6747 APPLICANT TO FILL IN INFORWLTION WITHIN REDLINES - USE BAA POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT'l FICATI APPLICATION & PERMIT
aooAEu _ 6747.
BUILDING'-ELECTRICAL-PLUMBING-MECHANICAL
PLAN CHECK VALIDATION
5A♦ / QTY. ELECTRIC PERMIT FEE
FACIO.x N • PHONE O 5,O
NANinncions-F.
NAME pie UTLETS-SWITCHES-RECEP 5.00/1.00 ! /
-
• LIC.NO. LIGHTING FIXTURES - 5.00/1.00 - bid.oZ ,
CONTRACTORS _ - PPLIANCES-RESIDENTIAL 4.00
AppRE55
PHONE PANELS 5-OO DATE OF APPLICATION
ARCHITECT SIGNS B PLAN CHECK FEE P.C.NO.
OR i
ENGINEER
R n
2 sic.No. SIGNS TRANS. 3.00
AR. ENG. PERMIT VALIDATION
ADDRESS
ss ._ JJ A- 4¢30L � SPECIAL CIRCUIT 5.00
6 `J L.i�W1y0. EpL ¢IvEMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS rr //�J
bKT/Io Cc. LU Qr�tkV SERVICE CHANGE
w p o LICENSED CONTRACTORS DECLARA' ION W
n
ovisions of Chapter 9
a w (commen ingATE
f w hfion lSecthat lon 701X))of Divam fik�cnoed a ioner r3 of the Business anJ BLDG.1� LANCE G. MECH.
H o z Profesions Code,and my license is in full force and effect. ❑ ❑
z o`�- License Clan Lic.Number MY ) rI
f
O O Uutc Contractor D rti.._
BUILDING PERMIT
¢ ¢ i OWNER-BUILDER DECLARATION INFORMATION
wr I hereby affirm that I am exempt from the Convectors License MISC..- REFER TO ORD
u o J Ww for the following riason.(Sec.7031.5,Business and Pooes.s1ons VALUATION
H _ PERMIT ISSUANCE 6.00to
GxCode:Any city or countywh icy regolresep it., to amstrucL also 7,1rt ¢4 improve,demolish,or repair any SINCIure,prior to it,issuance,alfa ELEC.CONTR. LIC.NO. ELEC.
D¢ requires the applicant for such permll to file a signed statement that TOTAL - PERMIT TO
u w S" he is licensed pursuant to the provisions of the Contractor's Limns n
HiQLaw(Chapter 9(commencing with Section 7000)of Division 3 oflhe 'Y`'�/.� ddb.. �/✓�
Business and Prolctsnons Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ 0 the basis for the alleged exemption.Any violation of Section 7031.5 STORIE TYPE CONS
wby any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
four more Than five humlred dollars(5500).1:
❑ I,a5 owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole crnnpensatinn,will do the work,and the structure is not
intended or offered for sale(Sec 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,CONE). 4.DO
Code:The Contni:tor'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.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
memsarcnot intended oroffered for sale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS.4.00
or improvenrvnt is sold within one year of completion.are owner. GAS-EA.SYSTEM-OVER 4(EA.)'' 1.00 BUILDING USE
builder will have the burden of proving that he did not build or iso-. r RES IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00
l` I,aP owner of the prowny,am exclusively canlracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(SCC.7044,Ross. LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORSPARCEL NO.
and Professions Codc:T'he Contractoh 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 contractor(s))licensed pursuant to
' the Contractor s LICCoW law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO� PARCEL NO.
❑ 1 am ekcmpt urrdcr ' .B.&P.C. WATER HEATER W/VENT 4.00
rl:a Vlll
L1wr5of - Dutc' WATER SYSTEM - 4.00 ACC.DATE ACC.FILE NO,
WERS
ORKPENSATION DECLARATION- WATER TREATING EQUIP. - 4.00
I hereby of firm that 1 have a cenificxte of consent m self-insure.. ZONING ENG.SITE NO.
or a certificate of Workers Compensation Iniumn c,or a certifiedr
ropy thereof(Scc.3800,WbL.).
Policy Nn. Company '
❑ Ccrtilred copy is hereby furnished, ' FIRE SPRINK ENERGY T 24
Z Z ❑ Cerafmd copy h fled with the city inspection division. MISC.- REFER TO ORD.
0 Applicant - Y N❑ 'Y F] N❑.
cr. y CERT IFICATIi OP 1 xrmpTION FROM WORKERS' PERMIT ISSUANCE 6.00 FLOOOZONE A.L.u.C.
LLI >_ COMPENSAT1014 INSURANCE PLG.CONTR. LIC.NO., PLG.
11 ❑ (This wours wed not be completed if the permit is for ow TOTAL Y❑ N❑ Y❑ IN
Z) Z hu ndred dollars(S 100)or les.)
U O 1 certify Ibut in we.perliumance of the work for which this per- QTY MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- nit is issued,I staff not employ any persue in any manner so as to
U Mcome subject to the Workers'Compensation Laws of California. p Ig-0
Do C. Dae ApplicanBUILDING
t ALTER OR ADD TO MECH. q,pp �!
