8836 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BDILD G �, APPLICATION & PERMIT
noon
OL-I r",(1Q� .PoClt BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
8836
OwNER9 ` PLAN CHECK VALIDATION
n ME x )1kL .S ,�� CITY, ELECTRIC PERMIT FEE
(NT F--, 777 PHONE T
\ u0nrae AcroRs UTLETS-SWITCHES-RECEP 10.00/1.00 0 "
C A/I uCnOLIGHTING FIXTURES 10.00/1.00
CONTRAC
A ORE"TOJR�S T/b^e /�J1�� J PPLIANCES-RESIDENTIAL 4.00
y -44Io\ DyPHONE268-736$ PANELS 10.00 DATE OF APPLICATION
ORRCHITECT PANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P. .N .
ENGINEER
uc.NO SIGNS TRANS. 3.00
Aooa'Eas ENG. SPECIAL CIRCUIT 5,00 PERMIT VALIDATION
zip TEMP. METER OR POLE INS. 20.00 PAD )
ADDRESS rs MOTORSS H. {v7.(�j
SERVICE CHANGE 20.00 Q' /^
D o LICENSED CONTRACTORS DECLARATIONTEMP.POLE 130b0 SSU s I
av I hereby affirm that I am licensed under pronsvisioof Chapter 9 City iYE(Ev^
H < m (commencing with Section 7000)of Division 3 of the Business and e„g BLDG. ELECT.' PLG. MECH.
r- z Profevions Code,a d m license is In(call to fife R 0 ❑
Qi W Licenq 2k�/p] Lic.Number Ocity
Z,r Datc �ComtrxcWr
2 w u OWNER-BUILDER DECLARATION BUILDING PER IT
w ' H I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD INFORMATION
u.o Code:Any city Law for the following reason,(Sec.7031.5,Business and Professions 6 _ VALUATION $/FT.
I- - g PERMIT ISSUANCE 10.00 �O
or county which regmrese permit to is issuance.
alter,
rt ¢ ¢Q improve,demolish,or repair any structure,prior to its issuance,Aho ELEC.CONTR. LIC.NO. ELEC.
DLL requires the applicant for such permit to file a signed statement that TOTAL a V
w m he i5 licensed pursuant to the provisions of the Contractor's License PERMIT TO
H i law(Chapter 9(commencing with Section 71X0)of Division 3 oftlte Q/LT
io Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE 'r-^'/�"�
a H the basis for the alleged exemption.Any violation of Section 7031.5
ic mit; by any applicant for a persubjects the applicant ton,civil penal) - STORIES TYPE CONSTR.
of not more than live hundred dollars(5500).):
Penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 4.0Q OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
tended or offered for sale (Sec. 7040. 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 improve,thereon,and who does such work FIXTURES-PER TRAP 5.00 so.ET FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
Jmenu are not intended or offered for sale.11,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
I.
improvement is sold within one year of completion,the owner-
budder will have the burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
prove for purpose ofsale.). INDUSTRIAL WASTE INTER3000 - RES IND CON PB Omer
. .
❑ 1,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to comlruct 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 prnperty who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contmclons)licensed pursuant to
the Contractors License Law. SEWER-SANITARY-ST tt/10.00 TRACT NO. PARCEL NO.
❑ l am exempt under Sec..,B.&P.C.for this WATER HEAT ER W/VE 6.00
reason
Owner Date WATER SYSTEM I K C)-r� 5.00 ACD.DATE ACC.FILE NO.
WORT:ERS'COMPENSATION DFCLARA'f10N WATER TREATIN O I , 5.00
1 hereby affirm that I have a certificate of consent to selGinsum, ,,E
or a ccrtifiwte of Workers'Compensation tifieI
Compensation lnrancc,or a cer
d IIRO ZONING ENG.SITE NO.
copy themof(Scc.3800,Lab.C).
Policy No. Company
O ❑ Certified copy is hereby furnished.
Z Z ❑ Certified copy Is filed with the city inspection division. FIRE SPRINK ENERGY T-Z4
f- O Applicant MISC.- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
Cr rn CERTIFICATE,01'EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00U FLOOD ZONE A.L.U.C.
