4666 APPLICANT TO FILL IN INFORMATION'WITHIN RED LINES — USE BALL POINT PEN ONLY
''
UI LDI NG PROJECT IDENTIFICATION PERMIT NUMBER
RDILDING APPLICATION & PERMIT,
ADDPE55 4 6 6 6
- BUILDING -ELECTRICAL-PLUMBING -MECHANICAL ACC C
OWNER'S PLAN CHECK VALIDATION
NAME °' DTV. ELECTRIC PERMIT FEE '
PHONE I
NAMERAcroRs UTLETS-SWITCHES-PIECED 5.00/1.00
LA LIC.No. LIGHTING FIXTURES5.00/1,00
CONTRACRESSTOR R's - / APPLIANCES-RESIDENTIAL 4.00
P > OO PANELS 5.00 - DATE OF APPLICATION
ORRCNI Cr SIGNS 6 OQ PLAN CHECK FEE P.C.NO.
ENGINEER uG.No. SIGNS TRANS. 3.00
AARCH,OR DDRESS ENG. SPECIAL CIRCUIT 5.00 • PERMIT VALIDATION
ZIP rrEMP.METER OR POLE INS. 15.00
APPLICANT - MOTORS SEE FEE SCH. i
ADDRESS
SERVICE CHANGE 10.00 ({'�/�
Mai LICENSED CONTRACTORS DECLARATION, I/I/
a u I hereby affirm that I am licensed under provisions of Chspler 9 �,e�` ry/-/k6-�� .� 0 0�— 6 DATE
y¢ (commencing with Section 7000)of Division 3 of the Business and
to BLDG. PLG. MECH.
F to Professions Code,and my license is in full force and effect. n aC D ❑
z o m License Cla Lia Number
o m H w Daley/t�Contraclar -
¢ ¢ w NER-BUILDER DECLARATION - C1 NLIWI67DISIG INFORMATION
w; y I hereby affirm that I am exempt from the Contractor's License MISC.- EFER TO ORD rr pry
F u o< Law for the following reason.(See.703 1.5,Business and Professions PERMIT ISSUANCE 6,00 /pf{yUi Ilzuperti 0 $)FT.
Code:Any city or county which requiresa permit reconstruct,alter,
ELEC.CONED. LIC.NO.
¢ M ¢ p improve,demolish,or repair any stnmture,prior to its issuance,also ELEC. /A�-Z /
i ¢ requires the applicant for such permit to file a signed statement that TOTAL rJ•-{7 L- PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License - O ��
H Z:a Law(Chapter 9(commencing with Section 7000)of Division 3 of the C i7/� .�Z
4 c Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
¢ t- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 '
of not more than five hundred dollars(85001.1', -
❑ I,as owner of the property,or my employees with wages as BACKFLOW PROTECT. DEVICE 2,00 OCC.GROUP RES.UNITS
their-sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Cade:The Contractor's License Law does not apply to an'owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP . 4.00 SO.FT.FLOORAREA TOTALACREAGE
himself re through his own employees.provided that such imPrmro-
mentsarenetintended or employer,provided
that r.suhebuilding GAS-EA.SVSTEM-11NC.40UTLETB 4.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4(EA ) 100 -BUILDING USE
builder will have the burden of proving that h . . ,
e did not build or im- RES IND CON PB Omer
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 20.00 ❑ El❑ I,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does 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 contractors)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
Cl I am exempt under Seca ;B:&P.C.for this
WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
py thereof(Sec. 800,Lab.C.) /w
®(company n
Q ❑ C r I led copy Is hereby famished, _ FIRE SPR INK ENERGY T-24
Z� ❑ Certifie py is filed with I city sPeaion: ivision. MISC.- REFER TO ORD.
0 Applicant �- Y N V N
K y C17RTIFICATEOF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.0 C.
LU > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 IT his section need not be completes) it the permit Is for one TOTAL Y N❑ Y ❑ N❑
D Z hundred dollar,IS 100)or less.)
U 0 1 certify that in the performance of the work for 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
U become subject to the Workers'Compensation Laws of Calilarniu.
W " Dale—Applicant - - BUILDING 10 _s2t
a ALTER OR ADD TO MECH. 4.00
} N NOTICE you APPLICANT: If,after making this Certificate sa Ex
FZ emvisionyou should become
e, youto the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions io the Labor Cade, you must forthwith comply with FEE.
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.)' 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCTI 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT(OV ER 100,000 B.T.U.IT.50 ELECTRIC W
Lender's Address y--_
'I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 '
information is correct. I agree to comply-,with all city and county. PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00
lie
representatives of this city to enter upon the BOILER-COMP (Over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue gainst said City in consequence of the PERMIT ISSUANCE 3.00
gr ming of is permit MECH.CONT. LIC.NO. MECH. U�
TOT"` TOTAL 7 �—
urAninimMontiaefor D' e
OFFICE COPY -
i, CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
4667 862 Lilv Avenue
ADDRESS
Repair Fire Damage Ferrari OWNER
PERMIT ISSUED DATE "ELECTRICAL DATE INSP:
ui in
Electrical
Plurb—ink Power Pole
ec1 apicalr oun
e as ec ou ,
Solar a s . .
Fire Sprinkler 'Ceiling
6ignixF xtures Int/Ext
Misc. otors
Grounding
ower
Other
FINAL INSPECTIONS DATE INSP, Not .Approveff
Gas
Electric Z, _ Z
. e�ianial PLUMBING DATE INSP.
�oar _ Backflow
'qW0o er un
Gra in9 MiFerlioor
Planning Partial Rough
Fire Dept.- Roun UompTete
pe t e t. o ar ou
uiI in _z- ater ', T n s ul at ion
Other
in ain
o rain
as
Other
BUILDING
DATE INSP, Not rove I
Pad Certification
Foundation
re- rte ELECTRICAL DATE INSP.
Slab-Membrane Underfloor S.M.
Bond eam Ducts & Insu-ra'tion
Un-derfloor Girders ire ers
Floor Steel ire ace
ie owns Grease Duct & Ted
iara our Shaft
i�ecSacCondensate
Drain
Walls-Panels Equipment Anc ora e '
-Frame Plue-s7 Comb. r
t
Other
'%Wa oar nt xt. of Appr-o-v-e-T—
Pirewalis
Other
Wet rove