} m NOTICE'TO APPLICANT': If,after making this Certificate of Ex-
F Z en,own,you should becmne subject to the Workers'Compensitiml APPLIANCE 4.00 PLAN CHECK
provisions of (lie UNIT Code, you Inted forthwith comply with FEE
U
such provisions or this permit shall bis deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.U) 3.00 �•
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IQOODC.F.M.) 5.00 SEISMIC FEE 7 �
1 I hereby affirm that ahem is a construction lending agency for EXHAUST HOOD(WITH DUCT) 2.00
the perfonna ec of the work for which this permit is issued(Sec. MICROFILM
3097,Cv.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's No. HEATING UNIT 100,000 B.T.U.17.50 ELECTRIC
Lender's Address
I certify that I have read this application and nae 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 hadding construction, and BOILER-DOW(3 H.P.or 100,000 B.T.U.) 4.00
hereby suthmve repfesentatives of this city to enter .,on the BOILER-COMP (Oar 100.000 BTU)SEE FEE SCH. MECHANICAL
aWve-mentioned property for trmpecllan popovs.
(We) agree to save, indemnify and keep hamiless the City of MISC.- REFER TO ORD.
Co Nnino against liabilities,jud eats, costs and expenses which CONST.TAX
may in any way ace ugai said City in consequence of the PERMIT ISSUANCE 3.00
his wrmi - MECH.CONT. LIC.NO. MECH. Q
TOTAL TOTAL
Signe reofAc 'ontmctor Date '
OFFICECOPY ,
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY
/KPC6424�
OWNER
PE= ISSUED DATE "ELECTRICAL DATE INSP.=
ui n
ctrica
R
Power Pole
c anica r un
emP as ec RougH win
Solar Walls
Fire Spr=ier Ceiling 3- -f
Sign fixtures Int/Ext
Motors
Misc.
Ground—in
e ower
er
FINAL INSPECTIONS DATE INSP. NotApproved
Gas
Electric
Plumbing PLUMBING DATE INSP.
anica
. ar Backflow -
Gol UndergroundrAJ--. - 5
r in r oor
inartla u
ire t. - u ete
Health t. Solar u i
Buildinwater *& insulation
Other in ain
oDrain
Gas 3—
er
BUILDING DATE INSP. Not rove
Pad Certification Q _tn 70• l -�s-PS _-
oLm ation /- _ f ELECTRICAL DATE INSP.
PTe-Gunite
Slab-Membrane
Underfloor S.M.
amcts 7—Insulation
mWderfloor Uirders ire ers
oor tee Fireplace
ie owns urease ijuct oo _
Diaphranis e ourShatt - r
eismecracin z — Condensate rain
a s- ane s uipment An ora e
tame ues r
3 er
(_4W,i oar Int/Ext. of ATproved
drew s
Other
Net
et rove
BUILDING
ELECTRICAL •
PLUMBING
MECHANICAL
TUSCELLANEWS
s
APPLICANT TO FILL IN INFOR TION WITHIN RED LINES - USE,B POINT PEN ONLY
N BUILDING PROJECT I DENTIFICATI ,� PERMIT NUMBER
i mionNG APPLICATION & PERM T '•a' 6747
I ADDRESS ��e
.,,r BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
4 Ow ER"5 l^ PLAN CHECK VALIDATION
� NAM �l yy QTY. ELECTRIC PERMIT FEE
f I/1 OR k_r t I h PRONE O O O II'9 /5 �_1Lp
ONTRACTOR$ -1T�J E/
Name Ta 13s Sel,oa'rL� UTLETS-SWITCHES-RECEP 5.00I7.00 /
LIC.No. LIGHTING FIXTURES 5.00/1.00
CONTRACTOR s
AONTRASDRESSPPLIANCES-RESIDENTIAL 4.00
C
PHONE PANELS 5.00 DATE OF APPLICATION
ARCHITECT SIGNS 6.00 PLAN CHECK FEE P.C.NO.
