15072A
r
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
. BUILDING PROJECT IDENTIFICATION
BUILDING - ELECTRICAL- PLUMBING - MECHANICAL
.
PERMIT NUMBEREaJ1LmnAPPLICATION&PERMIT' ^ r07n
V~ G
I
ADDRENG
aa
OWNER'S
NAME
O Y. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
eS l PHONE
DATE OF APPLICATION .
CONTRACTTOROR S
1 NAME ,A1
G -C LIJNCY LIc. No 103-2
� OUTLETS-SWITCHES-RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.00
4"Ci'
no RESS as Rjyo,T4^-C( (�
�,lr l' ��V �fwk FNONEB�- �i
APPLIANCES -RESIDENTIAL 4.00
PANELS 10.00
ARCHITE i
on
ENGINEER - LIC. NO,
PANELS (OVER 200 AMP( 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ADDRESS ENG' -
SPECIAL CIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00APPLICANT
ZIP
/1 �•
5
ADDRESS
MOTORS SEE FEE SCH,
SERVICE CHANGE 20.00
/
-7111W
LICENSFD CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9'
7000) of Division 3 of the Business and
(commencing with it
Professions Cod • a d my license R in full forte /M it
License ss [-Y,/ L' Lic. Number / 03
UnIC Contractor
OWNER -BUILDER DECLARATION
-
A.
ISSUANCE GATE '
B ELECT. PLG. MECH.
❑ ❑ ❑
-
CiMANty UI
ILDING PERMIT
I hereby affirm that I am exempt from the Contractor's License
MISC. - REFER TO ORD
INFORMATION
I
ISSUANCE _
VALUATION
-
$)FT.
Law forthe followingreauni.(Sec. 7031.5, Business and ProfessionspERMIT
Coda Any city or county which requires a permit to'constnimL alter,
ELEC. CONTR. LIC. NO.
ELEC. p
TOTAL t7 ,.�
iniprove, 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 0a Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 ofthe
PERMIT TO
€
Business and Professions Code) or that he is exempt therefrom and
the basis for the Wlegud exemption. Any violetan, of Section 7031.5
by any applicant fire permit sobjects lar,$500).licunttoacivil penilty
i
of not more than five hundred dollars (my
OTY. PLUMBING PERMIT FEE
ALTER-DRAIN-WATER(EA.)5.00
�
STORIES
TYPE CONBTR.
❑ hes owner of the property, or my employees with wages as
amp
(hens
ir sole compeation, will do the work, and the structure is not
intended or offered for sale (Sec 7044, Business and Professions
Code; The Contractors License Law does not apply to 5m owner of
property who builds or Improves thereon, and who does such work
himself or through his own employees, provided that such improve-
meats are not intended or offered for sale. If, however, the building
BACK FLOW PROTECT. DEV ICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AR EA,CON D. 5.00
FIXTURES - PER TRAP 5.00
,
GAS - EA. SYSTEM -11NC.40UTLETS 6.00
SO, FT. FLOOR AREA
TOTAL ACREAGE
or improvement is sold within one year of completion, the owner-
builder will have the burden of proving that lie did not build or ire-
prove for purpose.1 the.).
O d as owner of the construct he exclusively . 7044. ins with
licensed contructon ro construe the project (Sec 7044, Business
and Professions Code: The Coniraaor's License Law does not apply
GAS - EA. SYSTEM -OVER 4 (EA.) 2.00
BUILDING USE
RE IIN CON PB Dom.,
INDUSTRIAL WASTE INTER. 30.00
LAWN SPRINKLERS - 1 INC 5 V. B. 6.00
ASSESSORS PARCEL NO.
LAWE
- OVER 5 (EA.) 1.00
to an owner of property who builds or improves thereon, and who
contracts for such projects with a Contractors%) licensed pursuant to
tlm Contmaor's License Law.
❑ 1 wn exempt raider Sec. ,B.&I'.C, tiir tllis le.lonWATENT
SEWER-SANITARY-STORMTORM EA. 200ft/10.00
TRACT NO.
PARCEL NO.
6.00
Owner Date
WAT5.00
WORKERS'COMPF.NSATION DECLARATION
ACC. DATE
ACC. FILE N0.
WATQUIP, 5.00
1 hereby affirm that I have a certificate of consent m sell' -insure;,
or u certificate of Workers' Compensation Insurance, or a certified
COPY therepfy�y jA[I�Q�). p I
Policy No (I/.2-Cirm St/iTG tJ.JG� L
ZONING
ENG. SITE NO.
Certified cop, isherebyfurnished.
FIRE SPRINK
- Y[] NO
ENERGY T24
'Yo NE]
Certife py is fl it wilt' the city inspection division.
Apicant
CF,RTI HCA Of EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
i His section need not be completed if the permit is lin one
hundred dollars IS 100) or Icss.)
MISC.- REFER TO ORD.
PERMIT ISSUANCE - 10.00
FLOOD ZONE
Y ❑ N
A.L.U.C.
Y [J No
PLG. CONTR. LIC. NO.
PLG.
TOTAL
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
kccrtify that in the perforoancc of the work for which this per
niit is issued, I slmll not employ any person in an manner, manner sa as to
become subject to the Workers' Compensation Laws of California.
