1048 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ON
All, BUILDIING PROJECT IDENTIFICATION P UMBER
, aDILDING APPLICATION & PERMIT 1i5l 048
[BULDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME CITY. ELECTRIC PERMIT FEE
HONE
II N NrRgcraR '/ �j� f� / UTLETS-SWITCHES-RECEP 5.00/1.00 O
G!/ Ia NoX(� 11� LIGHTING FIXTURES 5.00/1.00
XCONTRACTORS PPLIANCES-RESIDENTIAL 4.00
gO0RE55 vj
'-4 E 9 `� PANELS 5.00 DATE OF APPLICATION
ARCHITECT PLAN CHECIZ77 D.C.NO. ,
OR SIGNS 6.00 -
ENGINEER
I. IIIc.No. SIGNS TRANS. 3.00
noo ess ENG' SPECIALCIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00 -
APPLICANT s
ADDRESS MOTORS SEE FEE SCH.
' SERVICE CHANGE 10.000.00 '
w o O- LICENSED CONTRACTORS DECLARATION -
0 y 1 hereby affirm that 1 am licensed under provisions of Chapter 9 �UPLH IINO ISSUANCE DATE
1°JN`y (commencing with Section 7000)of Division 3 of the Business and
G a BLDG. ELECT. PLG. MECH.
t., o z Professions Code, d my license is in full far of ❑ ❑ ❑
o i,h, o Licc Cs Lic.Numher
2 w h j Eat Contract.,
a Y Will
BUILDING PERMIT
i o a o OWNER-BUILDER DECLARA ON INFORMATION
X ; I- I hereby affirm that I am exempt from the Contractors License MISC.- ER TO ORD
VALUATION
F Ia0 w J Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 6.00 ✓
yt m° Code:Any cit y or court t y which requires a perm i l to Construct,al le r, 1<9 QDO
2 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONED. LIC.NO. ELEC.IS 0
i E I] a requires the applicant for such permit to file a signed statement that TOTAL CK- PERMIT TO -
X w he is licensed pursuant to the provisions of the Contractor's License '
Fi > Law(Chapter 9(commencingwith Section 7000)of Division 3 of the 9
i 9 ao Business and Professions Code)or Dist he is exempt therefrom and OTY. PLUMBING PERMIT FEE
s_$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
y � of not ore than fora uncle dollar,
lite applicant too ClVII penalty ALTER-DRAIN -WATER (EA.) 4.00 Ua / �/} W
of not more than flue hundred dollars lite ap.1', �^�` �I�"P'�I�S
❑ I,as owner of the property,or my employees wish wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AR EA,COND. 4.00 ��Z
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 4.00 & SO.FT.FLOOR AREA TOTAL ACREAGE
rents are not hrough
ownemployees,for sale.
If,however,
the
improve- GAS-EA.SYSTEM-I 4.00
nests are not intended or offered for sale.If,ed that s the building 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 slid not build or im. x
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 RES 'IND Cglry PB Other
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ � ❑ ❑
licensed contractors to Construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 5.00 g5$ESSORSPAPLELNO.-
and Professions Code:The Com act.r'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 cemtructogs)licensed pu ,tmnl to SEWER-SANITARY-STORM EA.200ft/6.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ l am exempt under Sec. ,B.&P.C.1'o,this
reason WATER HEATER WIVENT 4.00
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP, 4.00 et
I hereby affirm that I have 3 certificate ofcoosenl R,self-insure, ZONING. ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy they f ec.3800,Lab CA,
Polic N q a
0 ❑yCerf f�OdT141 B r C . FIRESPRINK ENERGY T 24
Z 2 ❑ Certif d cop tied wi [it cit inspe tion division.
O Applicant syil�� MISC.. REFER TO ORD. Y ❑ N❑„ Y ❑ No
X T CER-1'IFICATE OF BXEMPTIO, FROM WORKERS' PERMIT ISSUANCE 6.00 sly, FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG,
0- Z Y( This section need not be completed if the petit is for one TOTAL 3(T/4O Y ElN❑ Y ❑ N❑
hundred dollars(81001 or ICSa.)
U O I certify that in the performance of the work for which this per- OTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL f mil is issued. I shall not employ any person in any manner so as to
O W L become subject to the Workers'Compensation Laws of California.
y
Date-Applicant ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE TO APPLICANT: IL,'after making this Certificate of Ex
I,. Z amp mm,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
L.1 such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1I C.F.M.) 5.00 SEISMIC'FEE t�
I hereby affirmthat there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
(be performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie.C.). - HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATI NG UNIT(OV ER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I"have read this application and state that the above VENTILATION FAN (SINGLE) 3.00 -
Information is 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 slate laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEESCH. MECHANICAL
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 CONST.TAX
BI min any way scene, against said City in consequence of the '
granting Dill pertpit. //y� MECH.CONT, LIC.NO. MECH.
1. TOTAL TOTAL
ignatu of pplicant/C for Ua[e OO
OFFICE COPY
GIFY 01' CUPERTINO I11SPYGTIOL' RECORD (Office .Copy)
1048 20445 Pacifica Dr.
PintiT N0. SANITARY DIST. 110. LOT PLO. ADDRESS ---
rRemodel Interior Rudolph Dittrich
PROJECT OWNER JOB SITE PIIONE NO.
PERMIT ISSUED Date ELECTRICAL
Buil dine 9-11-81 Date Insp.
Electrical 9-11-81 Power Pole
Plumhinr 9-11-81 Under ground
NechanLcal Rou ,h Wiring
'Temp. Gas/Elect. Halls
Solar Ceiling
Fire Sprinkler Fixtures Int/Ext
Sign (rotors
Grounding
hist. Temp. Power
Other
FINAL. INSPECTIONS Not Approved
Date Insp.
Ge.s _
PLUMBING
Electric - Date Insp.
Plumbing Backflow
Ile.chanical Underground
Solar Underfloor
Ponl Partial Rough
Grading Rough Complete
PLanning Solar Rough
Fire Dept. Plater & Insulation '
Health Dept. Main Drain
Building R/of/S Drain
Other Gas
Other
BUILDING Not Approved
Date Insp.
('ad Certification MECHANICAL
Foundation Date Insp.
Pre-Gunite Underfloor S.M.
Slab-rlembrane Ducts & Insulation
Bond Beam Fire Dampers
Underfloor Girders Fireplace
` Floor Steel Grease Duct & hood
Tiedowns One Hour Shaft
Diaphrams --
n Condensate Drain
Seismic Bracing Equipment Anchorage
Ual.ls-Vanels Flues & Comb. Air
Frame i//,� Other
Lath Not Approved
11allboards Int/Ext.
Firewalls
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
t�
11ECHMICAL
J
1
MISCELLANEOUS