R
O
ENGINEER
- TIC.NO, ��5 SIGNS TRANS. 3.00
t ARCH.OR LNG. PERMIT VALIDATION
-� ADDRESS I7/lr C14'3OL SPECIAL CIRCUIT 5.00
f0 h R T Zu, TEMP.METER OR POLE INS. 15.00
ADDRESS
AREESSSS RMOTORS SEE FEE SCH. I V�/�"/ J
: � I
I U'110 �U y `V 4.-�,W SERVICE CHANGE 10.00 //31/hS
-,00 LICENSED CONI'RACfORS DECLARA ON O
c u 1 hereby affirm that 1 am Iiee..d under provisionso(Chapter 9 ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
ris i Professions Code,and my license is in full force and effect. ❑ O ❑
z o y- License Class Lia Number
g z -w Date Contractor
a Y s - BUILDING PERMIT
w < OWNER-BUILDER DECLARATION INFORMATION
A 0 MISC.- REFER TO ORD
3: me
4
a, 3 LL N I hereby allinn Thal I am exempt from the Can NUC(or's LicenseVALUATION
F u 0 e law for the following reason(Sec.7031.5.B.,messand Professions PERMIT ISSUANCE 6.00
0-' Code:Any city or county which requires a perall to construct,alter,
QQ¢0 inrprnve,Acnmlish,or repair any slm,mor,prior to its issuance,also ELEC.CONTR. LIC.rvO' ELEC. O/ �
E requires the applicant fur Snell permit to file a signed statemmal Ilml TOTAL PERMITTO
u w w u he is licensed pursuunl Co The provisions of the Contractor's License
Hsi ].aw(Clmplur9(comicacingwlthSection 7000)nfoivizion 3 of the
Business Told Profession,Code)or that be is exempt Iherefrma and QTY. PLUMBING PERMIT FEE
W ro the basis for the alleged excmplion.Any violation of Secliou 7031.5 STORI T P6CGNST*,V
a ;m by any alidicanl for a permit subjects the applicant toaclvll penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more limn five hwldred dollars(5500).):
❑ Ines oveder of the properly,or my employees wilt,wages as BACK F LOW PROTECT.DEVICE 2.00 ocC.cgouP RES.urv,TS
their role compemtion,will Jo the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND, 4.00
Code:The Contractors License Law does not apply to an owner of
proper,,Whn 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.
ments are not intended or offered for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
,or improvement is send within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 100 BUILDING USE
builder will have tile . . .
e burden of proving that he did not build or im- RES IND CON PB _ OIM1er
prove for purpose of xale.l. INDUSTRIALWASTE INTER. 20.00
ffl I,as owner of the property,an exclusively contracting with El 1:1 El 0 - C]lic.eased contractors to construct The project(Sec 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO,
and Professions Code 1'he ContraclRr'z License Law Jues not apply ..�
to on owner of property who builds or improves thereon.and who LAWN SPR IN KLERS-OVER 5(EA.) 1.00
r Contracts for such projects with a contractors)licensed pursuunl to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/6.00 TRACT NO. PARCEL NO.
I ❑ I an,exempt lender ,B.&P.C.I rte's WATER HEATER W/VENT 4.00
fen5011
Owner utile 1. I WATER SYSTEM 4.00
ACC.DATE ACC.PILE No.
WORK liRs 'I:Nsn'1'1GN u[cLnlinnON WATER TREATING EQUIP. 4.00
r lhcreby uftirnl Limit I have o certificate of consent to sell-insure, ZONING
or u ceititicme of Workers'Compensolion Insurance,ar a clod cd
ENG.SITE NO.
col,Themof(See 3800,LA".).
Policy Nu. Company
O ❑ Certified copy ix hereby fum fished. FIRE SPRINK ENERGYT24
Z Z 0 Certified copy is flied will, The city inspection division. MISC- REFER TO ORD.
U Applicant YE:] N❑ Y ❑ N❑
F rn- PERMIT ISSUANCE 6.00 FLOODZONE A.L.uc.
fli R'I'I PICAT6OP 17 EM TION ION FROM WORAIiRS'
_ COh11'IiNSATIQN INSURANCE PLG.CONTE. LIC.rvo. L.G.P
CL O Cillis section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
D Z h,indred dollars IS 100)or less.)
U O 1 certify That in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit ix issued,1 shall not employ any person in any manner suits to
U bei'ome subject to the Workers'Compensation Laws of California.
W D:iln ApplicamALTER OR ADD TO MECH. 4.00 BUILDING Y'-d
} W NO17CIi 1'0 APPLICANT: 11,after making this Certificate of
- F Z nription,you should become subject to The Workers'Compensalion APPLIANCE 4.00 PLAN CHECK
prbvisiunz ul' the Lu
hor Code, you ,Cast forthwith comply will, FEE
U such pnwisiuit,or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10/JODC.F.M.) 3.00
CONSTRUCT ION� LENDING AGENCY AIR HANDLING UNITIOVER 10,o00C.F.M.) 5.00 SEISMIC FEE /f�V I hereby m'I'irn, that there is a construction landing agency tar EXHAUST HOOD(WITH DUCT) 2.00 _ -
Ihe Pcrorniance ret the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 4.00 MICROFILM
1007,Cie.C.). -
' Lc,nder Name
Lender w address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I-
I certify Tim Dave read This application and state that The above41BOILEIR-COMP
NTILATION FAN (SINGLE) 3.00
iNimnart.. is correct I agree to
comply with all city and county PLUMBING
ordinances and state laws relating to building construction, andLE -COMP H.P.or 100,000 B.T.U.) 4.00
hereby authorise representatives of this city to enter upon the
lover too.aoO RruI SEE FEE SCH. MECHANICAL
above-menlioneJ property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City ofSC.- REFER TO ORD.
Cupertino against liabilities,ju meats, casts and expenses which CON ST.TAX
may in any Way ace agai t said City in consequence of The
PERMIT ISSUANCE 3.00
gra0 this perm MECH.CONT. LIC.NO. MECH. `
TOTAL TOTAL ,(,p/ / v
/ Sign' are of sea onlmcm Date/
It INSPECTOR COPY