6627CITY OF CUPERTINO INSPECTION RECORD
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —.USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION
APPLICATION & PERMIT -
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BUILDING—ELECTRICAL—PLUMBING—MECHANICAL
PERMIT NUMBER
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ADDRESS
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OWNLR'S
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CITY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
.
NAMERAcraHs
UTLETS- SWITCHES -RECEP 5.00/1.00
LIGHTING FIXTURES . 5.00/1.00
uc.No.
CONTRACTORS
PPLIANCES- RESIDENTIAL _ 4.00
PANELS 5.00
PHONE
DATE OF APPLICATION
RCHITEDr
OR
SIGNS 6,00
•' PLAN CHECK FEE P.C. NO,
ENGINEER•
Llc. nO.
SIGNS TRANS. 3.00
ARCHE sv ENG'
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
ZIP
EMP. -METER OR POLE INS. 16.00
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As
ADDRESS
ESS
MOTORS SEE FEE SCH.
SERVICE CHANGE
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LICENSED CONT RACI'ORS DECLARATION
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I hereby altirm that 1 son licensed under provisionx of Chapter 9
(commencing with Sev.'Iyi 7000) of Division 3 of the Businessand
Pref cions Codc, and my liccme is in full force and effect.
License Clan
ISSUANCE GATE
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BLDG. ELECT.
❑ ❑
PLG. MECH.
❑ ❑
C.ClooNumber
Du@ Conlrector
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BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION s
I hereby allirm that I am exempt from the Contracmr's Liceme
Law for the following reason. (Sec. 703 I.S. Business and Professions
Code Any city or county which requires u permil to Construct, oiler,
MISC.— REFER TO ORD
PERMIT ISSUANCE 6,00
-
VALUATION SIFT.
O
ELEC. CONTR. .LIC. NO, ELEC' JUN
TOTAL.
CITY. PLUMBING PERMIT F�
impro,e, demolish, or repair any structure, It to its Lssuance, also
unfaires the applicant for such permit to rite a signed statement -that
he is licensed pursuant to the provisions of the Contractor's License
Law(Chapter I)(commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that ho is exempt therefrom and
T
PERMIT TO �•
7
W
1640 (JNA j,�L [�
the basis for the alleged exemption. Any violation of Section 7031.$
hyanyapplicanlforaperntitsubjcctslhc applirnttoacie.it penalty
of not mom than live hundred dollars (S50 ).):
it� IJI
IE TYPE CONSTR.
is u'd\
ALTER -DRAIN
❑ 1, as owner of the property, or try employees with wages as
their sole compensation, will do the work, and the stnlcmre I, nut
J
BACK FLOW PROTECT. DEVICE - 2,00
Occ. GROUP
RES. UNITS .
DRAINS -FLOOR, ROOF, AR EA, COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions
Calc 'f he Contractor's License Law docs not apply to an ewnei'of
FIXTURES - PER TRAP 4.00
GAS - EA. SYSTEM -11 NC.4 OUTLETS 4.00
property who huilds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsamnot intended oroffered for sale. If, however, the building
SO. Pr, FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of prevint that he did not build or im-
GAS _ EA. SYSTEM -OVER 4 IEA.) 7.00
BUILDING USE
Provl• for purpose of sale.).
p I, as owner of the property, am exclusively contracting with
RES IND CON PB Omer
1:1 El El F-1 C1
•' INDUSTRIAL WASTE INTER. 20.00
LAWWSPR INKLERS -I INC 5 V.B. 5.00
LAWN SPRINKLERS' OVER 5 (EA.) 1.00
licensed contractors to construct the project (Sec 7044, Business
and Professions Code: The Contractors License Law does not apply
to an owner of property who builds or improves thereon, and who
ASSESSORS PARCEL NO.
CO nacts lir such projects with u contractons) licensed pursuant to
the Contractor's License Law.
❑ lain exempt under Sec.B.&P.C.forthis
reason
SEWER -SANITARY -STORM EA. 200ft/8.00 I
TRACT NO.
PARCEL NO.
WATER HEATER W/VENT 4.00
DwnCr /•l D
WATER SYSTEM 4.00
ACC.OATE
ACC. FILE NO.
WATER TREATING EQUIP. 4.00
WORK Ii RS'COMPENSATION DECLARATION
-
I hereby alfrm that I have a certificate of consent to self -insure,
- ZONING
ENG. SITE NO.
or a certificate of Worker,' Compensation Insumnee, or a Cert, fed
-
copy thereof (Sec. 3800, Lah IC.
policy Nn. Company
'
I. '
misc.- REFER TO ORD.
❑ Certified copy shereby furnished. -
❑ nrtifltd copy is fled with the city •impetlion divkdon.
Applicant
FIRE SPRINK
r [:] ry
ENERGY Tod
v E) N[:)
CER 'I'IFIGATE OIs EXEMPTION PROM WORK Ii RS'
PERMIT ISSUANCE 6.00
FLOOD ZorvE
A. L. U. C.
COMPENSATION INSURANCE
(This Section need not be completed if the pennit is for one
PLG, CONTR. LIC. NO.
PLG.
TOTAL
Y [] N
Y E] N ❑
hundred dollars IS 100) or It,,)
I certify that in the perl'ormanm of the work for which this per-
mit is issued. I shall not employ any parson in any manner so as.to
CITY MECHANICAL PERMIT FEE
FEE SUMMARY
BUILDING
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heconm subact to the Wruo,s Contpen.wtion Laws of California.
Date Applicant
ALTER OR ADD TO MECH. q00
,
NOTICE TO APPLICANT: If, after making this Certificate of Ex -
APPLIANCE _ 4.00
AIR HANDLING UNIT (TO 10SWC.F.M.) 3.00
PLAN CHECK'
FEE
p
a
emption, you should become subject to the Workers' Compensation
s of the labor Codc, you must (Orthwith comply with
provisionovision, or this pcnnh'shxll rt
such prbe damned ,.ked.
AIR HANDLING UNIT (OVER 10=CF.M.) 5.00
SEISMIC FEE
ofd
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
the performance of the work for which Ihls permit is issued (Sec.
3097, Cn.C.).
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 4.00
Lender's Name
Lender's Address
HEATING UNIT (OVER 100,000 B.T.U.)7.50
ELECTRIC
I certify that I have read thisappli utionend Stam that the above
VENTILATION FAN (SINGLE) 3.00
information is correct. 1 agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
BOILER-COMP(3 H. P. or 100,000 B.T.U.) 4.00
hereby authorize representatives of thin city to toter open the
alwve- mentioned property for inspection purposes:
BOILER -COMP (Ove1100,000 BTU) SEE FEE SCH.
MECHANICAL
(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
accrue against said City in Consequence of the
MISC. - REFER TO ORD.
PERMIT ISSUANCE 3.00
CONST. TAX
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MECH. CONT. LIC. N0.
MECH.TOTALOTAL
73- IF a
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cant/Contractors Dam
OFFICE COPY