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APPLICANT -TO FILL IN-INFORMATION'WITHIN RED LINES -'USE BALL POINT PEN ONLY.
BUI LDI NG PROJECT I DENTI F ONP
BUILDING APPLICATION & I VI IT
ADDRESS
BUILDING -ELECTRICAL- PLUMBING-,MECHANICA
(P 6i 115VkD 177-
IT NUM8ER
3 3 7
PLAN CHECK VALIDATION
'y'�--J�/G
v a i
OWNER'S -
�yi\A\ME YP�'�QQ � j��i QTY. ELECTRIC PERMIT FEE,
V ,, rEtTS L A'L;> PHONE 01201��/
coNrRAcroRs
OUTLETS - SWITCHES -RECEP 5.00/1.00 -•
ILIGHTING'FIXT,URES 5.00/1.00
LIC. NO.
DATE OF APPLICATION
CONTRACTORS t -
ADDRESS yy
1 e/W '66F E�% PHONF�(I- 4S.SO
PPLIANCES`-RESIDENTIAL '' 4.00
PANELS 5.00
ARCHITECT
OR • _.
SIGNS'. 6.00
-PLAN CHECK FEE
P.C. NO.
'
ENGINEER
LIC. NO.
SIGNS TRANS. 3.00 -
ARCH. OR ENG.
ADDRESS
ZIP
SPECIAL -CIRCUIT 5.00
-PERMIT VALIDATION
l
PADDRESS
P.
TEMP. METER OR POLE INS p15.00
APPLICANTS
MOTORS SEE, FEE SCH.
SERVICE CHANGE '
NN 11 �C) �1
ISSUANCE DATE
LICENSED CONTRACTORS DECLARATION
I"hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the'Business and
Professions Code, ty license is in full fors e(GeLt
License Class ( Cic. Number LG J V
q
Date Contractor j�rZ'%
It of Cupertino-
BLDG.
2
ELECT. PLG.
1 "t 11 .1
MECH-
O
BUILDING PERMIT
INFORMATION
OWNER -BUILDER DECLARATION -
I hereby affirm [hat I am exempt from the Contractor's License
Law for the following reason. (Sec. 7.031.5, Businessand Professions
Code: Any city or county which requires a permit to construct, alter,
improve, demolish, or repair any structure, prior to its issuance, also
- D
MISC. REFER TO OR
PERMIT ISSUANCE 6.00 �
-
VALUATION
/
SIFT.
ELEC. CONTR. LIC. NO.
ELEC.
requires the applicant for such permit to file a Signed Statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter -9 (cornmencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and
-
TOTAL d
RMIT TO P:l-! 7
E 7,
O G
QTY. PLUMBING PERMIT FEE
STORIES -
TYPE CONSTR.
/V-1 --
the basis for the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penally
of not more than five hundred dollars (5500).):
ALTER -DRAIN &VENT -WATER (EA.) 4.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work; and the structure is not
BACK FLOW PROTECT. DEVICE 2.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF; AREA,COND. 4.00
intended or offered for sale (Sec. 7044, Business and Professions-
Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
ments are not intended or offered for sale. If, however, the building
FIXTURES - PER TRAP 4.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
GAS - EA. SYSTEM -.1. INC. 4 OUTLETS 4.00
or improvement is sold within one year of completion, the owner-
builder will -have the burden of proving that he did not build or im-
.prove for purpose of sale.).
❑ I, as owner of the property, am exclusively. contracting.with
GAS - EA. SYSTEM -OVER 4 (EA.) 100
.
BUILDING USE
RES IND' CON: PB Other
1:1 1:1El❑ ❑
INDUSTRIAL WASTE INTER. 20.00
licensed contractors to construct the project (Sec. 7044, Business
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 - 1 INC'5 V.B. 5.00
ASSESSORS PARCEL NO.
/
LAWN SPRINKLERS -OVER 5 (EA.) 1.00
contracts for such projects with a contractor(s) licensed pursuant to
the Contractor's License Law.
SEWER -SANITARY -STORM, ft/8.00
.
TRACT NO.
PARCEL NO.
❑ 1 am exempt under Sec. B.&P.C., for this.
reason
Date Owner
WATER HEATER W/V ENT
WATER SYSTEM •
ACC. DATE.
ACC. FILE NO.
WATER TREATING EQUIP, 4x00
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure.
or a certificate of Workers' Compensation Insurance, or a certified
(y O
-ZONING
- ,
ENG. SITE NO.
CIO
L ' 6 d
copy thereof (Sec. 3800, Lab.C.): /�
Policy No. Company �/ VIII&P
'--•
FIRE SPRINK
Y N❑
ENERGY T-24
Y ❑ N❑
0cer,ified copy " er y furnished.
Cert if' co led 1V tthh the city inspection division.
Applicant
MISC. REFER TO ORD.
C RTIFICATE OF EXEMPTION FROM WORKERS_'
'PERMIT ISSUANCE 6.00
FL000 ZONE
A.L.U.C.
COMPENSATION INSURANCE-
(This section need not be completed if the permit is for one
Y ❑ N ❑
Y ❑ N ❑
PLG.CONTR. 'LIC. NO.
pLQ.. CV
TOTAL �p
hundredars (S 100) or less.)
