4884 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALI_ POINT PEN ONLY
LU
I LQI NG PROJECT,I DENT[FICA? PERMIT NUMBER
ROILOINf. APPLICATION & PE 4884
7 ADRREss
E-,-, t-1 111 Gj BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
1OWN R' PLAN CHECK VALIDATION
ti NAME
i OTY. ELECTRIC PERMIT FEE
N Hv Q PHONE - 07
NAMERAcroRs / UTLETS-SWITCHES-RECEP 5.00/1.00 S�
'� SQ CAS 60, LIC.NO. 2S10 I LIGHTING FIXTURES 5.00/1.00
"y A/oo�groes Sri �OJd PPLIANCES-RESIDENTIAL 4.00
TCO N Vtl till frA PHONE PANELS - - 5.00 DATE OF APPLICATION
AARRCHITECT SIGNS 6.00 PLAN CHECK.FEE P.C.NO.
ENGINEEfl - ,
LIC.No, SIGNS TRANS. 3.00
ARCH OR ADDRESS ENG. SPECIALCIRCUIT PERMIT VALIDATION
zIP - EMP.METER OR POLE INS. 15.00
• APPLICANTS -
ADDRESS MOTORS F E�Cljllp
SERVICE CHANGE 10.00
-OL
o LICENSED CONTRACTORS DECLARATION Cijy of rH,e,4 r
a is 1 hereby affirm that I am licensed under provisions of Chapter 9 ISSU DATE
m a u (comm nocing with Section 7000)of Division 3 of the Business and BLDG. ELEC MECH.
r y i Professions Co, `and my license Is in full force'Mdow
❑Z O w- License Class Lic.Number
~]f
¢ ¢ w a OWNIi R.BUILDER DECLARAIION BUMN PE
WU INFORMATION;LL 1 hereby affirm that I am exempt from the Contracmr's License ]MISC. REFER TO ORD VAL FT.
u O¢ law for the following reason.(Sec.7031.5,Business and Professions pERMIT ISSUANCE df Cu
g p
iwm Code:Any city or county which requiresa permit toconstruct,;dteq 6.00 OOO Ill
re a Q FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. ��
A. 0 II: requires the applicant for such permit to file a signed statement that TOTAL pERMIT TO ,(JJ
W m Ile Is licensed pursuant to the provisions of the Contractor's License AA
Uzi Law(Chapter 9(commencingwith Section 70000of Division 3 of the
0/7"
a Business and Professions Code)or that he is exempt therefrom and GTY. PLUMBING PERMIT FEE VV
¢ Imo-0 the basis for the alleged exemption.Any violation of Seclem 7031.5 dollars
STORIES TYPE CONSTR.
o ;? by any applicant fora permit llrs the loacivil penalty
of not more than flue hundred dollars($5001.) ALTER-DRAIN&VENT-WATER (EA.) 4.00:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their side compensalion,will do Om work,and the fracture is not ,
intended or offered for sale(Sec. 7044, Business and Professions - DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's License Law does not apply 1
0 an owner of
property who builds or improves thereon,and'who does such work FIXTURES-PER TRAP 4.00 SO,FT.FLOOR AREA TOTAL ACREAGE
� himself or through his own employees,provided that such improve.
I ments are not intended or offered for sale.If,however,the budding GAS-EA.SYSTEM-11NC.4OUTLETS 4.00
or improvement Is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build Or am-
Provefor purposeofsale.). INDUSTRIALWASTE INTER. 20.00 RES IND CON PB Omer
❑ 1,as owner of the property,am exclusively contracting with El ❑ ❑ 0 ❑
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 docs not apply q ����
to an owner of properly who builds or improves thereon,find who LAWN SPRINKLERS-OVER 5 (EA.) 1.00 _ -2
contracts for such projects with a contractor(s)licensed pursuant to ,
the Contractor's License Law. I ISEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—.BAP.C.lot this WATER HEATER W/VENT 4.00
reason
Date Owner. WATER SYSTEM 4,00 ACC.GATE ACC FILE NO.