Lu > COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. qqOx
CL D (This section need not be Completed if the permit is for one TOTAL 00< (- Y❑ N❑ Y ❑ N❑
LD Z hundred dollars(S100)or less-)
U O 1 certify that in the performance of the work for which this per- DTV MECHANICAL PERMIT FEE
FEE SUMMARY
0 U mit is i>umd,1 shall not employ any person in any manner
or is to
bew t s b), the Workeri Com ensation Lows of California.
U y Date-�.-BBYY Applicant A&= ALTER OR ADD TO MECH. 5.00 BUILDING .�
} so NOTICE: TO APPLICANT: If,after making this Certificate of Ex-
F" ? empfion,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
U
provisions of the Labor Code, you must forthwith comply with FEE such provisions car thispermit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.NL) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=CF.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.
3097,CieC.L HEATING UNIT (TO 100,000 B-T.U.) 8.00 MICROFILM
Lender's Name
Lender's Address HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC p�o
I certify that I have read this application and state Ihat the above VENTILATION FAN (SINGLE) 4.00
imformmlon n correct, I agree to comply with all city ucti county BOILER-CC P(3 H.P.or 100,000 B.T.U.) 6.00 PLUMBING -Za
'information
and state lows relating to c to building construction, and my
hereby enti authorize rope property
for ins of on city to enter upon the 801 LER-COMP (Ove,100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned properly forinspof this
purposes. -
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgmcrts, ensu and expenses which CONST.TAX
may ire any way mxru Inst sa'd City m consequence of the PERMIT ISSUANCE 10.00
gFuning Of this permit. MECH.CONT. LIC.NO. MECH.
- �,t /t -3 _ g� TOTAL TOTAL f
Signature of Applicant/Contractor Date
OFFICE COPY -
POST THIS CARD NEAR FRONT OF BUILDING-
- PERMIT NUMBER
CITY OF CUPERTINO " 8$36
INSPECTION DIVISION
JOB INSPE//{ TION RECORD
PERMIT EXPIRATION .
JOB ADDRESS UNIT LOT#
PERMIT EXPIRES IF WORK -
0 NER CONTRACTOR- IS NOT STARTED WITHIN
IN T N DATE INSPECTOR 1. INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATI NANCE OR 180 DAYS FROM
UFER _ T'LAST CALLED INSPECTION.
PREGUNITE PERMn MA LIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED • ,
UNDERGROUND / L B - -
PLUMBING
ELECTRICAL '
.I uANCE o TE
MECHANICAL BLDG-- ELECT. PLG. MECH..
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BD INc RMIT
INFOR XT
WOOD FLOOR vALUATION $/FT.
PLUMBING -
MECHANICAL 'v{
ELECTRICAL „ PERMIr To -
FRAMING
qM
INSULATION ` T -
STORI S vPECONSTR.
-
\ - e OCC.GROUP RES,UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF _ 50.lT.FLOOR AREA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
HES IND CON PB op,,
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑•, 1 ❑ ❑
ROUGH ASSESSORS PARCEL NO.
PLUMBING
GAS TEST 'TRACTNO. PARCEL NO.
MECHANICAL - ..
. .
ELECTRICAL ��( FINALS- DATE INSP. ACCDATE ACCFILE NO.
FRAMING - SAN #
INSULATION �l �T �6 PLUMBING 1 �p ZONING ENG.SITE NO.
GAS
MECHANICAL
FIRE SPRINK ENERGY T-24
'
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED 1HEATING Y "1 Y ❑ u11
^O M, FLOOD ZONE fi L.0,C.
LATH—INTERIOR ELECTRICAL JL.
LATH—EXTERIOR - FIRE DEPT. - Y❑ Nv ❑ NO
SHEETROCK GRADE FEE 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
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNEDBY BUILDING INSPECTOR. MICROFILM
1 ,
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
LLI� ONE WORKING DAY•BEFO.RE REQUIRED INSPECTION: ' PLUMBING
PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z MECHANICAL
— SEE PERMIT FOR EXPI RATION DATE —
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
` OFFICE COPY