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5799. 1FLICANT TO FILL IN INFOMATION WITHIN, RED LINES, -USE BALL POINT PEN ONLY - BUILDING PROJECT IDENTIFICJWN APPLICATION & PEWIT BUILDING - ELECTRICAL— PLUMBING — MECHANICAL PERMIT NUMBER ,.� - RLTDING ADDRESS LR�2 (�� OWNER S ' . NAME / - -- DTV. ' ELECTRIC PERMIT FEE PLAN CRE VALIOATION4*'% J) /� 1f ��j�' CONTRACTOR"S`R- NAME OUTLETS -SWITCHES -RECEP 5.00/1.00 _ LIGHTING FIXTURES 5.00/1.00 15— CONTRACTOR'S ADDRESS'— ., '• APPLIANCES -RESIDENTIAL 4.00 t PANELS - 5.00 S PHONE OATE OF APPLICATION ARCHITECT OR ENGINEER LIC. NO: SIGNS _• 6A0 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 ADR. ENG. ADDDRESSSS " ZIP SPECIAL CIRCUIT 5.00 PERMIT VALIDATION �� yy ,( TEMP. METER OR -POLE INS. �- 15.00 APPLIC- MOTORS - SEE FEE SCH. SERVICE CHANGE ,10.00 /3 LICENSED CONTRACTORS DECLARATION - I hereby tdlirrn 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 force and effect umber Licensc chs,—'Lia Number— ISSUANCE DATE A BLDG. ❑ ELECT. I El PLG. MECH. El Dale Contractor Date BUILD]DIT INFO OWNER -BUILDER DECLARATION l fi License I hereby arm that I am exempt liom the Contractor Law I'or the following reason. (See. 7031.5. Business and Professions Code: Any cityor 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 signed stateent Omt m he is licensed pursuant to the provisions of the Contractor's License r. 4• MISC.— REFER TO ORD - VALU�T,IQN . 7 / FIJI LT 3 2(0 (/D'� $/FT. 1984 PERMIT ISSUANCE 6.00 ELEC. CONTR. - LIC. NO. ELEC. _ TOTAL V RMI � T Ru��lno OTV. PLUMBING PERMIT FEE Law (Chapter 9 (commencing with Section 7000)01' Division 3 of the Business and Professions Code) or that he is exempt lheodrom and !151 STORIES TYPE CONSTR. the basis for the alleged exemption. Any violation of Section 703 LS 1 ALTER -DRAIN by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).} . C 'DCC. ❑ 1, 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 far sale (Sec 7044, Business and Professions BACK FLOW PROTECT. DEVICE 2.00 GROUP - RES. UNITS - ' DRAINS -FLOOR, ROOF, AREA, COND. 4.00 Code: The Contractor's License Law docs not apply Io an owner of properly who builds or improves thereon, and who does such work F IXTUR ES - PER TRAP 4.00 SOL FT. FLOOR AREA TO—r,.L ACREAGE himself or through his own employees, provided that such improve-•. ments are not intended oroffered forsale. If, however, the building GAS-GAS-11NC.40UTLETS 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 a saleJ. ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 70FI4, Business GAS - EA. SYSTEM - OVER 4 (EA.) 1.00 BUILDING USE RES IND CON PB - Other ❑ ❑ ❑ ❑ ❑ INDUSTRIAL WASTE INTER. 20.00 LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO. and Professions Code :'I'he Contractor's License Law docs not apply to an owner of property who builds or improves thereon. and who LAWN SPRINKLERS - OVER 5 (EA.) 1.00 contracts for such projects with a contractot(s) licensed pursuant to theContractor's LicunscLaw. SEWER -SANITARY -STORM EA. 200ft/8.00 TRACT NO. PARCEL NO. WATER HEATER W/VE4.00 ❑ lam exempt under Sac.—, B &P.C. for alis reason Owner Date Q'— •- WATER SYSTEM 4.00 ACC.DATE AcG. Fn.E NO. WATER TREATIN P .00 WORKERS'[ MPIiNSATION DECLARATION 1 hereby affirm that 1 hove a certificate of umscm to xlf-insure, ora certifca PC of Workers' Compensation Insurance, or a certified ZONING ENG. SITE NO. copy thercof(Se, 3800, Lab.C.L - Policy NO. Company ' CI Certified copy is hereby lumodual. ❑ CCrtiDed COPY is filed with the city inspection division. Applic'unt FIRE SPRINK V ❑ N ❑ ENERGY T"YC Y ❑ N❑ MISC. - REFER TO ORD. - ISSUANCE 6.00 FLOODZONE A.L.u,C . CER'1'IF[CA'f Ii OP EXEMPTION FROM WORKERS'PERMIT PLG. CONTR. LIC. NO. PLG. SO �� COMPENSATION INSURANCE - ('Phis sactimt need not be completed if the permit is foroneTOTAL V ❑ N ❑' v F] NE] DTV. MECHANICAL PERMIT FEE FEE SUMMARY hundred dollars IS 100) or less.) I Certify that in the performance of the work for which this per- mit is issued, 1 shall not employ any person in tory manner s l as to - become subject to the Workeri Compensation Laws of'California.