12494 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTIFICATION APPtICA-TION Sl PERMIT
1 a.,l IRe 12494
�"OYAu, r+A 1 � BUILDING—ELECTRICAL:—PLUMBING—MECHANICAL
IVQI�f' 1011 Y PLAN CHECK VALIDATION-
�ql 'NNE. µ —
`nl L DTjo,. ELECTRIC PERMIT FEE'
NniAcroRs OUTLETS-SWITCHES-RECEP
NOME 10.00/1.00
NA
_
LIC.NO LIGHTING FIXTURES 10.00/1.00 Q � S�
C-DNTR ACTOR'S - APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE - PANELS 10,08 C) DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMP) 20,08 PLAN CHECK FEE P.C.NO.
OR
ENGINEER LIC NO SIGNS TRANS. 3.00
ARCH.OR ENG. - SPECIALCIRCUIT 5,00 PELT at(gL'IOA I ION
ADDRESS
ZIP EMP.METER OR POLE INS. 20.00 s
APPLICANT'S MOTORS SEE FEE SCH. 0
ADDRESS V
SERVICE CHANGE 20,00
o O LICENSED CONTRACTORS DECLARATION
w rr s ISSUANCE DATE
a 0 U 1 hereby affirm that I am licensed under provisions of Chapter 9 \�t1 N
IH <w, (commencing with Section 7000)of Division 3 of the Business and P. 0 BLDG. ELECT, PLG. MECH.
F N z Professions Code,and my license is in full force and effect. ❑ ❑
z o m— License ClassLic.Number-
2
umber o w F w Date—Cmqo�clml
BUILDING PERMIT
a ¢ w u
OWNER-BUILDER DECLARATION INFORMATION
X
LL H 1 hereby affirm that 1 am exempt from the Contractor's License MISC.— REFER TO ORD
gra' PERMIT ISSUANCE 10.00 vALunnoN S/FT.
H w 0< Law for the following reason.(Sec.7031.5,Business and Professions Q
Code:Any city orcounty whiehnm
retluiresupenilloconslat, ELEC.CONTR. LIG NO.alter,
¢ ¢ ¢ 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC. D ov
O ¢ requires the applicant for such permit to file a signed statement that TOTAL PERMIT TO
a m" he is licensed pursuant to the provisions of the Contractor's License 7sq
as Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
i o Business and Professions Code)or that he is exempt therefrom and OT`Y• PLUMBING PERMIT FEE
¢ H $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for a permit subjects the applicant ma civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars(S500)J:
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their IS compensation,will do the work,and the structure Is not
intended or offered for sale (See. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
-inkCode:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.60 SD.FL FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
�, menus are not intended or offered for sale,If,however,the building
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 un- RES IND ICON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 ❑ ❑ ❑ ❑ ❑
❑ 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sea 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's Licenu 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 contractors)licensed pursuant to SEWER-SANITARV•ST LM En.200ft/10.00 TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ lam exempt under Sec. ,B.&P.C.for this WATER HEATER W/VE . 6.00
�p reqs
J Own- MCiftWATER SYSTEM q ^,1� 5.00 ACC.DATE +ACC.FILE NO.
ORK.R 'COM :NSATION 'CLARATION WATER TREATING EDUIP. 5.00
I hereby affirm that I have a certificate ofconsent to self-insure, 4 \\(�Q�I ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.C.). \
Policy No.—Company
—
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed will,,the city inspection division. MISC- REFER TO ORD. Y❑ N❑ y ❑ N❑
p: Applicant
- - PERMIT ISSUANCE 10.00 d
� > CERTIFICATE OF EXEMPTION FROM WORKERS' FLOOD ZONE A.L.U.C.
W _ COMPENSATION INSURANCE _ PLG.CONTR. LIC.NO. PLG. /
CL0Ni Y❑ N❑ Y❑ N❑
(This section need not be completed if the permit is for one
:) Z hundred dollars 1$100)or less) ' - 4 -
L) O 1 certify that in the performance of the work for which this per, QTY.: MECHANICAL PERMIT FEE FEE SUMMARY
LL P mil is issued,I shall not employ any person In any manner so as to
O W hcanne subject to the Workers'Compensation Laws of California. BUILDING
Dale Applicant ALTER OR ADD TO 5.00 �.�
} tan NOTICE TO APPLICANT: 11,after making this Certificate of Ex -
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions Or this permit shall be deemed revoked. ✓ AIR HANDLING'UN ,(TO 10p0DCF.M.) 4.00 2�,4
CONSTRUCTION LENDING AGENCY AIR HANDLINGUN IDV RlO=pC.F_ 6.00 SEISMIC FEE /
I hereby affirm that there iso construction lending agency for EXHAUST HOOD(WITH I)U�f x 5.00
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO lOd,000 B.T.U.) 8.00 .L MICROFILM
3097,Cie.CJ.
