6411 ' rA�tESS
ICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
UI LDI NG PROJECT I DENTI FICATION PERMIT NUMBER
BUILDING
APPLICATION & PERMIT . ^
re�U _ b
BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
a 411
PLAN CHECK VALIDATION
NAME 4Z333't� DTV. ELECTRIC PERMIT FEES
co TRACTORS IUTLETS-SWITCHES-RECEP 5.00/1,00 VV
NAME AA
je
uc.0 LIGHTING FIXTURES 5.00/1.00 MAY ..9 i4 i�
ADORES rolls ,` 19 r NA 6� APPLIANCES-RESIDENTIAL 4.00 {� ^{ p��ISQ�
�i 9 PHONE' PANELS - 5.00 C1sbdll=AUPWW' 0ION
ARCHlituTPLAN CHECK FEE P.C.NO.
OR
LIC.Na SIGNS TRANS. 3.00
ARCH.OR ENG. - SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDFIEas
zlr EMP.METER OR POLE INS. 15.00
APPLICANTS MOTORS SEE FEE SCH.ADDRESS
- SERVICE CHANGE 10.00 ' I
('dJC/
o'o LICIiNSI:D CONTRACTORS DECLARATION
¢ u U 1 hereby affirm that I am licensed under provisions of Chapter 9 - - E DATE
, a, (commencing with Section 7000)of Division 3 of the Rusinevs and
wi. Professions Code,and my license is in full fl LD ELE PLG. MECH.
z 0- - Licen.0 ss. _Lic bunsber ❑ ❑
'.�//(_Conlractn
owNF;R-BU I LDER DECLA RA'f1ON - "'IP�' B ILDINGPEION .
E ¢ U - INFORMATION
w 3 A N I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
U. Law Ior The following reieno(Sec.7031.5,Businessand Professions PERMIT ISSUANCE - VAWATION S/FT.
Code:A ny city or county which miluos a permit to const red,af". Cu 0 ��'00
Q.� < 0 improve;demolish,nr repair any structure,prior tO its LRuanlT,aISU ELEC.CONTR. - LIC.NO' ELEC.
DLL r quires the applicant for such permit lo,file a signed statement that TOTAL
d w m he is licensed pursuant to the provisions of the Contractor's Licen4
I- za
Law(Chapter 9(commencing with Section 7000)OfDivision 3 of the
ZED Rusincss and P...essions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT' FEE
¢ r the basis for the alleged'exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
sg _ by any apphcanl for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 4.00 -
of not more than five hundred dollars(5500).): -
❑'1,as owner of the pinpeny,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC:GROUP RES.UNITS
their sole compmnalmn,will do the work,and the structure is nal
intended or URcred for sok ss(Sec. 7044, Busineand Professions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:'rhe Cont ractur%License Law does not apply to an owner of
.. properly who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 4.00 - SG.FT FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such impor
ments are not intended oroffered'for sale.If,however.the building GAS-EA.SYSTEM-I INC.4 OUTLETS 4.00
or Impfovemc n is soW within one year of completion,the owner. GAS EASYSTEM-OVER 4 IEA.) 1.fX) BUILDING USE
builder will have the burden of proving that he did not build or im- - . REB IND CON PB Oma
r
prove for purpo.v:of sale.). INDUSTRIAL WASTE INTER. 20.00
0 1,as o of the property',am exclusively cuntrachug with E] El El. El- ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPR IN KLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contmelar's License Low does not apply
to an Owner o1'property who builds or improves thereon,and who LAWN SPRINKLERS-OV ER 5(EA.) 1.00
contracts for such projects with a conoactods)licensed pursuant to
the Contractor's Licenm,Lsw. 4 SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO. PARCEL NO.