WORK ERs.COMPHNSAI'ION DECLARATION WATER TREATING EQUIP. 4.00
1 hereby affirm that 1 have a certificate of consent to sell'-insure, ZONING Or a certificate of Workers'Compensation Insurance,or a cerlified ENG.SITE NO.
copy thereof(Sec.3800,Lab C.).
Policy No. Company
Q O Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z 2C1 Certified copy is filed with the city inspection dwision.
p pphcant MISC.- REFER TO ORD. Y N❑. - Y ❑ N❑
EY H CERTIFICATE 01'i:xEMPfION FROM WOR KERS• PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.c.
LU > COMPENSATION INSURANCIi PLG.CONTR. LIC.NO. PLG,
CL a (This section need not be completed if the permit is for one TOTAL Y C] N� V N�
hundred dollars IS 100)or less)
L) O 1 certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
H mit is issued. I shall not employ any person in any manner so as to
U becofny sub�'ect"to the Workers'C. a do "'Cal
fonsiu.
Go Datc_/-/.�t,LApplicam p � ALTER OR ADD TO MECH. q00 �O BUILDING
tail NOTICE TO APPLICANT: If,after this Cer Ifcale OI Ex-
I- Z emRim,you should become subject babe Workers'Compens;dion APPLIANCE 0 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
C.) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT ITO 10 .) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLINGUNIT(OVER 5 SEISMIC FEE / 12
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH D QT) 2.00
the performance of the work far which this permit is issued(Sec. MICROFILM
3097,Civ.0.). - HEATING UNIT (TO 100,0 0
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.P.50
Lender's Address ELECTRIC -•�
I certify that l have read this application and slate that the above VENTILATION FAN (SINGLE) .3.00
information n correct I ,agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
ordinances and state laws relato c t0 comply
with
l city lInd v0 and
hereby authorize representatives Df this city to enter upon the BOILER-COMP Inver 100,000BTUI SEE FEE SCH. MECHANICAL
70-6
I above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD,
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3,00 Q CONST.TAX
may in any way accrue against said City in consequence Of the
granting Ills permit. MECH.CONT. LIC.NO. MECH.
TOTAL 7 00 TOTAL
gna ve of pli /COntracmr Date /
OFFICE COPY
CI'3y OF CUPERTINO INSPECTION RECORD.
(OFFICE COPY)
SS,-dill -
291Tj- oNj
PERMIT ISSUED DATE ELECTRICAL PATE INSP.
We
c inE . -�
,/5-
ectrica
urn�ln Power Pole
-- eclanlca ,' �- > Underground
end as ec Kori Wiring
6olay
-ire Sprin ler ei in
y� Fixtures Int/Ext
Motors
Misc. Grounding
ng
Te mower
er
FINAL INSPECTIONS DATE INSP, NotAppro-v—ecT—
Gas
Electric
Plumbing G PLUMBING DATE INSP.
Mechanical
: Ir Backflow
Undergrou—nT—
Urading Underiloor
Pi ingPartial
ou
71 Peire ept. ouiF��oi ete
Health Dept. S05T ouQ
u�ii�cing �K,+d-tre &( :1-� ✓ at��nsu ation
t lera�nnDDrai—"n — --
o rain
Gas
Other
BUILDING DATE INSP, Not Approved
Pad Certification
Foundation ELECTRICAL DATE INSP.
re- unite
Slab-Membrane Underfloor S.M.
Bond eam Ducts nsu anon
Underfloor Girders Fireers
Floor Steel
ire
�ep�lace
ie ownsr�ease ct & Hood
i�anis P 11 r Rcloft if to -3.ra4 One lour Shaft
eismec Bracing Condensate Drain
balls- ane1s ui ment Anc orae
runT'� egh .��1t� ¢ e� ii�n MNV\ • ��-� Flues icomb.Air
z--1 trier
oar s n xt. Not Approved
,,Firewalls
tier I ,
9t Approved