5752ARPLICANT TO FILL IN INFORMATION WITH IN,RED LINES-* USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT
BUILDING -ELECTRICAL- PLUMBING -MECHANICAL
PERMIT NUMBER
Stoo-DNG
A
la o &COt3/3 ��5752
OWNER'S 7� 8
NAME /
�JrP vxory 1Q-
- -
'` fi y.'� ., .1
TVie4"` E,r.:=ELECTRICPERMIT �' 'jFEE''.
PLAN CHIL ID ATION
A
AUG 2 U
^84
city ofCn
Cupertino
DATE OF APPLICATION
CONTRACTORS / O
D�IJ�L l'���/ Uc. NO. 35z85
UTLETS-SWITCHES-RECEP 5.00/1.00
LIGHTI NG FIXTURES 5.00/1.00
CONTRACTORS 1 S
R 5
�/ I\'•6•f pnON
pPLIANCES-RESIDENTIAL 4.00
PANELS S.00
aRCHrtECTPLAN
OR s }'�K
xF R�A -S . Llk7 - uc. No.3J/J �.�
SIGNS 6.00
CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH. OR ENG. ��v5,��r•/� ('�[
ADDRESS NF1 " �/L r
.26395 Y Va Dt.
SPECIALCIRCUIT . - 5.00
PERMIT VALIDATION
O /7
TEMP. METER OR POLE INS. 15.00
ANTS
ADDRESS
g,gS , STOt4Ie I' M�4 V V 0
Ivo(�
MOTORS SEE FEE SCH.
SERVICE CHANGE 10.00
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions C an my licenLi is ire full forTc,pn¢� 0 c
I Lie- Number �S
ISSUANCEDATE
a
BLD ELECT. PLG.
❑ , ❑
MECH.
❑
)re-
])are
Dnh�-ContractorDECL.
;BUILIDING,PERMIT
,-`) w P`Tr NFURMA'TION
'-
OWNER -BUILDER DECLARATION
R
I hereby.Thom That 1 um exempt from the Contractor's License
Law for the following reawn. (Seo. 703 1.5, Business and Pro(essiunsVALUATION
'Code: Any city or anly which requires permit to construct, alter,
m
improve, demolish, or repair any structure, prior to its issuance, alsoELEC.
requires the applicant for such permit to File a signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencingwllh Section 7000)of Division 3 oflhe
Business and Professions Code) or that he is exempt therefrom and
the basis foi the alleged exemption Any violation of Section 7031 5
byany,applicum for a permit subjects the applicant to a civil penally
.of not more than five hundred dollars(5500).):
-
MISC. - REFER TO ORD
PERMIT ISSUANCE 6.00
f/FT.
CONTE, LIC. NO. ELEC.
TOTAL
"*"'E
DTV."�`4/„PL'UMBINGIPERMIT4rC1`^•w :. >EEE;,
3 w m S. 5. I+
PERMIT T
,
"
.STORIES
TYPE CONSTR.
ALTER -DRAIN & VENT -WATER (EA.) 4.00
❑ 1, as owner of the properly, or my employees with wages as
their Sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 4.00
intended or offered for sale (Sec: 7044, Business and Professions
Code. The Contractor's License Law dos not apply to an owner of
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided (hat such improve-
menti am not intended or offered I'ur sale. If, however, the building
FIXTURES - PER TRAP 4.00
50. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA.SVSTEM-I INC.40UTLETS 4.00
or improvement is Sold within one year of completion, the owner-
builder will have III. burden of proving that he did not build or im-
prove for purpose of sale.).
❑ as owner of the properly, exclusively contracting with
GAS - EA. SYSTEM -OVER 4 IEA.) 1.00
BUILDING USE
RES IND CON PB Omer
0 0 0 0 0
INDUSTRIAL WASTE INTER. 20.00
d he
licensed contractorsCode: The
and eContrathe project (Sec. 7044, Business apply
and Professions Code: The Contractor's improv Law dues not apply
to owner of property who builds improves thereon. and who
LAWN SPRINKLERS -1 INC5 V.B. 5.00
LAWN SPRINKLERS -OVER 5(EA.) 1.00
ASSESSORS PARCEL NO.