❑ 1 am exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 4.00
reason
Owner Date WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKI:RS'CONIP17NSATION DECLARATION WATER TREATING EQUIP. 4.00
1 hamby uffiner that I have a certificate of consent to xnlf-insure, ZONING ENG.SITE NO.
or a certificate of Worker,Compensation Insurance,or a certified
dopy dmreof(Sec.3800.Lah f.)�.' '
Policy NO. Compulylla 7 "- A
-O ❑ Certified copy is hereby fton sFhcd. FIRE SPRINK ENERGY T 24
Z 2 U..Certified copy is ,tiled with the city inspection division. MISC.- REFER TO ORD, v N Y N
O Applicant _ ❑ ❑ ❑ No
~ wPERMIT ISSUANCE 6.00 FLOOD ZONE A.L:U.C. '
� > CIiRTI I'ICA'1'Ii 0171 AX IO ('INS FROM WORKERS'
W COh1Por be be ON INSURANCE PLG.CONTR. LIC.NO. PLG. ' Y❑ N❑ Y ❑ N❑�
Q This section need nut completed if the pern mit for one � TOTAL '
Z hundred dollars($100)or less.)
U O 1 certify that in the performance of the work for which this"", QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL P- mit is issued. I shall not employ any person in any manner so as to
O become subject to the Workers'Compen ation Laws of California. )
O w Dale A licant BUILDING
Ire ALTER,OR ADD TO MECH. 4.00
} y NO'I'ICF TO APPLICANT'. If,after making this Certificate of Ex-
F Z eruption,you should become subject to the Workers Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply' with FEE'
U such provisions or this permit shall be deemed revokeJ. AIR.HANDLING UNIT(TO 10=C.F.PA) 3.00
CoNs'fRUCIONLENUINGAGENCY AIRHANOLWGUNIT(OVER 10000C.F.M.) 5.00 SEISMIC FEE oS�
I hereby affirm that there is a construction lending agericy for .EXHAUST HOOD_ WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. r HEATING UNIT(TO 100.000 B.T.U.) 4.00
Lender,NamekAl�- HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC (�
Lender's Address
I ¢Nily that I have real This applicwion and state it,,,Ilio ubose VENTILATION FAN (SINGLE) 3.DO .
information u correct, I agree to comply volVall city unit county - PLUMBING
•' ordinances and sum laws relating to building'construction, and BOILER-CONP I3 H.P.or t00,0006.T.U.1 4.00
hereby authorize repro motives of (his city lO-enter Upon the g01 LER-COMP 1Over 100,000 BTUI SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify unit keep hornless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, Costs and expenses which CONST.TAX
may in any accrue against mid City in consequence of the PERMIT ISSUANCE 3.00
r m8 r, hi p nit, MECH.CONT. LIC.NO. MECH, TOTAL .
SI a m0 A licant omrect Date fH
-
OFFICE COPY '
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COPY)
FERN111 NO. ADDRESS 7 '
PERMIT ISSUED DATE ELECTRICAL DATE INSP.'
ui in
ctrica _
Plumbing Power Pole
Mechanicalr un
emP as ecoR!gh wiring
SolaraW lls
ire Sprinkler i in
b.ign Fi=res nt xt
tors
Misc. roue in
'I a ower
Other
FINAL INSPECTIONS DATE INSP. Not Approved
Gas
Electric
umin PME3ING DATE INSP.
49 f-
anica
•�o ar Backflow
fool Underund
Grading LMdertgi2oor
Plannin Partialu i
ire a t. i eu te
Health t. Solar
1 171
Water '& n5 ation
Other ain
oDrain
Gas
,Other
BUILDING DATE INSP. Not rove
Pad Certification
Foundation ELECTRICAL DATE INSP.
Pre-Gunite
Slab-M&mbrane Underfloor 'S.M.
Bond Beam Ducts & Insulation
Underfloor Girders Fire Dampers
Floor Steeli ace
ie owns Grease Duct oo
is rams One our Shaft
eismec Bracing Condensate Drain
WHI Ts--T ane s ui ffient Anc ora e
Frame Flues r
raa eft rFi —
� oar nt ct. of rove
Firewalls
Other
Net ApproTe
BUILDING
ELECTRICAL
PLUMBING
MECHANICAL
MISCELLANEOUS