�y� - Applicant - NOTICE '1'O APPLICANT: If, after making this Certificate of Ex- en,dion, you should become Subject 1H the Wmkers'Cnmp,mation Provisions of theLabor Code, you most forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING J10Date aC Q ALTER OR ADD TO MECH. 4.00 APPLIANCE 4.00 - PLAN CHECK FEE + AIR HANDLING UNIT (TO 10pODGF.M.) 3.00 3 AIR HANDLING UNIT (OVER 10=C.F.M.) 5.00 SEISMIC FEE a CONSTRUCTION LENDING AGENCY EXHAUST HOOD (WITH DUCT) - 2.00 MICROFILM 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.). ,. - Ulmer', Name HEATING UNIT (TO 100,000 B.T.U.) 4.00 oZ HEATIN 4J9,000 B.T.U.)7.50 ELECTRIC p epi i Lenders Address I certify that I have read this application and stale that the above intnrmation is correct. I agree to comply with all city and county ordinances and stale laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes.., (We) agree to save, indemn' an harmless the City of Cupertino against liabilities, j P,ments, cos and expenses which any We accrue agai said City in onseyuence of the is m : VENTILATION FAN ( LE) 3.00 PLUMBING BOILER -CO r 10 .T.U.) 400 BAILER -CO P (Over ,000 1 EE FEE SCH. MECHANICAL , MISC. - R FER TO ORD. CONST. TAX ' PERMIT ISSUA C 3.00 MECH. CONT. - 'LIC. NO. MECH TOTAL Signature of tractor OFFICECOPV 0 z F 0 CC LU 0- 0 z U 0 L U 0w } o_ H Z Z ADDITIONAL PERMIT FEES BU ILDINGPROJECT IDENTIFICATION VALUATION BVILDING ADORESS 1 u?3Cp agNER'R i PHONE FEE SUMMARY BUILDING corvTRACTOR s NnME uc. NO. PLAN CHECK FEE CONTRACTOR'S ADDRESS P ... E SEISMIC FEE CITY. ELECTRIC PERMIT FEE ELECTRIC UTLETS- SWITCHES -RECEP LIGHTING FIXTURES PLUMBING APPLIANCES RESIDENTIAL MECHANICAL PANELS SIGNS TOTAL SIGNS TRANS. SPECIAL CIRCUIT EMP. METER OR POLE INS. PERMIT VALIDATION aL; V ISSUANCE DATE MOTORS SEE FEE S SERVICE CHANGE TOWL OTY. PLUMBING PERMIT �` p FEE BLDG ELECT. ❑ PED. ❑ MEC.. ❑ ALTER DRAIN & VENT -WATER IEA.) BACKFLOW PROTECT. DEVICE (�• DRAINS -FLOOR, ROOF, AREA,COND. FIXTURES -PER TRAP GAS-EA.SYSTEM-1 INC.40UTLETS GAS - EA. SYSTEM - OVER 4(EA.) INDUSTRIAL WASTE INTER. LAWN SPRINKLERS 1 INC 5 V.B. LAWN SPRINKLERS - OVER 5 (EA.) SEWER -SANITARY -STORM EA. 200ft/ WATER HEATER W/VENT WATER SYSTEM WATER TREATING EQUIP. TnTAI CITY. MECHANICAL PERMIT FEE ALTER OR ADD TO MECH. - APPLIANCE AIR HANDLING UNIT (TO 10j"C.F.M.1 AIR HANDLING UNIT IOV ER 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) BOILER COW (3 H.P. or 100,000 B.T.U.) BILLER COMP IDvn 100,000 BTU) SEE FEE SCH. TOTAL T 0 Z Z �:: 0 cc — LU 5 O_ O z 1U_O LL O w is ♦— L ADDITIONAL PERNffT FEES BUILDING PROJECT IDENTIFICATION VALUATION D emLDINO ADUF yS OWNERS nwE E FEE SUMMARY BUILDING CONTRACTORS NAME MC. No, PLAN CHECK FEE f7ON7RACTCR E ADDRESS PHONE SEISMIC FEE OTY. ELECTRIC PERMIT FEE UTLETS- SWITCHES -RECEP ELECTRIC LIGHTING FIXTURES PLUMBING PPLIANCES- RESIDENTIAL PANELS MECHANICAL 6 �_ SIGNS TOTAL SIGNS TRANS. SPECIAL CIRCUIT EMP. METER OR POLE INS. PERMIT VALIDATION �� ISSUANCE DATE MOTORS SEE FEE SCH. SERVICE CHANGE'/,/ TOTAL DTV. PLUMBING PERMIT FEE BLOa ELECT. PLO. MECH. ALTERIDRAIN & VENT -WATER (EA.) BACKFLOW PROTECT. DEVICE ' ^ ^ •`� DRAINS.FLOOR, ROOF, AREA,COND. FIXTURES - PER TRAP GAS - EA. SYSTEM -1 INC.4 OUTLETS GAS -EA. SYSTEM - OVER 4(EA.) INDUSTRIAL WASTE INTER. LAWN SPRINKLERS - 1 INC 5 V.B. LAWN SPRINKLERS - OVER 5(EA.) SEWER -SANITARY -STORM EA. 200tH WATER HEATER W/VENT WATER SYSTEM WATER TREATING EQUIP. TOTAL QTY. MEC HilNpL PERMIT] ��D FEE r_R ALTER O ., ADD TO MECHn(jQ APPLIANCE) p ' W AIR HANDLING UNIT (TO loMc7.RM) IA AIR HAN IT1 RODW C_. F. M. \!li 1 EXHAUST HOOD (WITH DUCTWEI HEATING UNIT (TO 100,000 B.T.U.) HEATING UNIT (OVER 100,000 B.T.U.1 VENTILATION FAN (SINGLE) _ BOILER COMPQ H.P. or 100,000 BT.U.) v° ROI LER-COMP (0-1100000 BTUI SEE FEE SCH.� TOTAL CITY OF CUPERTINO INSPECTION RECORD f (OFFICE COPY) 5799_ 10726 Lar IVa Ad tion Wesley I'Jeigel P=cr OWNER FINAL INSPECTIONS DATE I INSP. Gas ELECTRICAL DATE IINSP. Power Pole ELECTRICAL DATE I INSP. S.M. BUILDING ' ELECTRICAL PLUMBING MECHANICAL DEIISCELLANEOUS