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3576APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL_ POINT PEN ONLY ' BUILDINGPROJECT YIDENTIFIC I BUILDING APPLICATION &PEI f ADDft S D � BUILDING -ELECTRICAL- PLUMBING -MECHANICAL V - - �•-��-�--� PERM T NUMBER 7 3576 56 I U OWNER'S NAME p OT/Y. ELECTRIC PERMITFEE e;1M41r PHONE PLAN CHECK VALIDATION - NON TRACTOR'S /- y_/�,A�Ne- - 0,4P Luc. No. 1 OUTLETS-SWITCHES-RECEP 5.00/1-00 LIGHTING FIXTURES 5.00/1.00 DATE OF APPLICATION ,ONTRACTOR'S / AD /%RESS • S,P1*,, r ,oi r PHONE APPLIANCES - RESIDENTIAL 4.00 PANELS 5.00 ARCHITECT - OR ENGINEER LIC. NO. - SIGNS 6.00 PLAN CHECK FEE C NO. ` SIGNS TRANS. -3.00 AReH. OR ENG.SPECIAL ADDRESS CIRCUIT 5.00 PERMIT VALIDATION TEMP. METER OR POLE INS. 15.00 ZIP APPLICANT'S ADDRESS MOTORS, SEE FEE SCH. SERVICE CHANGE10.00 PAID '- woo ¢ U G N ¢ u r 7 Z o uN - Z w Q w 3 LL N LL o ¢ 2 ¢ - ¢ w m y r Z > ¢ ¢ r o a ; m ISSU BLDG. ELE MECH. ❑ ING PE INFORMATION LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bus' s'M Professions Code lie nse' is in full fort - License lass tC i Lic. Number Date - Contractor_ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5. Businessand Professions Code: Any city or county which requiresa permit to construct, alter, improve, demolish, or repair any structure, prior to its issuance, also 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 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption.. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant toacivil penalty of not more than five hundred dollars (5500).): r' - - - City of Cupertino MISC. - - REFER TO ORD VALU411YOUT tUp rTIIJ01T. . �• ✓e PERMIT ISSUANCE 6.00 e ELEC. CONTR, LIC. NO. ELEC. TOTAL PERMIT TO QTY. PLUMBING PERMIT FEE ST IES TYPE CONSTR. ALTER -DRAIN &VENT -WATER (E A.) 4.00 ❑ I, as owner of the property, or myemployees 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 buildingGAS FIXTURES - PER TRAP 4.00 SQ. FT. FLOOR AREA TOTAL ACREAGE - 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 h e did not build or im- prove for purpose of,sale.). I, as owner of the property, am exclusively contracting with as . . GAS - EASYSTEM -OVER 4 (EA.) 1,.00 BUILDING USE RES IND CON PB Other 1:1 El E] 1:1 1:1❑ INDUSTRIAL WASTE INTER. 20.00 licensed to construct the project ,(Sec. 7044, Business and Professions Code: The Contractor's License Law floes 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-STOR ft/B.00 TRACT NO. PARCEL NO. ❑ 1 am exempt under Sec.' B.&P.C. for this reason WATER HEATER W/VENT ' 4.00 Date Owner WATER SYSTEM 4. 0 ACC. DATE ACC: FILE NO. TREATG E 4.00 WORKERS' COMPENSATION DECLARATION-11-1WATER 0 Z Z O - W d O 0 Z U O . LL H U O W } C% hereby affirm that I have a ' ' sent to self -insure. or a cern tate gqJ�2�Wp� sensation In ura , or ruffed copy (See 360 ab. i1 Policy No. npa i C:e ❑ Certified co er furnist c . ❑ Certified 's• e to city 1.54n division. Applicant CERTIFICATE OFE TION FR WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (S 100) or less.) I certify that in We performance of the work for which this per- mit is issued, I shall not employ any person en any manner so as to become subject to the Workers' Compensation Laws of California. Date Applicant - 20NIN , O� - ENG. SITE NO. - FIRE SPRINK Y ❑ N❑ ENERGY T-24 Y ❑ N❑ , MISC. REFER TO ORD. PERMIT ISSUANCE 6.00 