17175 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BU I LDING PROJECT I DENTIFICATI ON " PERMIT NUMBER
BUILDING APPLICATION & PERMIT _ q Zq 2[
J
ADDRESS I I
v, BUILDING-ELECTRICAL-PLUMBING-MECHANICAL i"
,WNEB'S ^ �7� PLAN CHECK VALIDATION
NAME I- CITY. ELECTRIC PERMIT FEE
�YF PHONE
CONTRACTORS
NAME e/O OUTLETS-SWITCHES-RECEP 10.00/1.00
�. uC.NO. LIGHTING FIXTURES 10.00/1.00
ADDRESS T0R5 _eC4j+T, 2-S)- PPLIANCES-RESIDENTIAL 4.00 -
ZY `jJ- PHONE'J5 3,6 PANELS 10.00 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE D.C.NO.
OR PANELS (OVER 200 AMP) 20.00
NGINEER
LIC.NO. SIGNS TRANS. 3.00
ARC H.OR ENG. PERMIT VALIDATION
ADDRESS SPECIAL CIRCUIT 5.00
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FEE SCH.
ADDRESS /7� Q
SERVICE CHANGE 20.00
w o o LICENSED CONTRACTORS DECLARATION
a u v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
y w (commend ng with Section 7000)of Division 3 of the Business and
6 BLDG, IT. PL❑G. MECH.
H N i• Professions Code,and my license is in full farce and effect. ❑
Z i m o Licens}•Class _Lie Numher 4Q$. C,4 _� • -
4 t-w Date-CO $ Contractor[ t-Ir #� 3 a-Y
< r a BUILDING PERMIT
¢ w u OWNER-BUILDER DECLARATION INFORMATION
Ax ;°'y I hereby afllrm that I am exempt from the Contractor's License M ISC.- FER TO ORD
w 1 VALUATION $/FT.
a_ U.
Law for the following reason.(Sec.703L5,Business and Professions ' PERMIT ISSUANCE -TiT.pp
m Code:Any'city or county which requiresa permit to construct,alter
rt to ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC NO. ELEC.
i w m¢ requires the applicant for such permit to file a signed statement that t 1 * TOTAL , PERMIT TO
he is licensed pursuant to the provisions of the Contractor's License
F ' i Law.(Chapter 9(commencing with Section 7000)of Division 3 of the 17-
yec Busness and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE
the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR. j
n3 by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
- of not more than five hundred dollars(5500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or Offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'rhe Contractor's License Law docs not apply to an owner of
Properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself'or through his own employees,provided that such improve-
mentsarenotintended or offered for sale.If,however,the building GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int- RES IND CON p0 Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the properly,am 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 contractor(s)licensed pursuant ru SEWER-SANITARY-STORM EA.200ft/10.00
the Contractors License Law. TRACT NO, PARCEL NO.
❑'I am exempt Under Sec..,B&P.C.litr this WATER HEATER W/VENT 6.00
reason
Owner Dale WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKS RS'COMPENSATION DECLARATION WATER TREATING EQUIP, 5.00
I hereby affirm that I have a certificate of-consent to sell'-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or u certified
copy Ihereof(Sce.3800,Lab.C.I�s'
Policy NoIy011!JWompeny_r�[(�'lTlhw'n (0nn Pn$r,7la
10 ❑ Cwil'icd copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z frd�CertifmJ c_ Ofy y( fQedswith the city inspection division. MISC.- REFER TO ORD.
O APplicant_/$O!a-(Ch/LkZ.L Y ❑ N❑ Y ❑ N❑
rn / PERMIT ISSUANCE U 10.00
LU - CERTII°ICI OP I Ar10N FROM WORKERS' FLOOD ZONE A.I..U.C.
