12154 APPLICANT TO FILL IN INFORMATION WITHINRED LINES,-, US,E, ALLFO1NT.FEN ONLY
;.
BUI LDI NG PROJECT I DENTI FI ON ^ 'ISI'-" - ^" - - - PERMIT
auILOINc c y J APPLICATION & P IT 12154
ADDRESS /0^] Z lJ. ]�
O BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
sixnwTMB s�£" O7C HB �!j-d8, �CHECKON
V EFF IZ E DTV. ELECTRIC PERMIT FEE
G HONE
MONTcroRs OUTLETS-SWITCHNAMEES-RECEP 10,00/1.00
LIGHTING FIXTURES 10.00/1.00
CONTRACTOR'. PPLIANCES-RESIDENTIAL 4.00
AOofless
r . PHONE PANELS 10.00 DATE OF APPLICATION
ARCHITECT PANELS (OVER 20
GINEER 0 AMP) 20.00 PLAN CHECK FEE P.C.NO.
OR
pAl
EN
LIC.NO. SIGNS TRANS. 3.00
ARCH.SS ENG. PERMIT VALIDATION
ADORES. SPECIAL CIRCUIT 5.00 ,�AN 8 1e�gi
ZIP EMP.METER OR POL 20.00
1, �
ADDRESS - MOTORS EE FEE SCH.
ADDRESS
SERVICE CHANGE0.00 /� /J7
w w o LICENSED CONTRACTORS DECLARATION / //
< o 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 BLDGit- . ELECT. PLG. MECH.
z i Professions Code,a I y license is in full forcend elle t. ❑ ❑ ❑ ❑
z O - License Class Lie NO
0 of H Doteq�---Cants M or
_/ BUILDING PERMIT
¢ ¢ 'owN R-BUILDER I F L INFORMATION
A. MISC.- REFER TO ORD
X ; n I hereby affirm that I am exempt om the Contractor's License VALUATION $/FT.
r u o J Law for the following reason(Sec.7031.5,Business and Prol'cssions PERMIT ISSUANCE 10.00 Q-
Code:Any city or county which requires permit to construct,alter,
¢ Q 0 Improve,demolish,or repair any slrnCtUM,prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC. r
O u requires the applicant for such permit to filo a signed statement that TOTAL �1- PERMIT TO
w$ he is licensed Pursuant to the provisions of the Contractor's License
F z¢ Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
4 0 Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
Ic f$ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
w. by any applicant for a permit subjects the applicant toacivil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00 -'
of not are than five hundred dollars($500).1:
❑ 1,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,GOND. 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 FIXTURES-PER TRAP 5.00 -MOT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SYSTEM-11NC.40UTLETS 6.00
ments are not intended or offered for sale.11,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.1 2.QQ BUILDING USE
builder will have the burden of proving that he did not build or in- RES IND CON PB Omer
prove for purpose of sale.). INDUSTRIAL WASTE INTER, 30.00
❑ 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 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 contractmfs)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY- EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,B.&P.C.for this WATER HEATER T 6.00
reason
Owner Date - WATER SYSTEM i 5.00 ACC.DATE ACC.FILE NO.
WORKS S'C30MPENSATION ECLARATION WATER TREATI P. 5.00
I hereby affirm that 1 have a certificate of consent to sell'"insure' ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,or a certified
copy thereof(Sec.3800,Lab.CJ.
Policy No.-, Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z O Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
cc to CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10,00 0 � FLOODZONE A.L.U.C.
LL > COMPENSATION INSURANCE. PLG.CONTR. LIC.NO. PLG.
d 0 1Th6 section need not he completed if the permit is for one TOTAL Y[:] N❑ Y❑ IN
Z hundred dollars(S 100)or less.)
U O 1 certify that in the performance of the work for which this per, QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL f not Is issued,I shall not employ any person in any mannerso as to
U become subject to the Workers'Com ensation Laws of California.
W Date-Applicant APPlicnnt p ' BUILDING
Q. ALTER OR ADD TO MECH. 5.00 _-
So NOTICE.TO APPLICANT: If,after making this Certificate of 17x-
1.. Z emplion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F,M.) 4.00
CONSTRUCT ION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.111 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD JWITH 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 NamAddress
HEATI NG UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC , / -
Lender's Address
I certify that l have read Bios application and.Ilac that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING Iz 0
ordinances and state laws relating to building construction, and BOILER-COUP(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon file 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 CONST.TAX
may in any way accrue against said City in consequence of lire
gloating of this ermiL MECH.CONT. LIC.NO. MECH. 3
TOTAL TOTAL //6
replic t/ ontractor - )ate
OFFICE COPY
POST THIS.CARD NEAR FRONT OF BUILDING
OF CUPERTINO
CIS • ERN,ITNUN,BER
INSPECTION DIVISION 12154 '
JOB INSPECTION RECORD
116 . l 052��
PERMIT-EXPIRATION
JOB ADDR ESS UNIT# LOT#
PERMIT EXPIRES IF WORK
OWNER C TRACTOR IS NOT STARTED WITHIN
IN ECTION DATE [-INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATI - ANCE OR 180 DAYS FROM
LASTCALLED INSPECTION.
UFER
PREGUNITE
PERMIT VALIDATION
! "
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING f. 7
ELECTRICAL I''SSUANCE DATE
MECHANICAL - BLDG, ELECT. PLG. MECH,
❑ ❑ ❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION
PLUMBING
MECHANICAL
ELECTRICAL PERMIT TO
FRAMING
STORIES —TYPE CONSTR.
INSULATION
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL"ABOVE HAS BEEN SIGNED
– SO.IT FLOOR AREA TOTAL ACREAGE
ROOF
DIAPHRAGM
tlUILD USE
' RES IND CON
PB Oq,n
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑
ASSESSORS PARCEL NO.
ROUGH
PLUMBING I
- TRACT NO. PARCEL
GAS TEST NO.
MECHANICAL
• ELECTRICAL rf FINALS DATE INSP. ncG Dnte ACC FILE No.
.
FRAMING SAN a
ZONING ENG.SITE NO.
INSULATION PLUMBING
GAS
fIRE SPRINK ENERGY T-24
MECHANICAL v � IN[:D Y ❑ N�
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
LATH—INTERIOR - - ELECTRICAL _ ` fL000 ZONE A,L.U.C.
.
0-4 � ,
LATH—EXTERIOR - YIN Y NE]
DEPT. '
SHEETROCK _ j, GRADE jFEE SUMMARY
SHEAR INTERIOR BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE r
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O� PLEASE GIVE JOB ADDRESS WHEN PHONING. -
2MECHANICAL
= SEE PERMIT FOR EXPIRATION DATE '-
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE
TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY