9050°{ APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY \7
BUILDING PROJECT I OF TI FICAT•^N PERMIT NUMBER
BUILDING . - !. - -' • APPLICATION & PEf, T
9050 Aoi s0? !� -^ (�(� J BUILDING-ELECTRICAL-PLUMBING�MECHANICAL
OWNER'S � G�
NANF J . ' ' ty` „,i,, ' .' PLAN CHECK VALIDATION
{/'��� ��//••�� 11 OTY.
PHONE ELECTRIC PERMIT "�. ``+af" ,'FEE=`
lL� '-I(j I. .I,L... ,. a 1. �Ce,tW1;r •,J/s.if(
°AMERAc*ons �(VUTLETS-SWITCHES-RECEP 10.00/1.
CC/ uc.No. SD I� LIGHTING FIXTURES 10.00/1.00
ADDRESS RAE
PPLIANCES-RESIDENTIAL 4.00
` NCf C � L ONE CIH(C-IC
LJ PANELS 10 On DATE OF APPLICATION
ORGHlrecT I PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C.NO.
ENGINEf
r Ie ), CI I41c No. SIGNS TRANS. 3.00
ARCH,OR ENG. I PE. TION
ADDRESS `� '-- SPECIAL CIRCUIT 5.00
�C •SCtlt
" (1 C ZIPCr
TEMP.METER OR POLE INS. 20.00
APPLICANT'S UG1
i;A �f
ADDRESS - MOTORS SEE FEE SCH. V JIYI
61 Ptync fz Cr h e9cct C i,.)ot ` SERVICE CHANGE 20.00
0 0 o LICENSED CONTRACTORS DECLARATION - TEMP.POLE 30.00 :City!Of Cdpeff100
a u u 1 hereby affirm that 1 am licensed under provisions of ChaPler 9
2 ISSUANCE DATE
w ¢ (connnencing with Section 7000)of Division 7 0(the Business and
BLDG. ELECT PLG. MECH.'
r N z Prokssions Cole, nJ my license is in full force{red c(jsct
O i w Datensn,C'LyS L)c.Number J,2 ,�
Ps 1-w Dam C011tmHub�jr-u]ly,t=(„�;.y
a m a OWNER-BUILDER DECLARATION BUIL IN PEO IT'"yds„��
a
°' D MISC.- REFER TO ORD `` T^ 'INF ORMATION;%`1':dv`
r I hereby affirm that 1 am exempt from the contractor's License VALUATION j/FT.
w LL o¢ Law for[lit following reason.(Sec.7031.5,Business and Professions
- h PERMIT ISSUANCE 10.00
S W Code:Any city Or cuunlY which rcquiresa Permit to eonstruet,alV•q
a a ¢ O improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTH, LIC.NO. ELEC.
O LL requims the applicant for such permit to file a signed statement that
TOTA !j
m S a he is licensed pursuant to the provisions of the Contractors License PERMIT TO
I z a Law(Chapter 9(commencing with Section 7000)cf Uivision Solthei, ..�',;.•
3 z o Business and Professions Code)or that he isexempt therefrom and OTY. - PLUMBING PERMIT.','.- „y �,1FEE% t
Lie r the basis for the altcged exemption.Any violation of Section 7031.5 t;Z%Ir e ! STORIES TYPE CONSTR.
ai - by any applicant fora permit subjects tiro applicant luucivilpenally �� ALTER-DRAIN& VENT-WATER (EA.) 5.00
of not morn than live hundred dollars t f5001J:
❑ I,as owner of Lite property,or my employees with wages us BACK FLOW PROTECT. DEVICE 4,00 C.GROUP RES.U I
their sole compensation,will Jo the work,and the structure is nut
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 in owner of q
property who builds or improves thereon,and who dun such work 12, IrIXTURES-PER TRAP 6.00 SO.FT.FLOOR AREA TOT L ACREAGE
himself or through his own employees,provided that such improve.
ments are not intended or offered for Sale.If,however,the building z GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
or improvement is sold within One year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or int `�
Prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 IN❑D C❑ON O Dow
❑ I,as owner of the properly,am exclusively contracting with
licensed contractoCD
rs to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractors License Law does not apply
to an owner of prop"ry who builds or improves thereon,and who -. LAWN SPRINKLERS-OVER 5(EA.) 1 Ool 3 S%- U 4G _ U b
Contracts for such projects with a contractoRs)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.1'or this /
reason If WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00
ACC.DA E ACL.FILE NO.
