13137 POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER
CITY ,OF CUPERTINO. — .'. 13137 ,
INSPECTION' DI-VISION
` C JOB INSPECTION'RECORD
/{�.,,(..�// 1' PERMITEXPI RATION _
JOB ADOR ESS I ��qq �✓��- ""£ G UNIT# 'LOT#
/ PERMIT EXPIRES IF WORKr
G IS NOT STARTED.WITHIN
+ OWNER.. /.} , •CONTRACTOR 0 ;
I PECTION . '"
` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
f BUILDING PROJECT IDENTIFICATION PERMITNUMBER
BUILOI APPLICATION & PERMIT
SS
4" ADDRE �j
/0- 1/1a-� gG,�J BUILDING - ELECTRICAL-PLUMBING-MECHANICAL 13137
OWNER'S 'i PLAN CHECKVALIDATION
NAME CITY: ,' ELECTRIC PERMIT FEE
ONE
CONTRACTOR'S
NE y/� UTLETS-SWITCHES-RECEP 10.00/1.00
L IC.NO, `/''�'L.0 LIGHTING FIXTURES 10.00/1.00,/(.) �
rorvTRgcroRs - APPLIANCES-RESIDENTIAL 4.00
ES �f Q
(� PHONE [7 PANELS 10.00 PATE OF APPLICATION
OARCHITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
ENGINEER - '
' LIC.No: SIGNS TRANS. 3.00
ARCH.OR
END' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Zip EMP.METER OR POLE INS. 20.00
ADORESS rs MOTORS SEE FEE SCH. n _
SERVICE CHANGE 20.00 G
H o D LICENSED CONTRACTORS DECLARATION
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSU(((ANCE DATE
(commencing with Section 7000)of Divisiort of a Bpsin and BLDG. ELECT. PLG. I.MECH.
i PrD(euions CoVs y license is in full fore -
z o D - License la li Lic.Number LC r ^
wI-w U51r - Contractor PSD - ❑ 'Q
r`
ISJ .f BUILDING PERMIT
Mtp w O NE -BUILDER DECLARATION
w ; n N 1 hereby affirm that I am exempt from the Contractor's License MISC.- - R€FER TO ORD INFORMATION
r a.o J Law for the following reason,(Sec.7031.5,Business and Professions PERMIT ISSUA .` 10.00 0 VALUATION $/FT.
� w� Code:Any city or county which requires a permit to construct,alter,
-
IF <0 improve,demolish,or repair any structure,prior to its issuance,also E .CON LIC C
i w m u requires the applicant for such permit to file a signed statement[hat TOTAL-l.T� PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License �' `�
r i Q Law(Chapter 9(commencing with Sect ion 7000)of Division 3 of t he' e-
2
f i. Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE IF
IS H m re basis for the alleged exemption.Any violation of Section 7031.5 - STORIES TYPE CONSTR.
A. ; - by any applicant for a permit subjects the applicant Holt civil penalty
ofnot more than five hundred dollars($500).)- - ALTER-DRAIN III VENT-WATER (EA.) 5.00
❑ I,as owner the property,or my employees with wages as
their sole compensation.will do Om work,and Ole structure is not BACK FLOW PROTECT. DEVICE, 4.00 UCC.GROUP RES.UNITS
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code: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 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-'
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00 "
or improvement is sold within one year of completion,the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- BUILDING USE
prove for purpose of sale.). 30.00 INDUSTRIAL WASTE INTER. RES IND CON PB Omar
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,IhlsineesLAWN SPRINKLERS-1 INC 5 V.B. 6.00 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 contractolts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft110.00
the Contractor's License Law. - TRACT NO. PARCEL NO.
❑. I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WOR KERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insura„ -
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy rereof(Sec.3800,Lab.CJ.
Policy No. Company
U tiGed opy is h eby furnishcd
Z Z rq Ce€rtif py II Ilh Ic c l division. - FIRE SPRINK ENERGY T24
O Applicant- MISC.- REFER TO ORD. Y❑ N❑ Y ❑ N❑
CC w CERTIFICATEOF F-XEMPI'ION 17ROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.C.
LU COMP17NSATION INSURANCE PLG.CONTH, LIC.NO, PLO,
IL 0 (This section need not be completed if the permit is for one TOTAL Y❑ N❑. Y,❑ N❑
Z hundred dollars IS 100)or IessJ - 'i
U O 1 certify that in the performance of the work for which this per- CITY'. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any manner It as Io
U W become subject to the Workers'Compensation Laws of California.
Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate nl lix-
F 2 emption,you should become subject to[he Workers'Compensalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
tileperformanceof the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name H EAT[NG U N IT(OV ER 100,000 B.T.U:SCH.
Lender's Address 'ELECTRIC
informationI certify that I have read this application and stale that the above VENTILATION FAN (SINGLE)
rdinanen correct. I agree to comply with all oily and county BOILER•OOMP(3 H.P.Dr 100,000 B.T.U.) PLUMBING
ordinances and erre laws tives of building construction, and -
above-hereby autioned representatives talives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEMECHANICAL
above-mentioned property for inspection purposes '
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TOCupertino against liabilities,judgmzff
proses whichPERMIT ISSUANCE CONST.TAX
may ' way accrue,againstuence o the
gr' m f this perm' . H.CONT. LIC.NO. MECH.
TOTAL TOTAL
-tel Signa[ o Applicant/Contract r Date
OF ICE COPY - -