16271 A-PPLICANT TO FILL IN INFORMATION WITHIN ,RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON 'PERMITNUMBER
BUILDING APPLICATION & PERMIT
ADDRESS �71 a^. 1 (�+I U 1 1
Z BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
c� /y)_"� l OTY. ELECTRIC PERMIT FEE
C� V�
va IMCT n•/ I y(y PHONE
NAME R
CONTRACTORS
NAME _ OUTLETS-SWITCHES-PIECED 10.00/1.00
L_L R-'�� uC,ND. �'O(C776S LIGHTING FIXTURES 10.00/1.00
CONTRACTORS
ADDRESS� f PPLIANCES-RESIDENTIAL 4.00 N 2��y�-- v1ioNE'Z7 -�13 PANELS 10.00
DATE OF APPLICATION
ogcHITECT - PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.O.NO,
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ADDRESS ENG SPECIALCIRCUIT 5,00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20.00
ADDRESS
APvucANr's MOTORS ' SEE FEE SCH.
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION U
tr u w I hereby affirm that I am licensed under provisions of Chair 9
Q Z y p Chapter ISSUANCE DATE
vs Q y (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N z Professions Code,and utlicense is in full for4&,%S
(� ❑ ❑ ❑
o0 w o License Cl u S C_-Z� Cie Nmnber v11
0 m j -Coniractor_1A� s�Q - �
Q w a OWNER-BUILDER D17CLARATION
BUILDING PERMIT
o A U INFORMATION
w ; m I hereby affrn that [.am exempt from the Contractor's License. MISC.- REFER TO ORD
F u. m v, Law Ior the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE 10.00 VALUATION S/FT.
vs0 Code:Any city orcounly which requires a permit o construct,alter.
Q 0 Improve,demolish,or repair any stmeture,prior to its issuance,also ELEC.CONTR. LIC.NO.
n ELEC. -
wD LL requires the applicant for such permit to file a signed statement that TOTAL
m he is licensed pursuant to the provisions of the Contractors License PERMITTO _
zi Law(Chapter 9(commencing with Section 7000)of Division 3 ofihe
4 o Business and Professions Code)or that he is exempt therefrom and QTY- PLUMBING PERMIT FEE
H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR..
a_ by any applicant for a permit Subjectsre Oro applicant to a Civil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not mothan five hundred dollars(8500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the Structure is not OCC.GROUP RES.UNITS
intended or offered for sale (Sec 7044. Business and ProfessionsDRAINS-FLOOR,ROOF,AREA,GOND. 5.00
Code The Contractor's License Law does not apply to an owner of
property who throuhhis ds rimproves employees,
proviand who does sucl1, IIWUrk FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedoroffered for sale.IL however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one your of cc opletion.life owner- GAS-EASYSTEM OVER 4(EA) 2.00
builder will have the burden of proving that he did not build or un- . - .
BUILDING USE
prove for purpose ofsalc)' INDUSTRIAL WASTE INTER. 30.00 RES IND CON PB Omer
❑ I,as owner of the property,um exclusively contracting with
licensed Contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ' ' ASSESSORS PARCEL NO.
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-OVER 5 (EA.) 1.00
contracts for such projects with a contractods)licensedpursuantto
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT No. PARCEL NO.
❑ lam exempt under Sea ,It.&P.C.for this
reason WATER HEATER W/VENT 6.00
Owner Uate- WATER SYSTEM 5.00 ACC.DATE 'ACC.FILE NO.
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby allirm that I have a certificate of consent to self-insure,Or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy theresffSec.3800,Lab.C.). (],.
I'Dlisy No. Company
O �� Certified copy is hereby famished. RE SPRINK ENERGY T
Z Z Certified copy is fled with the city inspection division. 24
♦•- O Applicant M 4 MISC.- REFER TO ORD. 'Y El N 1:1Y ❑ NEI
C
CCERTIFICATE 01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U.O.
LU > COMPI!NSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
Il O (Phis seetidn need not be complcfed if the permit is for one TOT Y E] NE] Y [3 NE]
:3 Z hundred dollars l$100)nr less.)
