1659 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. `� BUILDING PROJECT IDENTIFICATION PERMIT NUMBE
BUILDING APPLICATION & PERMIT
ADDRESS C'
i �d�U �,(//off/ LN• BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 M9
WNERS
O ' t
NAME ^ - j ,' PLAN CHECK VALIDATION
Qni I> LL PHONE DTV. ELECTRIC PERMIT FEE
9ti X4,2.
CONNAAMTERacTDRs - OUTLETS-SWITCHES-PIECED 5.00/1.00
LIGHTING FIXTURES 5.00/1.00
... ADDREss TOR S/ APPLIANCES'-RESIDENTIAL 4.00
06 +•S /' ft IPANELS 5.00 DATE OF APPLICATION
ARCHITECTPLAN CHECK FEE P,C.NO.
OR 2_6->-7Zy8 SIGNS 6.00
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG, SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 n�
ADDRESS rS - MOTORS SEE FEE SCH. 1 ,/'�1 '
ADDRESS
./ SERVICE CHANGE. 10.00 /0 _0 - q _.
w O O LICENSED CONTRACTORS DECLARATION 3/d-S/b 2/
< u u 1 hereby affirm that I am licensed under provisions of Chapter 9
I" (commencing with Section 7000)of Division 3 of the Business and ISSUANCE DATE
v,a a BLDG. ELECT. PLG. MECH.
H y i Professions Code an n license is in full forG�,�n�j,�f y 7 ❑ ❑ ❑
,z 20L License Class_ d/-Lic.Number-3S-
Date Contractor
a y s BUILDING PERMIT
a a 'OWNER-BUILDER DECLARATION
F. o a D INFORMATION
X ; w 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
ruovs Law for the following reason. 7031.5,Businessand Professions pERMITISSUANCE 600 QO VALUATION $/FT.
Code:Any city or county which requires a permit to cons'no, ,iter. -
ee c¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC /Q�
O LL requires the applicant for such permit to file a signed statement that tee TOTA.L /(0 0 PERMITTO
n w$ he is licensed pursuant to lbe provisions of the Contractor's License
Hir
Law(Chapter 9(commencing will,Section 7000)of Division 3of the 6_640-C7s i o Business and Professions Code)or that he Is exempt thereliom and CITY. PLUMBING PERMIT FEE
I- the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
n 3 - 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(8500).):
❑ L as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
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
Code:The Contractor's License Law does riot apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 so.FT.FLOOR Afl EA
.cuts
re TOTAL ACREAGE
himselfthrough his own employees provided thus such improve. '
mem proveme intended within
on for salt.o(f,however,completion thebuildingo net- GAS-EA.SYSTEM 1 INCA OUTLETS 4,00
or improvement is sold within one year of completion,use owner- GAS-EA.SYSTEM-OVER 4 (EA.) 1.00 BUILDING USE
builder will have the burden of proving that he lid not build or im- RES IND CON PB Other
prove 1,asofor neeose of sale.)' INDUSTRIALWASTE INTER. 20.00 ❑ ❑ ❑ ❑ ❑
❑ d as owner of the property,he exclusively.704 , Bu with
licensed contractors Cod 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
1n an owner of property who builds or improves thcrcon,and who LAWN SPR( ERS-OVER 5(EA.) 1.00
contracts for such projects with a commelous)licensed pursuant to SEWER-SAN A.200ft/8.00
the Contractor's License Law. TRACT NO, PARCEL NO.
❑ I am exempt under Sec. It,&P.C.for lips WATER HEATER W/VE
reason 0 4.00
Dale Owner WATER SYS !) 4.00 ACC.OATE ACC.FILE NO.
WORK IiRS'COMPENSA'TION DECLARATION WATER TREATING EOUI 4.00
I hereby affirm that I have a certificate ofconstm to self-insure. ZONING ENG.
or a certificate of Workers'Compensation Insurance,or a certified SITE NO.
copy thereof(Sec.3800,Lah.C.l.
Policy No. Company
Q ❑ Candied copy is hereby furnished. FIRE SPRINK ENERGY T-ZO
Z Z ❑ Certified copy is filed with the city inspection division. MISC. REFER TO ORD.
O Applicant V❑ N❑ Y ❑• N❑
~ va PERMIT ISSUANCE 6.00
- CERTIFICATE OF EXEMPTION FROM WORKERS' FLOODZONE A.L.u.C.
W COMPENSATION INSURANCE PLG,CONTR, LIC.NO. PLG
CL CI (This section need not be completed if the permit is For one TOTAL v❑ N❑ Y❑ N❑
D Z hundred dollars IS 100)or less.)
U O 1 certify that in the performance o1'the work for which this per- OTY. - MECHANICAL PERMIT FEE FEE SUMMARY
LL f mit is issued,1 shell not emplo ny person in an manner so as ro
U heron sub'cyLtyJ7 e Workers C mpensnti n lilor -
a' Uate11"-,U icant ALTER OR ADD TO MECH. 4.00 BUILDING
N NOTICE TO APPLICANT: a ler making lois Certificate of Ex-
2 emption,you should becom Subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
L) such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC.F EE '
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) ,2.00
the.performance of the work for which.this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000'B.T.U.) 4.00
Lender's Name
Lender's Address HEATING UNIT 100,000 B.T.U.)7.50 ELECTRIC I C
110-
I
certify that l have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
ordina res n correct 1 agree to comply with all cloy and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 4.00 PLUMBING
AP ordinances and state lows relating'C to building l City and CO and
hereby authorize representatives of this city to*enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection puposes.
(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 CONST.TAX
in any way accrue against said City in consequence of the
R
ing of[his permit MECH.CONT. LIC.N0. MECH.
.-tel TOTAL TOTAL
Ruu of APPlican CI tactor Uote
OFFICE COPY
• CITY Or CUPERTI`iO INSPECTION RECORD (Office Copy)
1659 7810 Orion Lane
PEPd1IT i'O. Sl:NITARY DIST. NO. LOT ?i0. ADDRESS
Elect. Tom Dill 996-7362
PROJECT OUNER JOB SITE PHONE NO.
Date ELECTRICAL
Buildinv Date Insp .
Electrical 3-25-82 Power Pole
Plumbing Underground
Mechanical • P`ough 4iiring
Tev.D. Gas/Elect. halls
Solar Ceiling
Fire Sprinkler Fixtures Int/E::t
Sion iIotors
Grounding
Misc. Temp. Power
Other
FIPIAL INSPECTIONS Not Approved
Date Insp. —
z.s
Electric PLnIBING
Date Insp.
Plumb ins Backflow
ilechanical Underground
Solar Underfloor
Pool Partial P..ous-h
Plan
.
Gradin Rough Complete
FireDeepDt. Solar Rough
Pere Uater S Insulation
Health Deo t. ?Iain Drain _
Bueldeng R/of/S Drain
Other " 6- 2
OV 41Gas
Other
STRUCTUP A Not Approved
Date Insp.
Pad Certification. `IECY.ANICAL
Foundation
Pre-Gunetz Underfloor S .M. Date Insp.
Slab-?Iemorane Ducts 6 Insulation
Bond Beam Fire Damners
Underfloor Girders Fireplace
Floor Steel
Teedocros Grease Duct 6 Hood
Deaphrams One :lour Shaft
Condensate Drain
Seismic Bracing Equipment e AnchoraS
[?alls-Panels
Flues 6 Comb . Air
Frame Other
Lath Not Approved
iIallboaras Inc/Ext.
Firewalls
4POther
Not Approved
BUILDING
ANIL
ELECmRICAL
PLLMING
?IE CFL1??I C AL
iIISCELLANTOUS