Dat` Applicant
NOTICE TO APPLICANT: If, after making this
BUILDING
ALTER OR ADD TO MECH. 5.00
emvisionyou should eLbecome Workers*
Workers Compensation
Compensation ion
e, you must
such prove io the Labor Code, you must forthwith comply with
such provisions Or this permit shall he deemed revoked. '
APPLIANCE 5.00
PLAN CHECK
FEE
AIR HANDLING UNIT (TO 10,000OF.M.) 4.00 '
CONSTRUCTION LENDING AGENCY
AIR HANDLING UNIT (OVER 10= C. EM.) 6.00
SEISMIC FEE
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued (Sec.
3097, Civ CA
Lender's Name
00
EXHAUST HOOD (WITH DUCT) 5WTOTAL
MICROFILM
HEATIN100,000 B.T.U.) 8.00
Lender's Address
HEATINIT (OVER 100,000 B.T.U.)9.50
ELECTRIC
3
VENTILN (SINGLE) 4.00
BOILER-,or100,0008.T.U.I 6.00
I certify thai I have read this application and state that the above
information is Correct. I agree to comply with all city and countyPLUMBING
ordinances and state laws relating to building construction, and
hereby authorize •• representatives of this city to enter upon life
above-mentioned property for inspection purposes.MECHANICAL
(We) agree to save, indemnify and keep larmless the City of
Cupertino against liabilities, judgments, costs and expenses whichCONST.
may in any way accrue against said City in consequence of the
pan 1 of this perp T. r
_
BOILER-COMPr 100,000 BTU( SEE FEE SCH.
MISC. -REFER TO ORD.
PERMIT- 10.00
TAX ,
MECH. CONT.IC. NO. MECH.
TOTAL
Signature of Applicant/Contractor DateTOTAL
OFFICE COPY
POST THIS CARD NEAR FRONT OF'BUILDING
CITY OF CUPERTINO.. R
PERMIT NUMBER
15072
INSPECTION DIVISION
JOB INSPECTION RECORD.
PERMIT EXPIRATION
�7 /[/,
`1.0 41 ;; �O
JOB ADDRESScp',0 UNIT# _LOT#
PERMIT EXPIRES IF WORK
OWNER /-( Z.L ,p-It__GS P CONTRACTOR
IS NOT STARTED WITHIN
180 DAYS OF PERMIT ISSU
ANCE OR 180 DAYS FROM
INSPECTION DATE INSPECTOR INSPECTION RECORD
FOUNDATION -
NOTE:
_
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
LAST CALLED INSPECTION.
PREGUNITE TO COMPLY WITH THE APPROVED PLANS AND CITY OF
PERMIT VAL IDATIGN.
-0UPERTINO STANDARDS..'
GARAGE SLABS
_ -•
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
'UNDERGROUND/SLAB
,
!
PLUMBING -
ELECTRICAL '
PAID(
- •.ISSUANCE DATE
MECHANICAL -
BLDG
EL cr
mEol
IL ABOVE HAS BEEN SIGN EO
DO NOT POUR FLOOR UNWOO
T
BUIWFiI'itfNAnoN
_
GOR
i
PLUMBING
vawAnoN -
AS/FT.
MECHANICAL
%,
' rT
ELECTRICAL-
PE""111 ip
• FRAMING��
INSULATION
STORIES
TYPE CONSTR.
OCC, GROUP
RES. UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
1 ROOF NOTE: NO FINAL INSP, SHALL BE MADE BEFORE
SO. IT. FLOOR ARCA
TOTAL ACREAGE
DIAPHRAGM ' THE CONSTRUCTION TAXIS PAID '
' ROOF SHEATHINGBUILDING
I
USE
-
RES IND CON PB Unln
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALSDATE INSP.
11❑ El 1:30
ROUGH SANA-
ASSESSORS PARCELNO
PLUMBING � ELECT. ENERGY
ELECT.
TUBS 8 SHOWER PANPLUMBING ENERGY
TRACT No.
PARCEL NO,
MECHANICAL MECH.ENERGY
'
ELECTRICAL BUILDING ENERGY
ACC.DATE
ACC. FILE NO
FRAMING ELECT. FINAL TEST
INSULATION PLUMBINGWIF
ZONING
ENG. SITE NO.
GAS TEST GAS. .
MECHANICALFIRE
SPRIN✓
❑ - 1:1
ENERGY Tea
Y ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATINGY
EXTERIOR SHEAR' - ELECTRICAL RELEASEPLoou
mme
❑' N❑
n.Lue.
v ❑ N❑
INTERIOR SHEAR FIRE DEPT.Y
SHEETROCK GRADE
SUMMARY
EXTERIOR LATHFEE
BUILDING
'BUILDING
' INTERIOR LATH TEMPORARY APPROVALS
SCRATCH COAT ELECTRIC
PLAN CHECK
FEE.
i
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEENSIGNED. DCCuaANCY
SEISMIC FEE
ti CUPANCY OF BUILDING ISNOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BV BUILDING INR.SPECTO
•
MICROFILM
k ARRANGE FOR INSPECTION BY PHONING 252-4505,
ELECTRIC
1`7 ONE WORKING DAY BEFORE'REQUIRED INSPECTION.
PLUMBING
D \ PLEASE GIVE JOB ADDRESS WHEN PHONING.
z
MECHANICAL
—SEE PERMIT FOR EXPIRATION DATE —
IMPORTANT!
CONST. TAX
PLEASE READ REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION:
TOTAL
OFFICE COPY ��