WORKERS'COMPENSATION DECLARATION - WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent to self-insure,
or a certificate of Worke"'Compensation Insurance,or a certified ZONING ENG,SITE NO.
copy thereuf(Sec.3800,Lab.C.I�Y C7 _ C •G
Policy No. Company- '
0 ��d❑d, Certified copy is hereby furnished.
Z Z A• Certified copy is filed with the city inspection division. FIRE SPANK ENERGY TQ4
O Applicant (abed r-lrp MISC.- REFER TO ORD. Y ❑ N❑ Y N❑
O: T CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOODZONE A.L.U,C.
LU > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG. N Y N
d O (This suction need not be completed if the Permit is for one TOTA Y❑ ❑ ❑ ❑
2 hundred dollars IS 100)or less)
V O I certify that in the performance Of the work fur which this Pur :; r I ';!s` FEE SUMMAfl VI
U.
in
is issued,I shall not employ any person in any manner so as to QTY' MECHANICAL PERMIT v, FEE d
U become subject to the Workers'Compensation Laws of California. �'`
W Dace Applicant BUILDING,
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex. 1 ALTER OR ADD TO MECH. 5.00 _
F-. Z emption,you Should become subject to the WOrkeri Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10PMC.F,M,) 6.00 SEISMIC FEE
I hereby effsmt that there is a construction lending agency her EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(See. MICROFILM
3097,Civ.C.). _ HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Names H 1lf\
Lender's Addree• tr✓ 'J'1'�IC 11 1sY pi �-. HEATING UNIT(OVER 100,000 B.T.U.)8.50 ELECTRIC
1 certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
`Yq information is cored. I agree to comply with all city and county PLUMBING G
ndinances end State laws relating to building construction, and "' BOILER-COMP(3 H.P.or 100,000 B,T.U.) 6.00
'1'1 ^ above-luridly entionid representatives for ins inspection
this city lu enter upon the �+ BOILER•COMO 10 or 100,000 BTU)SEE FEE SCH. MECHANICAL /
above-mentioned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless Ose City of MISC.- REFER TO ORD.
Cupertino against 4,bililies,judgments,costs and expenses which CONST.TAXQ�
may in any way accrue against Said City in consequence of the PERMIT ISSUANCE 10.00 If
Onlin tJ'lhis per it. ^ MECH.CONT. LIC.NO, MECH.
�� TOTAL
Signature of Ap aant/(Stractor am
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
PFRMR NUMBER
CIT'" -OF CUPER i INO � ,�
INSPECTION DIVISION to
JOB INSPECTION RECORD
• 11 JOB ADDRESS L' D�"� ` V�y � � UNIT# LOT# PERMIT EXPIRATION
PERMIT EXPIRES IF WORK
OWNER `. 1 CONTRACTOR I IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER c
PREGUNITE L� PERI.RA{11
ITION
y
POUR NO CONCRETE UNTIL ABOVE HAS BEE SIGNED AUG
UNDERGROUND /SLAB
PLUMBING City of Cupertino
ELECTRICAL ISSUANCE DATE
BLDG. ELECT. PLG. MECH.
MECHANICAL
DO NOT POUR FLOOR UNTIL.ABOVE HAS BEEN SIGNED BU I NG ERMIT
INFORMATION
WOOD FLOOR
VALUATION $/FT.
PLUMBING Q_ _
MECHANICAL
ELECTRICAL PERMIT TO
FRAMING 'L _ d
STORTES TYPE'CONSTR.
INS CATION
W „ O,(LG-9RDUP RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
SO.FT.FLOOR AREA TOT4L ACHEAGE
ROOF —
DIAPHRAGM
'BUILDING USE
RES hl IND CON PB OM.,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED0 ID 0 13ROUGH I TU19
ASSESSORS PARCEL NO }
PLUMBING
GAS TEST
TRACT, NO. PARCEL NO.
2, . ,
MECHANICALa, y bj
ELECTRICAL ' ACC DATE' ACC FRE
/s`- FINALS DATE INSP.
FRAMING — SAN � !
ZONING ENG.SITE NO.
INSULATION - PLUMBING
GAS
�� FIRE SPRINK ENERGY T T<
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING N Y [3 N[-]
LATH-INTERIOR s3q ELECTRICAL FLOOD ZONE A.L.u.c. ;
LATH-EXTERIOR FIRE DEPT. Y[] NC] Y ❑ N❑
SHEETROCK -Z6 k7 GRADE FEE SUMMARY
SHEAR INTERIOR I - BUILDING
SHEAR EXTERIOR O- TEMPORARY APPROVALS BUILDING
FIREWALLS _gam ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTILBUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM `
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H
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