C 9065 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUI LDI NG PROJECT I DENTI FICA - PERMIT NUMBER
✓,, BDILDIN APPLICATION & PEF tA%T
FODnE55 9065
BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
NAMEOWNERS ./ Fa !A PLAN CHECK VA LIOATJON
NAME t 1��NNI � TI"1M IL L�'C � `/^Ulll//\'
C`tC$ 11 CITY.. ELECTRIC PERMIT FEE / &L+ _0
PHONE �
CONTPALTOR'S P [ B �/
V NOME '; OUTLETS 10.00/1.003
-LS LIGHTING FIXTURES 10.00/1.00 `(
CONTRACTOR S. PPLIANCES-RESIDENTIAL 4.00
ADDRESS �/1x __�
Q Q/-) PHONE !'a�,� PANELS 10.00 GATE OF APPLICATION
OR
CHITECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
up
c.ND. �2-1� SIGNS TRANS. 3.00
ADDRESS EN ` , SPECIAL CIRCUIT 5.00 PERMI ON
'300 S V V ZIP EMP.METER OR POLE INS. 20.00
APPLICANTS MOTORS SEE FFM
(J' ✓V t
ADDRESS
IN d SE RVICE CHANGE 20.00
r ♦ �p
Doo LICENSED CONTRACTORS DECLARATION TEMP.POLE I 9 .BO Cit @rio
w
a U v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
w a w (commencing with Section 7000)of Division 3 of the Business and city O BLDG. ELECT. PLG. MECH.
H w i Professions Code,.,oKt� y license is in full force n c c
z
0. - License Clus3_IZ_Lic.Number � i-
o m r w Date_L-..��¢�-contractor-q.wJ-A.q_p.�__
ams -+ BUILDING'PERMIT
o a D OWNER-BUILD17R DECLARATION INFORMATIONS
K
;w w I hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
uOa Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE _ 10.00 VALUATION $/FT.
L- - Code:Any city orcounly which requiresa permit toc'unit"ct.alter, Oma' �-y--d
w i ELEC.CONTE. LIC.NO.
a improve,demolish,or repair any structure,prior m its issuance,also ELEC.
y D,a. requires the applicant for such permit to file a signed statement that TOTAL (0 O r/ PERMIT TO
w m m he is licensed pursuant to the provisions of the Contractor's License
H z s Law(Chapter 9(commencing with Section 7000)of Division 3 oflhe
a Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
X Imo- $ the basis for(lie alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
by any applicant for A permit subjects the applicant too civil penalty ALTER-DRAIN -WATER IEA.) 5.00
of not more than rive hundred dollars($500).):
❑ 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,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 docs such work FIXTURES-PER TRAP 5.00 SQ FT.FLOOR AREA TOTAL ACREAGE
• himself re through his own employees. le,I provided,howevt au ch improve-
hioupts mself a through his or employees,ffered for ithat sthe building GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EASYSTEM-OVER 4 IEA.) 2.00 aulLmrvG USE
builder will have the burden of proving that he did not build or im . RES IND CON PB OhM1ar
.
prove for purpose ofsale.). INDUSTRIAL WASTE INTER. 3000
❑ 1,as owner of the property;am exclusively contracting with 1:1 11 El Q
licensed contractors to 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 riot apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
convects for such projects with a contractorts)licensed punuunt to SEWER-SANITARY-STORM EA.200ft/10.00
the Contractor's License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK F.RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00 Ali
I hereby affirm that I have a certificate of consent to sell'-insure,
or a certificate of Workers'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(See.3800,Lab.C.Le 7L •-r 4� -
Policy No. Company
O ❑ Certified 'oDY is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 CertifieJ i filed i the y inspection division.
O A; iEnt 'Y`'' s MISC.- REFER TO ORD. v NE] v 0 N[3
CC CERTIFICATE OSPTIPROMWORKFRS' PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.u.c.
LU COMINWION INSURANCE R.
PLG.CONTE. LIC.N0. PLG.