U O I certify that in the performance of the work for which this per-
CITY MECHANICAL PERMIT �jEE' FEE SUMMARY
LL U mit is issued,1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws of California. J
0. Date Applicant ALTER OR ADD TO MECH. ILDING
} w NOTICE: TO APPLICANT': If,after slaking this Certificate of Ex-
Z emptinn,YOU should become subject to the Workers'Compensation APPLIANCE 5e4% PLAN CHECK
U suehslrovs onstlhe Labor Code, you most forthwith comply with FEE
p permit shat[be deemed revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4. 0
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=11F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a cmutructinn lending agency tie EXHAUST HOOD (WITH DUCT) 5.00
The performance of the work for which this permit is issued(Sea MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UN IT(OVER 100,000 B.T.U.)9.50ELECTRIC
I certify I,,,I have read this application and She that the above VENTILATION FAN (SINGLE) 4.00
information is correct, 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorise representatives ins of This city to enter upon the BOI LER-COMP IOver 100,000 BTU)SEE FEE SCH. 30 d-e
about-mentioned property for inspection purposes. MECHANICAL •_
(We) agree to save, indemnify and keep Glumness the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way averre against said City in consequence of the PERMIT ISSUANCE -ULDO a
•ranting of this permit, MECH.CONT. . LIC.NO. MECH.
TOTAL,3 C) TOTAL
Signature of Applicant Contractor Date
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
- rEVMiT NUMBER
CITY OF CUPERTINO 16271
INSPECTION DIVISION
JOB INSPECTION RECORD
// P�TME.I�-C�-�'✓O / V� PERMIT EXPIRATION
JOB ADDRESS UNIT# _LOT# '
r•, PERMIT EXPIRES IF WORK'
OWNER .p-Yl0/ CONTE CTOR .LQ IS NOT STARTED WITHIN
INSPECTION DATE I INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU.
FOUNDATION ANCE OR 180 DAYS FROM
NOTE:
UFER: ALL GRADING AND DRAINAGE SHALL BE INSTALLED LAST CALLED INSPECTION.
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT VAUUATICN
CUPERTINO STANDARDS.
GARAGE SLABS
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED RoDF � U I fi
UNDERGROUND /SLAB OaTStpE p _ ` " `
' PLUMBING
d
ELECTRICAL ISSUANCE DATE
MECHANICAL SLUG, ELECTPLG. MECR.
El ❑ o
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED ' BUILDING PERMIT
WOOD FLOOR INFORMATION
PLUMBING, VALUATION SIFT.
MECHANICAL
ELECTRICAL / PERMIT To
FRAMING
INSULATION STORIES TYPE CONSTR.
OCC.GROUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
" 50 E 1000RARIA TOTAL ACREAGE
ROOF NOTE:NO FINAL INSP.SHALL B
DIAPHRAGM E MAp� RE tl��
00
THE CONSTRUCTION TAX IS PAID r QQ'
BUIL
ROOF SHEDING USE
ATHING �� RES 'IND .LON PH
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ ❑ El- ❑ ❑
ROUGH SAN.it ASSESSORS PARCEL NO.
PLUMBING ELECT.ENERGY
TUBE&SHOWER PAN PLUMBING ENERGY TRACT NO, PARCEL No
MECHANICAL MECH.ENERGY
ELECTRICAL BUILDING ENERGY ACC DATE ACC.FILE NO,
FRAMING
ELECT.FINAL TEST 1,
INSULATION PLUMBING - ZONING 'ENG.SITE NO.
GAS TEST - GAS
MECHANICAL FIRE SHRINK ENERGY T-2G
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING Y ❑ ' -D Y ❑ N❑
EXTERIOR SHEAR ELECTRICAL RELEASE FLOOD ZONE A.LuC
INTERIOR SHEAR FIRE DEPT. Y❑ N D1 Y ❑ N❑
SHEETROCK GRADE FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATHTEMPORARY APPROVALS BUILDING
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
.MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H� ONE WORKING DAY BEFORE REQUIRED INSPECTION.
z
PLEASE GIVE JOB ADDRESS WHEN PHONING. PLUMBING
— SEE PERMIT FOR EXPIRATION DATE"— MECHANICAL 3�de1
.. IMPORTANT! ' CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL'
CALLING FOR FINAL INSPECTION.
OFFICE COPY