"
tr
contracts for such projects with a contmctor(s) licensed pursuant to
tr
the Contractor's License Law.
SEWER -SANITARY -STORM EA. 200ft/8.00
TRACT NO.
PARCEL NO.
Cl I am exempt under Sec.-, BAPC, or this
.mon
WATER HEATER W/VENT 4.00
Owner Date
WATER SYSTEM 4.00
ACC. DATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORKERS'COMPENSATION DECLARATION
1 hereby infirm that I have a certificate ol'consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
ZONING
ENG. SITE NO. ..
1 copy thereof (Sec. 3800, LPh.CJ.
I'ulicY No. rep ray
❑ Certified ,y her sy nislmd.
jl CerUfi o is a "t s the city inspection division.
APP can"-
FIRESPRINK
Y N
�
ENERGY T$4
Y N
0 E]
MISC. - REFER TO ORD.
CF.RTIFICAT1; OF EXEMPTION FROM WORKERS'
PERMIT ISSUANCE 6.00
FLOOD ZONE
A.L.U.C.
PLG. CONTE. LIC. NO.
PLG. i .
TOTAL
COMPENSATION INSURANCE
(This section need not be conmleled if the permit is I'or one
Y 0 N
Y No
DTVi ;: (. g_;�;; MECHANICAL'PERMIT - a 'FEE ,
-
_ FEE SUMMARY 1x,+A Os'ffi
•�
hundred dollars($100) or Ic..)
I certify that in the performance of the work fur, which this p r
mit Is Issued, I shall not employ any person in any manner So as to
become subject to the Workers' Compensation Laws of California.
Date - Applicant
NOTICE TO APPLICANT: If, after making this Certificate of I..x.
BUILDING
tS�
ALTER OR ADD TO MECH. 4.00
APPLIANCE 4.00
PLAN CHECK
emplion, 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 deemedrevoked.
AIR HANDLING UNIT (TO 10=C F.M.)' 3.00
FEE
AIR HANDLING UNIT (OVER 10PWC.EM) 5.00
SEISMIC FEE
�•6
CONSTRUCTION LENDING AGENCY
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
1 hereby affirm that there is a construction lending agency for
the perl'ormance Of the k for which this permit is issued ISec.
3097, Civ.CJ. -
HEATING UNIT IT 100,000 B.T.U.) 4.00
HEATING UNIT(OVER 100,000 B.T.U.P.50
ELECTRIC
/1L/1 N/IQL.
Lender's Name I% -
Lender's Address
I certify that l have read this application and stale that the above
information is correct. I agree to comply with all city and county
ordinances and stale laws relating to building construction, and
hereby awhorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
VENTILATION FAN (SINGLE) - 3.00 -'
PLUMBING
BOILER - COMP (3 H.P. or 100,000 B.T.U.) 4.00
BOILER -COMP (Over 100,000STU) SEE FEESCH.
MECHANICAL
MISC. - REFER TO ORD:
CONST. TAX
- (Wc) agree. to vve, indemnify and keep harmless the City of
CuPeri einy 1'' bilit'es, judgments, costs and expenses which
may i way 'r ayinsl said City in fffonSequence of the
-
PERMIT ISSUANCE 3.00
MELH. CONT. LIQ NO. MECH.
TOTAL
TOTAL
gmnli g _t isp /
/
Signa arc of Apphwnl/ oral ate} ctor ate
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY
PEW 1ADDRES6
FINAL INSPECTIONS DATE INSP.
Gas
BUILDING
Pad
DATE I INSP.
, -kt ts% to r y -fs by �&V
UL (jr
[o Z -g
ELECTRICAL DATE I INSP:
Power Pole
ELECTRICAL DATE I INSP.
Underfloor S.M.
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS
N