W CO
� COMPC:NSATIION INSURANCE PLG.CONTH, LIC.N0. PLG. '
CL Z( This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑' N❑
hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL �- mit is issued,I shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of California.
a Dote ApplicantALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE TO APPLICANT': If,after making this Certificate of fix
Z eruption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked, AIR HANDLING UNIT(TO 10,0)0C.F.M.) 4.00
CONSTRUCTION LENDING AG17NCY AIR HANDLING UNIT(OVER 10MC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.19.50
Lender's Address ELECTRIC
I Certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
informm
Urination is correct. I agree to Coply with all City and county PLUMBING
ordinances and stare laws relating to building construction, and BOILER-COW(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(over[00,000 BTU)SELF EE$CFI. MECHANICAL
above-mentioned property for inspection purposes,-(WO agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs:aid expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ranting of this ern MECH.CONT. LIC.NO. MECH.
y3oG , /0&ek� TOTAL TOTAL 2Z�
Stgna[ure of Applicant ontractor Date
OFFICE COPY
;. ". POST THIS CARD NEAR FRONT OF BUILDING PERMITNUMBER
CITY OF CUPERTINO ' 17175`'
INSPECTION DIVISION
\ JOB INSPECTION RECORD
PERMIT EXPIRATION
JOB ADDRESS /JO v `� �!I r `� ✓ ISPIIT t _LOT#
�/�['// ,� . PERMIT EXPIRES IF WORK
OWNER CONTRACTOR J� A_,- r-L IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION ANCE OR 180 DAYS FROM
NOTE: LASTCALLED INSPECTION.
LIFER - ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE - - TO COMPLY WITH THE APPROVED PLANS AND CITY OF PERMIT'VALIDATIGN
GARAGE SLABS
CUPERTINO STANDARDS. n it " ou ,
- Nvl
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED - p
UNDERGROUND /SLAB PAID MIDI ['�' �• /
PLUMBING 1989
ELECTRICAL 7 ISSUANCE DATe
MECHANICAL - - BLOG I ELECT I PLG. MECII
Citv of Cunertino ❑ ')j' ❑ ❑ '
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION SIFT.
PLUMBING
MECHANICAL '
ELECTRICAL - - yPERMIT TO
FRAMING
INSULATION - " - STORIES TYPE CONSTR.
OCC.GROUP RES UNITS
-� PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
"ROOF NOTE:NOFINALINSP.SHALL BE MADE BEFORE so
s r FLooR AREA To?AL ACREAGE
DIAPHRAGM THE CONSTRUCTION TAX IS PAID-
/ BUILDING USE
ROOF SHEATHING 1 - Res - wo CON- PB oMr,
-APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS DATE INSP. ❑ - ID ❑
ASSE SSCRS PARCEL NO
' ROUGH SANS
PLUMBING ELECT.ENERGY -
iRACTNO. PARCEL NO
- •. TUBS 8 SHOWER PAN � PLUMBING ENERGY
MECHANICAL - MECH.ENERGY
.
ELECTRICAL _ BUILDING ENERGY - - ACC DATE ACCFILE NO
-
FRAMINGELECT.FINAL TEST
ZONING ENG.SITE NO.
INSULATION � � PLUMBING '
GAS TEST- GAS
MECHANICAL FIRE SPRINK ENI:RGY T,24
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING N[] ' "o
. '.
' EXTERIOR SHEAR � ELECTRICAL RELEASE FLOOD ZONE ALU C.
❑.
INTERIOR SHEAR FIRE DEPT. " Y E] N Y L iN,[D
SHEETROCK - GRADE - FEE SUMMARY
EXTERIOR LATH " - BUILDING .
INTERIOR LATH TEMPORARY APPROVALS BUILDING,
SCRATCH COAT ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUI LOING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED.BY BUILDING INSPECTOR. MICROFILM
w ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC 6�
�� o•� ONE WORKING DAY BEFORE REQUIRED INSPECTION.• PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z - MECHANICAL
- SEE PERMIT FOR EXPIRATION DATE -
IMPORTANT! CONST. TAX ^�
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY