6021 f
PLICANT TO FILL IN INFORP 'TION WITHIN RED LINES - USE BA POINT PEN ONLY
, ' BUILDING PROJECT IDENTIFICATIO PERMIT NUMBER
DING APPLICATION & PERMIT6 21
RESS10 BUILDING—ELECTRICAL—PLUMBING—MECHANICALER5PLAN CHECK VALIDATION
QTY. ELECTRIC PERMIT FEE
P«oxE -TRACTORS UTLETS-SWITCHES-RECEP 5.00/1.00
EUc.NO.' LIGHTING FIXTURES 5.00/1.00HE sTORS PPLIANCES-RESIDENTIAL 4.00
PHONE PANELS 5.00 DATE OF.APPLICATION
HITECT SIGNS - B.00 PLAN CHECK FEE .C.NO.
A 11INEERuc.No. ' SIGNS TRANS.. 3.00 Is Taess ENG. SPECIAL CIRCUIT '5.00 •I(,1 1 PERMIT VALIDATION -
zIF TEMP.METER OR POLE INS. 15.95
ADDRES Nrs MOTORS .:' SEE FEE SCH.
ADDRESS pP,l Lln
' SERVICECHANGE oWly
a0 o LICENSED CONTRACTORS DECLARATION /y /��•
¢u I hereby affirm that Ivan licensed under provisions of Chapter 9 - ISSUANCE DATE
t. a i Icommrncing with Section 70001 of Division 3 of the Business and BLDG. ELECT. PLG. MECH,
H N i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
j Z o m — License Class Lic.Number
9 r Dam Contractor
lay 5 • - .. BUILDING PERMIT
¢ ¢w¢ OWNFR-BUILDER DECLARATION FORMATION
s6 Owe' MISC.— REFER TO ORD
1 w ; LL n 1 hereby affirm that I am exempt from the Contracror's License � N S/FT.
ii .,_ Lov for the following reason.(Sec.7031.5,Bnjeestand Professions PERMIT ISSUANCE 6.00
J~ wv, Code'.Any city or county which requires a permit to conslruet;aBcr, qq
2¢Q improve,Jcinolish,or repair any structure,prior to its issuance,alw ELEC.CONTR. .LIC.NO. ELEC. i R 't�t
— DLL requires rhe applicant for such permit to fih n signed statement that TOTAL PERMIT TO
w$ he N licensed pursuant to the provisions of the Contractor's License
Law(Chapter 9(commencing with Section]00001'Division 3 ofthe ANT OQC
—< Bu iness and Professimrs Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r o the basis for the alleged exemption.Any violation of Section 7031.5 L1111TUAIM TYPE CONSTR.
La by any applicant for a permit subjects the applicant toa civil penally ALTER-DRAIN&VENT-WATER (EA.) 4.00
of not more than five hundred dollars(S50i
❑ I,as owner of the property,or my employers with wages as BACK FLOW PROTECT.DEVICE 2.00 OCCGROUP RES.UNITS
their vale compensation,will do the work,and tire .e structure is not . .
intended to-,ffered for sale (Sec. 7044, Business and Prefessions DRAINS-FLOOR,ROOF,AREA,COND. 4.00
Code:The Contractor's Licensc law docs not apply,to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 S 1 FT.FLOGR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ment,am"at intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC-4 OUTLETS 4.00
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 did not build or ice RES IND CON PB Omer
pro a for purpose ofsalc.). INDUSTRIAL WASTE INTER. 20.00 -
Lx^ I,as owner of the properly,am exclusively contracting with El El El ❑ El sv�d amltrecton to conxtruet Ilse project(Sec.7044,Business. LAWN SPRINKLERS-1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Profssions CmI T'he Contractor's License Law does not apply
to an owner of properly who builds or improvr,s thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a Contractoslsl licensed pursuant to
[tic Contractor's License'Law. - - . SEWER-SANITARY-STORM EA.200ft/8.00 TRACTN0. PARCEL NO.
