11829 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
ELI LOI NG PROJECT I DENTI FICATION - PERMIT NUMBER
al1ILDINGAPPLICATION & PERMIT
Ao ;E 1
G.78 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL 1 1 829
OWNER'S PLAN CHECK VALIDATION
• J NAME OTY. ELECTRIC PERMIT FEE
/d4E-7'7- PHONE
CONTRACTOR'S
NAME f=A „ S- UTLETS-SWITCHES-RECEP 10.00/1.00
E0.m, �a-r rn.• LUNO,-- �S 3 LIGHTING FIXTURES 10.00/1,00
CONTIACT s - PPLIANCES-RESIDENTIAL 4.00
ADOR East g0. , acA IC
AF p
f•, /.2 Zj a YJ,j� 9p PHONE3'70.7Q&2 PANELS 10.00 DATE OF APPLICATION
ORCNITECTPANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.N0.
OR
ENGINEER �
LIC.No, SIGNS TRANS. 3.00
ADDRESS ENG. SPECIAL CIRCUIT 5.0Q PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 20,00
APPucwrvrs MOTORS SEE FEE SCH.
ADDflEaS ��-
SERVICE CHANGE 20.00 S//
mF.o
Z.
LICENSED CONTRACTORS DECLARATION �// /
< uG I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
Z i (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
7 Professions.Co e,and In Iiceyy( m full force and a fgcI ❑ ❑ ❑
2 s-uMS License Class- a r w'I,ic uanbe10]_J�� p
O H
Date Contractor
a x ,A-n BUILDING PERMIT
¢ ec M a
OWNER-BUILDER DECLARATION INFORMATION
o a U MISC.- REFER TO ORD I-
w;LL vHi 1 hereby affirm that I am exempt from the Contractor's License QG -VALUATION
S/FT.
Fay ¢ Law for the following reason(Sec.7031.5,tlusinessand Professions PERMIT ISSUANCE 10.00
Code:Any city Circularity which requires permit to construct,alter,
2 ¢ ¢Fa improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTE. LIC.NO. ELEC. (�
o S, requires the applicant for such permit to file a Signed statement that TOTAL LII`J PERMIT TO
n w m he is licensed pursuant to the provisions of the Contractor's License .�
FIQ
Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe
i c Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ F the basis for the alleged exemption.Any violation of Section 7031.5 STORIES T E CONSTR.
by any applicant for a permit subjects the applicant toa civil penalty ALTER-DRAIN III VENT-WATER IEA.) 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,AR EA,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 FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mentsarenotintendedorofferedforsale.If,however,the building GAS-EA.SYSTEM-11NC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.QD BUILDING USE
builder will have the burden of proving that he did not build or im- REB IND CON PB Other
prove for purpose of sale.). INDUSTRIAL WASTE INT ER. 30.00
❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors 1. Construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORSPARCEL NO.
and Professions Code:The Contractor's License Law docs not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contractorfs)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ lemexemptunder Sec. ,B.&P.C.bu ODs WATER.HEATER W/VENT 6.00
reason
Owner . Data WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EOUIP. 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
Copy thcrcof(Sec.3R00,Lab.C.). D
Policy No. Company
Q ❑ Cerlifieit Copy rs If byf mished. FIRESPRINK ENERGY T-24
Z Z A Certified Is file with a city Ilion division. MISC.- REFER TO ORD.
F O APPliwnt Y ❑ N❑ Y ❑ N❑
K - : TIFICATE OFEXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LU COMPENSATION INSURANCE PILO.CONTE. LIC.NO. PLG.
CL o (This section need not he completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) Z hundred dollars 1$100)or less.)
V O 1 certify that in the performance of the work for which this per, DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mil is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
0 w Dale Applicant BUILDING
a ALTER OR ADD TO MECH. 5.00 q
} r4 NOTICE TO APPLICANT: If,after making this Certificate va Ex-_
F Z emptio n you should become Code, yo to the W forthwith
comply ion APPLIANCE 5.00 PLAN CHECK
provisions io the Labor Code, you mus[ forthwith comply with FEE
V such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000 C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER IO,000C.EM.) 6.00 SEISMIC FEE ,S�D
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. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.). -
Lender's Name HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
. I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct:1 agree to comply with all city end county PLUMBING
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.1 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTUI SEE FEESCH. 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,judgm is, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way acerue-against Id City in consequence of the
grantin this pe d MECH.CONT. LIC.NO. MECH.
•/,'.��, TOTAL TOTAL 3�a
u e Ap Icanl/Contractor Dale
OFFICE COPY
" POST THIS CARD NEAR FRONT OF BUILDING
PERMIT NUMBER'
CITY OF CUPERTINO 11829 .
INSPECTION DIVISION `,
JOB INSPECTION RECORD
I 'z�„ PERMIT EXPIRATION
V
JOB ADDRESS /D IlJ�V L(//L flLi UNIT# LOT '
PERMIT EXPIRES,IF WORK
OWNER 1 CONTRACTOR r-YC(� ITYL -Q rYK.I to IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - •
ANCE OR 180 DAYS FROM
LIFER LASTCALLED INSPECTION..
PERMIT VALIDATION
PREGUNITE ,
.i
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL 1 ISSUANCE DATE
MECHANICAL + - BL G. ELECT. -PLG. MECH.
❑ ❑ . ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
' INFORMATION
WOOD FLOOR
VALUATION SIFT.
PLUMBING - -
MECHANICAL
'PER M_IT TO
ELECTRICAL -
y .�.- ,I
FRAMING • ���r E
STORIES TVP CONSTR.:
INSULATION
OCC.GROUP RES'.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF SO.FT.FLOOF ANEA TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
HES IND CON PS OMee '
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED 0 ❑ Ej ❑ El.
ASSESSORS PARCEL NO,
ROUGH
PLUMBING -
TRACT NO. PARCEL NO.
GAS TEST
MECHANICAL
ACC.DATE ACC,FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING, SAN #
' ZONING' ENG.SITE NO.
INSULATION PLUMBING
GAS
- MECHANICAL FIRESPRINK ENERGY T 2
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING � OO NE Y E] NE]
LATH—INTERIOR ELECTRICAL FLOOD zo • A.L;u.c. -
LATH-EXTERIOR FIRE DEPT. _ Y❑ ."❑ Y I] '"❑
SHEETROCK A GRADE y FEE SUMMARY
SHEAR INTERIOR BUILDING /by BUILDING
SHEAR EXTERIOR • - TEMPORARY APPROVALS
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
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
H ,.ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
O� 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
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