14091 APPLICANT TO FILL IN INFC iATION WITHIN RED LINES - USE -L POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING
/J l� APPLICATION & PERMIT
ADDRESS
D,°o L `� �T/� RD 14091
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'5 PLAN CHECK VALIDATION
"Am DTVte . ELECTRIC PERMIT FEE
(�(/nfV'• PHONE
•CONTRACTORS
NAME �0�6 �j UTLETS-SWITCHES-RECEP 10.00/1.00
di9c�/1 Y aR�V. uc No. e- -Sa LIGHTING FIXTURES 10.00/1.00
ADDRESS OR's 4.15 392 PPLIANCES-RESIDENTIAL 4.00
CONTRA 11�sI�� l�e(aa``�1��J
'110 Aftr" W. MrV''IIGZ.E PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDROR ESS E"D' SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zlv EMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS
SERVICE CHANGE 20.00 rL>"
w
02 LICENSED CONTRACTORS DECLARATION
a u,C, I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
n <W (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
r N A Professions Code„ d m license is in full for n f
tom License Class V LO Lic.Number ❑ ❑ ❑
w r w Dale e,n 9A -A2q Contmetor
i y F J �T�-L-�-s- BUILDING PERMIT
iw u OWNER-BUILDER DECLARATION INFORMATION
u ;LL N I herebyaffirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
p VALUATION SIFT.
LL0 < Law for the followingoUson.(Sec.7031.5,Business and Professions PERMIT ISSUANCES 10.00
i
' 0J Code:Any city orcounty which requires a permit to construct.alter,
Wa At Fo improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIQ NO.
ELEC.
C O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT i
w he is licensed pursuant to the provisions of the Contractor's License
r Z i
Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
< Business and Professions Code)or that he isexempt therefrom and OTY. PLUMBING PERMIT - FEE
H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
i ;m by any applicant for a permit subjects the applicant(oa 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:The Contractors License Law does not apply to an owner of
property who builds at improves thereon,and who does such work FIXTURES-PER TRAP 5.00 5Q FT.FLOOR AREA TOTAL ACREAGE
•himself or through his own employees.provided that such improve.
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 (EA.) 200 BUILDING USE
builder will have the burden of proving that he did not build or im- . . ,
RES IND CON PB Omar
prove for purpose of Sale.). JINDUSTRIAL WASTE INTER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(See. 7044,Business ILAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law docs 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 contrzclods)licensed pursuant to
the Contmctor's License Law. SEWER-SANITARY-STORM EA.200f1/70.00 TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-.B&PC.for(his WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.-DATE ACC.FILE NO,
WORK ERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate o(consent to self-insure. ZONING ENG.SITE t.0.
or a certificate of Workers'Compensation Insurance.ora certified
cop thereo'(Sec Lab.C.l. Y QL/IlnG
P c �rll Pant 1 �I 111a�/ ff �I
O CertiGe copy is he furnished. FIRE SPRINK ENERGY LZa
z, Z ❑ Cer(if copy ed.pR71 t �city nspection division. MISC.- REFER TO ORD. ❑ ❑ ❑ ❑
F p`:
Applicant { v N v N
ICERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 vL000 ZONE A.L.0 c.
= > COMPENSATION INSURANCE: PLG.CONTR. LIC.NO. PLG.
1 O (This section need not be completed if the permit is for one TOTAL Y C] N❑ Y [:] N❑
7) Z hundred dollars(SI00)or less.) n '
U O 1 certify that in the performance of the work for which this per- GTY MECHANICAL ERMIT FEE FEE SUMMARY
LL I- mit is issued,I shall not employ any person in any manner so as to ,
O
L) become subject to the Worker Compensation Laws of California. BUILDING
Date Applicant ALTER OR ADD TO MECH. 5.00
} N NOTICE TO APPLICANT: If,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
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MOC.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MCF.M.) 6.06 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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.CJ.
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4,00
• information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP 13 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP(Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 16 - CONST.TAX
ma 'in any way accrue against said City in consequence of the
ting O( ermiLMECH.CONT. LIC.NO. MECH.
TOTAL ,1�_ TOTAL
' nature of Applica UCo a o Uate T
OFFICE COPY
POST'THIS D NEAR FRONT OF BUILDING
PFRMITNVMBER
-CITY OF CUPERTINO 14091
INSPECTION DIVISION
JOB INSPECTION RECORD .
PERMIT EXPIRATION
JOB ADDRESS 10211 BUBB ROAD UNIT# LOT#
APPLE COMP EAST BAY: AIR COND, PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION' - ANCE OR 180 DAYS FROM "
LIFERLASTCALLED INSPECTION.
PERMIT VALIDATION
PREGUNITE ,
POUR NO CONCRETEUNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB 1
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL' BLDG. ELECT. I PLG. MECHI I
El,
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR
,VALUATION $/FT.
PLUMBING' _
MECHANICAL
ELECTRICAL vi , 6� •' PERMIr'-r•-p -
FRAMING .MJaQsr ^ I
,�.. oRlEs - TYPE coNSTR
INSULATION _
OCC.GROUP RES.UNITS
f
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED SG FT'FLOOR AREA TOTAL ACREAGE
• ROOF
DIAPHRAGM
-BUILDING USE
• RES IND -CON PB OIeH,.
