERMIT NO. / Q U THE BLDG. LOCJA�TED AT / . l 0n IA OWNED BY 1 cN LA, C- d 4 (COMPLETED T HAS BEE IgLTER FOR USE AS V BUILDING INSPECTOR ELECTRIC SERVICE NOTICE OFFICE COPY BUILDING INSPECTORS NOTICE CITY OF CUPERTINO 19 To You are hereby outt(hh/ ¢ed to Connect electricaaal service for Owner or Tenant E At 75 �7 N (tri-G-�,4.�� r�✓I � /� No.of Wires Size of Wiresn 1 Size o4$witch q db /T Motor Load - Voltage Phase Hearing Load K.W. Voltage `Y/ No.of Meters / ( L'ghr 110 New Service /` Reconnect (}) Heat 120Three Wire More Service_ No.of Add.Meters Power /�/+ '�- 'Three Phase Move Meier 1� ! ©� ELECTRICAL INSPECTOR c/`�L// 1 BUILDING INSPECTOR'S OFFICE CITY OF CUPERTINO Bldg,Dept. (� Office Copy O. Backflow Device SanitaryPermit:No. �f J — �© Sewer Connection Plumbing-Permit No. /O 2.P 3 Plumbing Final Lot—No,-,--/6 Owner or Tenant (f CL".., C At 76-2-7 Tract' , Date Connected Zy" _10d Date FinaIJ7----34 19 a h � OM PLG INSPEC�TO`R�J CITY OF CUPERTINO COPYE GAS SERVICE NOTICE 119 To You are hereby authorized to connect the GAS service for Owner or Tenant At i New Service i No. of Meters Reconnect � I No. of Add. Meters Move Service Move Meter PLUMBING INSPECTOR / p„ I