FLOOD ZONE Y ❑ N ❑ A. L. U.C. Y ❑ - N ❑ PLG. CONTR. LIC. NO. - PLG. / F TOTAL Q QTY. MECHANICAL PERMIT FEE FEE SUMMARY BUILDING NOTICE TO APPLICANT: If, after making this Certificate of Ex- APPLIANCE 4.00 PLAN CHECK emption, you should become subject to the Workers' Compensation - C) provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked.' FEE AIR HANDLING UNIT (TO 10=C.F.M.) 3.00 AIR HANDLING UNIT(OVER 10=1C.F.M.) 5.00 SEISMIC FEE CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DA -1.02.00 the performance of -the work for which this permit is issued (Sec. 3097; Civ.C.). MICROFILM - HEATING UNIT ITO 100,000 B,T.U.) 4,00 Lender's Name f�/h/'��� Lender's Address _ HEATINGUNIT(OVER , 0 ELECTRIC U �V 1 certify that I have read this.application and state that the above information is correct. I agree to comply with ' I city and county ordinances and state laws relating to buildi' .construction, and VENTILATION FAN (SINGLE) 3.00 PLUMBING �_ 0 BOILER-COMP(3H.P.or1 par Rf� BOI LER-COMP (Over 100,000 BTU) SEE FEE SCH. MECHANICAL hereby authorize representat'v s of this c' to enter upon the above -menti d pro or ins p poses. MISC. - REFER TO ORD. (we) e t indem and p harmless the.City of Cupert' a' abilities, ' gmen co t and,expenses which3 may - ny accrue a st s ' City . consequence of the CONST. TAX PERMIT ISSUANCE 3.00 _ - • gra I O rntit• MECH. CONT. LIC. -NO. MECH. TOTAL- TOTAL '77 04 i ur Date T- v OFFICE DOPY -C I T Y O F C U P E R T I N-0 Building Division PROJECT ' ADDRESS lo�e"T/ Oti TIT Cyst-*�-t�•� ADDRESS REP. ARCHITECT ADDRESS REP. CONTRACTOR �aQ ADDRESS REP. PLP24 CHECK HOURS � � J,-,, ( fz .�a 2 J PHONE 773 PHONE PHONE PHONE PHONE PHONE CONTROL N PFR? IT N 5 7(0 A.P.N. # Ski, # BLDG. TYPE OCC. GROUP VAL. $ e„5 eTO. STRUCT.PLAN CK ,fibo S/.7 -P3 BLDG.PLAN.CK 0�8 PERMIT FEE 7 T CAP FEE CONST. TAX ENERGY FEE PUBLIC WORKS MICRO FILM FEE TOTAL FEES 93 �a lst. Submittal 2nd. Submittal 3rd. Submittal DATE REC. DATE REC. * .DATE-REC. DATE REC. * DATE REC. DATE REC. BLDG. DEPT. ENG. DEPT. PLAN. DEPT. STRUCT. ENG. -- ENERGY HEALTH DEPT. - SAN. DIST. CENTRAL FIRE DIST. HANDICAPPED * A. - APPROVED * N.A. - NOT APPROVED +' CYFy OF :RTINO I11SPL:CTI011 RECORD (Off ice .)Copy) 3576 _ _ 10651 Castin.e--- Ave ... --- P[:P1II'r NO. SANITARY DIST. 110. LOT NO.. ADI)Ia:SS Sp_a _ Chuck Kinklen 773-0442 PROJECT OIINER JOB SITE PHONE NO. PERMIT ISSUED Date ELECTRICAL Rill dinr _ I Date I Insp. IIcchan>_cai hemp. G1s/Elect. _ Solar Fire Sprinkler Sign r, r s Date Insp. Flectric Plumbing Mechanical Solar Pool Gradin Plannin Fire Dept. Health Dept. Building Other ' BUILDING Date 1'ad Certification Insp. Foundation Pre-Gunite Slab -Membrane Bond Beam Underfloor Girders Floor Steel Tiedowns Diaphrams Seismic Bracing flails -Panels Frame Lnth llallboards Int/Ext. Firewalls Other Not Approved Underground _ Rough Wiring hails Ceiling Fixtures Int/Ext Hotors Grounding Temp. Power _ Other Not Approved PLUMBING Date Backflow Insp. Underground & Underfloor Partial Rough Rough Complete Solar Rough Water & Insulation Main Drain R/of/S Drain _ Gas 3 Other Not Approved MECHANICAL Date Underfloor S.M. Insp. Ducts & Insulation Fire Dampers Fireplace Grease Duct & Hood One (lour Shaft Condensate Drain _ Equipment Anchorage Flues & Comb. Air Other Not Approved �~ \ • •j ^' BUILDING ELECTRICAL PLUMBING 11ECHANICAL MISCELLANEOUS