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑ ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING
TRACT NO. PARCEL NO
GAS TEST
MECHANICAL /-A.-flf
ACC.DATE ACC.FILE N0.
ELECTRICAL FINALS DATE INSP.
FRAMING SAN # zonlwc - ENG.SITE No.
INSULATION PLUMBING
GAS
FIRE SPRINK.. ENERGY T24
MECHANICAL Y F] 'N[D Y ❑ N❑
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
F
' LATH-INTERIOR ELECTRICAL LOGO ZONE A.LG C.
LATH-EXTERIOR FIRE DEPT. 1 v❑ NE] v I] No
SHEETROCK - - GRADE .. FEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS euILDING
FIREWALLS 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 IS SIGNED BY BUILDING INSPECTOR, MICROFILM
LU ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
:! 0 PLEASE GIVE JOB ADDRESS WHEN PHONING. -
Z MECHANICAL �f
— SEE PERMIT FOR EXPIRATION DATE — '
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL.
CALLING FOR FINAL INSPECTION.
OFFICECOPY
'APP'LICANT TO FILL IN INF( ATION WITHIN RED LINES - LISEOL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
IuamNG APPLICATION & PERMIT
ADDRESS� , ► �� Ro 14091
BUILDING-ELECTRICAL-PLUMBING -MECHANICAL
OWNERS PLAN CHECK VALIDATION
"AM
�1•o OTY. ELECTRIC PERMIT FEE ,
.ONE
CONTRACTORS 3p�6 OUTLETS-SWITCHES-RECEP 10.00/1.00
gN/A�M ��k'g 1..- '1r A19 4OW LIC.NO. G r LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'SRESS MIS 312 APPLIANCES-RESIDENTIAL 4.00
4 /O /}oVJr/ Nf•,tfi^i, a PANELS 10.00 DATE OF APPLICATION
ARCHITECT I PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
ARCH.OR
E"G" SPECIALCIRCUIT 5,00 PERMIT VALIDATION
RESS
ZIP EMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH.
ADDRESS l�ti W'i(i/J
SERVICE CHANGE 20.00 / y�
w
00 LICENSED CONTRACTORS DECLARATION l d/ d
Q U u I hereby affirm that 1 am licensed under provisions of Chapter 9 ISSUANCE DATE
w (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT, PLG. MECH.
iProfessions Code„andIrw•license is in full for n}�fpJl
Z D u`Z License Class Gi L.(J Lic.Number ' (1.1 01' ❑ ❑ ❑
$w H w Date_�_,__fS 61" Contractor _-
a y
it
�a'�� vv �� BUILDING PERMIT
ar a w 4 OWNER-BUILDER DECLARATION INFORMATION
o A " REFER TO ORD
a'xs r 1 herebyaffirm that I am exempt from the Contractor's License MISC.-
P VALUATION $/FT.
Fu Oa Law forthe following mason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
Sic a,¢ FO improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. -
c, O u requires the applicant for such permit to file a signed statement that TOTAL PERMIT Tppp
he is licensed pursuant to the provisions of the Contractor's License
w m
H x <
Law(Chapter 9(Commencing with Section 7000)of Division 3 ofthe
Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
rc1� the basis for the alleged exemption.Any violation ofSection 7031.5 STORIES TYPE CONSTR.
uby any applicant for a permit subjects the applicant toa civil penalty gLTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred dollars(S500).):
❑ 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:The Contractor's License Law does not apply to an owner of -
• property who builds or improves thereon,and who does such work F IXTUR ES-PER TRAP 5.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments 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 im- RES IND CON PS Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
O I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSOR5 PARCEL NO.
and Professions Cade:The Contractor's License Law dues not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts forsuch projects with a contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO,
❑ lam exempt under Sec.-,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
owner Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to Self-insure, ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
co�p,j t�h,e,�Ac.I1(Sec. Lab.C.). �r 6
p`f iWA-IIg pang- 1 RRE1// II �I
O CCr4fe copy is hereby furnished. FIRE SPRINK ENERGY T-Z4
Z Z ❑ Certif copy ed t city inspection division. MISC.- REFER TO ORD.
Fj Applicanl�-._ a. V❑ N❑ V❑ N❑
� - CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.LLC.
> COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
CL - V N V ❑ NE]d 0 ' (This section need not he completed if the permit is for one ..-� TOTAL ❑ ❑
::) 2 hundred dollars(SI00)or less.)
V O I certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL N mit is issued,I shall not employ any person in any manner so as to
U becomesubject mthe Workers Compensation Laws of California. 74 BUILDING
LU
Date-Applicant ALTER OR ADD TOIMECH.ta x 5.00
} SO NOTICE TO APPLICANT: If,after making this Certificate of Ex.
2 empticn,you should become subject to the Workers'Compensation APPLIANCE nO .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,,10,000GF. ) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER I0)000C.F.M.) 6.00 SEISMIC FEE
1 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
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN ISINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon tire �
BOILER-COMP IOxrer 100,000 BTUI SEE FEE SCH. MECHANICAL / b
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which -� CONST.TAX
main any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
ling of � ermit. MECH.CONT. � - LIC.N0. MECH.
d TOTAL TOTAL
X ..lure of AppliIn t/Co a o Uate
' OFFICE COPY