CL Z( This section need not be completed if the permit is for one TOTAL Y E] NC] Y C] NE3
hundred doll...($1001 or less.) ,
U O 1 certify that in the performance of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY'
LL F mit is issued,I shall not employ any person in any manner so as t0
O W become subject to the Workers'Compensation Laws of California.
Ca. Datc Applicant 5.00 BUILDING
} Ln NOTICE TO APPLICANT: If,after making this Certificate of Ex- ALTER OR ADD TO MECH. " W
Z emption,you should become subject to the WorkersCompensation
F. '_ APPLIANCE 5.00 PLAN CHECK
provisions the Labor Code, you Most forthwith comply with FEE
U such provisions or this permit shat be decmeA revoked. AIR HANDLING UNIT(TO 10,0000 F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 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: MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 6.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and state 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(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes: BOILER-COMP (Over 100,000 BTU)SEE FEE SCR. MECHANICAL
(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
rimy in any w' acenhc against said City in consequence of the
gr lin Ili , ORMECH.CONT. - LIC.NO. MECH.
�7 . (-/ 7.,➢1 TOTAL TOTAL -27 QQ
Signal era of Ap icant Contractor Date
OFFICE COPY -
11
POST THIS CARD NEAR FRONT OF BUILDING
PFRMIT'NUMBER
CITWIF CUPERTINO X065
'INSPECTION DIVISION
JOB INSPECTION RECORD
PERMIT EXPIRATION
•. - iT
JOB ADDRESS• UNI # LOT# ' PERMIT EXPIRES IF WORK
OWNER CONTRACTOR' L` IS NOT STARTED WITHIN
INSPECTION INSPECTOR (I�NSPyCION RECORD f PERMIT ISSu
FOUNDATION ANCE OR 180
DAYS FROM
UFER LAST CALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED w� Ly_ '
UNDERGROUND /SLAB
PLUMBING
ELECTRICAL ISSUANCE DATE
MECHANICAL BLDG. ELECT. PLG.. MECH."
O I O: O
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED IBUILDING PERMIT'
- INFORMATION
WOOD FLOOR. VALUATION $/FT.
` PLUMBING . � .
MECHANICAL -
ELECTRICAL _ PRAT TO ,
FRAMING - -
STORIES PE CONSTR.
INSULATION '
OCC.GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED -
ROOF SO.FT.FLODR AREA TOTAL ACREAGE
DIAPHRAGM BUILDING USE
, I I I
RES IND CON PB OMl
APPLY NO ROOFING.UNTIL ABOVE HAS BEEN SIGNED 0 0 0 0 O
ROUGH
ASSESSORS PARCEL NO.
' � -
PLUMBING -
GAS TEST TRACT NO. PARCEL NO.
MECHANICAL
ACC.DATE ACC,FILE NO.
ELECTRICAL j FINALSDATE INSP.
FRAMING _ SAN #
"� ZONING ENG.SITE NO.
INSULATION • PLUMBING
GAS •
MEC ANI AL 'FIRE SPRINK. ENERGY T2
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HE ING
Y0 NO O_ .NO .
FLOOD ZONE
LATH-INTERIOR EETRICAL -
LATH-EXTERIOR - FIR DEPT - Y Q ' NQ, Y O NQI
SHEETROCK - GRADE - - FEESUMMARY '
SHEAR INTERIOR
Btli BUILDING;
SHEAR EXTERIOR TEMPORARY APPROVALS r;
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED JOCCUPANCY I I SEISMIC FEE _
OCCUPANCY OF BUILDIN G IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUI LDING INSPECTOR. MICROFILM
ARRANGE`FOR INSPECTION BY PHONING 252=4505, ELECTRIC
F ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
CIS PLEASE GIVE.JOB ADDRESS WHEN PHONING.. '
— SEE PERMIT FOR EXPIRATION DATE — MECHANICAL'
IMPORTANT! coysT.Tgxc
PLEASE READ,REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
' OFFICE COPY '
-I