I certif t a rformance of the rich this per-
Mil is issued, I shall not em son in any manner so as to
become subject to the Wompens. n ws of California.
Date pplicant
NOTIgR-F APPLICANT: If, after making this Certificate of Ex-
emption, you sltbuld become subject to the Workers' Compensation
provisions of [he Labor .Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked. •
OTY. MECHANICAL PERMIT 'FEE
FEE SUMMARY
BUILDING
/a'p—rD
ALTER OR ADD TO MECH. 4.00 t90
APPLIANCE Ip4.00
AIR HANDLING UNIT"(TO 10,000C.F.M.) 3.00
PLAN CHECK
FEE
AIR.HANDLINGUNIT (OVER )
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097,Civ.C.). . �iJ —
Lender's Name ''
Lender's Address
I certify that I have read this application and stale that the above
EXHAUST HOOD (WITH DUCT) 2.00
MICROFILM
HEATING UNIT (TO 100,0 • u e� O
HEATING UNIT (OVER 100,0 0 B.T.U.P.50'
ELECTRIC
�D
VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and county
ordinances and state laws relating to building construction, and
PLUMBING
OTJ
BOILER-COMP(3 H.P,or 100,000 B.T_U.) 4.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MECHANICAL
BOILER -COMP (Over 100,000 BTU) SEE FEE SCH.
(We) agree to save; indemnify and keep harmless the City of
Cupertino against liabili ies, judgments, costs and'expenses which
y' ecru against said 'City in consequence of. the
gr,.fp Of his nni •"
-
7N,
MISC. - REFER TO ORD.
CONST. TAX
.
-
PERMIT ISSUANCE 3.00
MECH..CONT. LIC. NO.
MECH. -
TOTAL 7 .Q V
TOTAL-Z-'�•
gal re o plicant/Contractor Date
,
OFFICE COPY
C I T Y O F C U P E R T I N 0
Building Division
PROJECT
CONTROL #7�
ADDRESS (,6
L° tiF,-v� D GT
PERDET # 3r. 3
OWNER CT• ;5-Ax/�10
PHONE
-Oleo A.P.N. #
ADDRESS
SAN. #
REP.
PHONE
BLDG. TYPE
ARCHITECT
PHONE
OCC. GROUP
ADDRESS
REP.
PHONE
CONTRACTOR �S,cinl(��
pUC PHONE
LJJZJ VAL.j�I�j
ADDRESS
STRUCT_.PLAN CK
REP.
PHONE
tB DG..LAN.CK
3
PLAN CHECK HOURS
PERIIIT FEE
CAP FEE
z
CONST. TAX
ENERGY FEE
PUBLIC WORKS
I
MICRO FILM FEE
TOTAL FEES
lst. Submittal
2nd. Submittal
3rd. Submittal
DATE REC.
DATE REC.
* .DATE REC.
DATE REC.
* DATE REC.
DATE REC.
BLDG. DEPT.
--
ENG. DEPT.
tl
PLAN. DEPT.
STRUCT. ENG.
----
ENEP.GY
—
—
HEALTH DEPT.
--
SAN. DIST.
CENTRAL FIRE DIST.
HANDICAPPED
* A. - APPROVED
* N.A. - NOT APPROVED
r
3637
C.J J Y U1 UUJ'I'.1C11rW 114b1'1."Ulf r' Mhuurw (uL1ice uopyJ
_ .6664 Clifford Ct
PI:PJIIT NO. SANITARY DIST. 140. LOT NO. ADI)I:].SS
Swimming Pool Sunset Pool
PROJECT OWNER JOB SITE PHONE NO.
PERMIT ISSUED Date ELECTRICAL
Buildin Date ' Insp.
Fl.ectrical 11679 3
PIumhinr 3
]'ower Pole
Underground
llcchanical
Temp. Cas/Elect.
P'augh Fairing
halls
Solar
Ceiling
Fire Sprinkler
Fixtures Int/Ext
Sign
ilotors
]•fisc.
Grounding
Temp. Power
FINAL INSPECTIONS
Date Insp.
�,�..s _ -/5--f
Electric /-
Plumbing
Ifechanical
Solar
Pool - -�
Gradin
1'lannin
Fire Dept.
Health Dept.
Building
Other
BUILDING
Date Insp.
Pad Certification
Foundation
Pre-Gunite (�
Slab-Hembrane
Bond Ream
Underfloor Girders
Floor Steel
Tiedowns
Diaphrams
Seismic Bracing
Walls -Panels
Frame
La t
Uallboards Int/Ext.
Firewalls
Other
Not Approved
Other rZjje
Not A roved'z!!o w,
PLUMBING
Backflow
Underground
Underfloor
Partial Rough
Rough Complete
Solar Rough
Water & Insulation
Main Drain
R/of/S Drain
G s
Not Approved
MECHANICAL
Date Insp.
-�-
- /5---
MECHANICAL
5-=
Date
Underfloor S.M.
Insp.
Ducts & Insulation
Fire Dampers
Fireplace
Grease Duct & flood
_
One flour Shaft
_
Condensate Drain
_
Equipment Anchorage
Flues & Comb. Air
Other
Not Approved
BUILDING
ELECTRICAL
PLUMBING
MiECHANICAL•
MISCELLANEOUS
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