Lender's Name H EATI N G UN IT(OV ER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
I certify that l have read this application and state(]lot the above VENTILATION FAPLUMBING
4.00 610information is correct.I agree to comply with all city and county BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.001PLUMBING
ordinances and stat, laws relating to building construction, and
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over)00,000 BTU)SEE FEE SCH. MECHANICAL ov
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of REFER TO ORD. .
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 e) CONST.TAX
L
may in any way ac a against said City in consequence of the
g of this per MECH.CONT. LIC.NO. Ma1AL
TOTAL
Signature of Ap icant/Contractor Data
OFFICE COPY
1 '
CITY OF CUPERTINO COPY V .,
i ` --d.J
GAS SERVICE NOTICE
iii — fs`1
119-
To vTo
You ore hereby authorized to connect the GAS service for ur
� i I
Owner or Tenant =�T���/c+ -••"
At
New Service
ha
No. of Meters Reconnect '•l
• !' No. of Add. Meters Move Service
Move Meter
PLUMBING INSPECTOR �/L=��y ,�`r� (E).
.. _ Cl .
r
L
POST THIS`CAR'D NEAR FRONT;OF BUILDING
( PPRMIT NUMBER
. CITY ' OF CUPERTWO.1 12494
INSPECTION DIVISION'
JOB INSPECTION RECORD ;
PERMIT EXPIRATION "
tJOBADDRESS '�C��a6 ' 17C NL[I/.F- "UNIT# LOT# '
PERMIT•EXPIRES IF WORK
r OWNER - U --S' 4/GAe7, CONTRACTOR IS NOT;STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTIOWRECORD " '180 DAYS OF PERMIT ISSU
' FOUNDATION -kk - O 7 ANCE'OR,180 DAYS FROM
.' LIFER
�ab "'2IpC,' . LASTCALLEDIN$PECTION,
'" PREGUNITEt' .k:, PERMIT VALIDATION .
�i w� �
POUR,NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED �l d (47'l
" UNDERGROUND /SLAB ri tEVIA
PLUMBING
ELECTRICAL ." , _ 'V ISSUANCEDATE� -
n
MECHANICAL' k • 'py h, BLDG ELECT. - PLG M CH
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED. 95,
BUILDING PERMIT
G��' INFORMATION
" U WOOD FLOOR - - - vnwnnoN slPr.
' PLUMBING
MECHANICAL- - - - -
ELECTRICAL' I - PERMIT TO
FRAMING - ;aD� -
- " INSULATION - ' - STORIES TYPE CONSTR.
_— OCC.GROUP RES,UNITS' -
_ NPLACE NO'SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
L
'iROOF SO FT.FLOOR AREA rTOTAL ACREAGE
DIAPHRAGM
tVh.!O O BUILDING USE
Res IND' CON PB Olh,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED " Z ❑ ` E-1 [T ❑ El. ROUGH' Assessoas PARCEL No.
PLUMBING
GAS TEST , .. T..ACT NO. PARCEL NO;
MECHANICVAL "
' ELECTRICAL - "FINALS ACC.;DATE ACC,FILE No, ,
1"v:D'ATE, - INSP. -
FRAMING .. " SAN,
INSULATION PLUMBING - ZONING ENG,SITE No.
. GAS. _ -•._.
J
MECHANICAL. „FIRE SPRINK" ENERGY T24
JOCOVEWNOWORK+'UNTILABOVVHASBEEN:;SIGNEO„,;; HEATING- YE], 'N❑ Y6❑ ' N❑
LATH_INTERIOR21 ELECTRICAL _/ I FLOOD ZONE.' A.L:U.C.
LATH-EXTERIOR: FIRE:DEPT.. - 'Y ❑' N❑ 'Y ❑ N❑
SHEETROCKIs - --
SHEAR INTERIOR. GRADE 'FEE SUMMARY :,gwu'"I”
- BUILDINGS, - _
SHEAR EXTERIOR " r BUILDINGTE
IO — TEMPORARYAPP OVALSFIREWALLS ELECTRIC, ;r. " - PLANCHEGAS . . FEE 'NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNFED OCCUPANCY SEISMIC FEOCCUPANCYOFBUILDINGISNOTPERMITTEDUNTILBUILDINGFINALISSIGNEDBYBUILDINGINSPECTOR. MICROFIL
ARRANGE FOR INSPECTION BY F'HONI-NG 252-4505, " ' ELECTRIC y /
H; ONE ,WORKING DAY BEFORE REQUIRED INSPECTION
PLUMBING'
zto PLEASE'GIVE JOB ADDRESS WH EN.PHONING
I I ,= SEEPERMIT FOR'EXPIRATIONDAT.E'—`6 MECHANICAL . f"
IMPORTANT! coNsr rax
PLEASE READ REVERSE.SIDE BEFORE ' . TOTAL ,
CALLING FOR FINAL INSPECTION.:
,OFFICE COPY,