❑ 'I umcxcmplunder Sc ,B.&I'.C.for this
reason WATER HEATER W/VENT 4.00
f Owner_ - Date . WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKERS'CON NSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby u Ifion (far l leve cudilicatc ofconsent losell'-insure, ZONING ENG.SITE NQ
or a certhwale of Workers'Compensation Insurance,or a evrti OeJ _ ,
copy thereof ISea.3800,lab C.).
Policy Nn. Company
❑ Curti fled copy is hereby furnished. FIRESPRINK ENERGY T-N
Z Z ❑ Certilled copy is filed with Ibe city inspection division. MISC.- REFER TO ORD.
O Applicant v ❑ N❑ Y ❑ N❑
Xy CER'I'IFICATIi OE EXEMPTION FROM WORKERS' PERMIT ISSUANCE 6.D0 PLODD ZONE A.L.U.0
LU > COMPENSATION INSURANCE PLG.CONTE. LIC.NO. PLG.
CL 1 This w,lum need net be completed if (lie permit is for one TOTAL Y❑ IN v❑ N❑
0 Z hundred dollarsO 100)or less.) '
U O 1 certify that In the performance of the work for which this per. CITY. MECHANICAL PERMIT FEE FEE SUMMARY
LL I— mit is issued,I shall nut employ any person in any manner so as to
V become subject to tire m
e Wkeri Com ation Laws of California. /L
pers —
' U,y Dmc Applicants ALTER OR ADD TO MECH. 4.00 BUILDING
} to NOTICE 'TO APPLICANT: If,after making the Certificate of Ex-
�, Z_ cmptioq you should become subject to the Workeri Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the labor Code, you must forthwith comply with FEE
U %rich provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10SMC.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.M.) 5.00 SEISMIC FEE
m O�
.I hereby affirthat there it a construction lending agency for EXHAUST HOOD (WITH DUCT) 2.00
the permrmance of the-work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 700,000 B.T.U.) 4.00 -
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)7.50
Lender's Address ELECTRIC
I certify that I have read his application and state that the above VENTILATION FAN ISI NGLEI 3,00
information is correct. I airier,to comply with all.city and county , PLUMBING
oalumnees and state lows Fclaim, to building construction, and B0ILER-ODW(3H.P.or100,000B.T.U.) 4.00
hereby authorize mpmxatatives of the city to.Crier upon the BOILER-COMP (ONr 100,000 BTU)SEE FEE SCH. MECHANICAL
above mentiorsed properly for inspection perfuses.
(We)'agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against,liabilities,judgments, costs and e,ter.which CONST.TAX
may in any way accrue a ainst acid City in Consequence of the - PERMIT ISSUANCE 3.00
A��Cfhcsmingof lpe MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL �SigA lis Contractor Date
OFFICE COPY
CITY OF CUPERTINO INSPECTION RECORD
(OFFICE COM1
UVNER
PERMIT ISSUED DATE ELECTRICAL DATE INSP.
ui in
ectrica
Plumbing Power Pole
Mechanicai I er ouncl
e as ec o!gWiring
o arlVaiis
Fire Sprinkler Ceiling
i ixtures int/Ext
Motors
Misc. rounding
e ower
Other
FINAL INSPECTIONS DATE INSP. Not ApproveT
Gas
Electric _
Plumbing PLUMBING DATE INSP.
Mechanicai
,Solar Backflow
)o r un
gra an er oor
Planning arta o
ire Dept. ou ete
Health Dept. arRou
buliding Water *4 insulation
Other Main .Urain
oDrain
ELS
Other
BUILDING DATE INSP, Not rove
Pad Certification
oun ation ELECTRICAL DA'L'E INSP,
re- unite
Slab-Membrane Underfloor S.M.
Bond am cts nsu ation /,;I-d 6
Ma—r oor GirdersFjre aceers
Floor ire
ie Towns Grease Duct o0
is rams e our a t
eismec J3Ing _ 1Z7p, oonndensate Drain
IT s- ane s Equipment Anchorage -'
rame Fiues 4 Comb. r
Lath Ot er
a oar Int/Ext. ofrove
ire"aiis
er
Not Approved