9125"APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
13UI LD1 NG PROJECT I DENTI FICA
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APPLICATION &PERM,
PERMIT NUMBER
^ ^
y G
ADDRESS
ADDRESS
I Tor�`E. atJBUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWANEA'S .� _r
�/ •15 �LG
/
IxV1G0 �N v �O PHONE .�j'TIOIL ZOO
QTY. ELECTRIC PERMIT FEE
PLAN CHECK VALIDATION
N,AMER`Ac.oR's '-7 �y
V./ G LIC. No.377 '7
UTLETS-SWITCHES -RECEP 10.00/1.00
LIGHTING FIXTURES 10.00/1.
CONTRACTORS LO Iry
ADDRESS Ked 1
PPLIANCES- RESIDENTIAL 4.00
PANELS 10.00
vHOrvE 57 f
DATE OF APPLICATION
ARCHITECT
OR
ENGINEER LIC.
` O c. rvo, 775-M
'PANELS (OVER 200 AMP) 20.00
PLAN CHECK FEE P.C. NO.
SIGNS TRANS. 3.00
ARCH.OR ENG ro;
SPECIALCIRCUIT 5.00
PERMIT VALIDATION
TEMP. METER OR POLE INS. 20.00
N. ZIP CtAx
P6/ 711(lf
ss,, [[E�D
U N 2 1 ESU1ANCATE
APPLICANTS
ADDRESS
Likzalmer"llrdyl.
MOTORS SEE FEE SCH.
SERVICE CHANGE 20.00
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and
Professions Code, my license is in full force and effect.
Cl..- Lic. Number
Date_�.!_t. L1rl5nt
Coractor_I/, k.`
-3-1-" OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License
Law for the following reason, (Sec. 7031.5, Businessand Professions
Code: Any city or county which reyuiresa permit U rcmltruct,ulteq
improve, demolish, or repair any structure, prior to its issuance, also
requires the applicant for such permit to IIIe a Signed statement that
he is licensed pursuant to the provisions of the Contractor's License
Law (Chapter 9(commencing with Section 7000) of Division 3 oflhe
Business and Professions Code) or that he is exempt therefrom and
TEMP. POLE 30.00
BLDG. ELECT. PLG. MECH.
1:3License
Ci�bf Cll�p rti o�
BUILDING PERMIT
INFORMATION
M ISC.- REFER TO ORD
VALUATION
�,.�s.�
4-u v v
SIFT.
PERMIT ISSUANCE 10.00
ELEC. CONTR. LIG NO.
ELEC.
TOTAL
PERMIT TO
I.
/,( AVLL /QQ OdC
T
CITY. PLUMBING PERMIT FEE
STORIES
TYPE CONSTR.
the basis For the alleged exemption. Any violation of Section 7031.5
by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars ($500).):
ALTER -DRAIN -WATER IEA.) 5.00
❑ 1, as owner of the property, or my employees with wages as
their sole compensation, will do the work, and the structure is not
BACK FLOW PROTECT. DEVICE 4.00
OCC. GROUP
RES. UNITS
DRAINS -FLOOR, ROOF, AREA,COND. 5.00
intended or offered for sale (See. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of
FIXTURES - PER TRAP 5.00
SO. FT. FLOOR AREA
TOTAL ACREAGE
properly who builds or improves thereon, and who does such work
himself or through his own employees, provided that such improve-
mentsarenot intended or offered for sale. If, however, the building
GAS-EA.SYSTEM-11NC.40UTLETS 6.00
or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or im-
Prove for purposeol'sale.).
❑ 1, as owner of Ilse property, am exclusively contracting with
GAS - EASYSTEM -OVER 4 (EA) 200
. . .
BUILDING USE
RES IND CDN PB Other
❑ ❑ ❑ ❑ ❑
.
INDUSTRIAL WASTE INTER30.00
licensed contractors to construct the project (Sec. 7044, Business
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 - 1 INC 5 V.B. 6.00
LAWN SPRINKLERS - OVER 5 (EA.) 1.00
ASSESSORS PARCEL NO.
contracts I'or such projects with a contmctoAs) licensed pursuant to
the Contractor'.s License Law.
SEWER -SANITARY -STORM EA. 200h/10.00
TRACT NO,
PARCEL NO.
❑ lam exempt under Sec.-, BAP.C. for this
reason
WATER HEATER W/VENT 6.00
Owner Date
WATER SYSTEM 5.00
ACC.DATE
ACC. FILE NO,
WATER TREATING EQUIP: 5.00
WORK ERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of ronsent to self -insure,
or a certificate .(Workers' Compensation Insurance, or a certified
copy thereof .r
cPolicy opygOQ Lab., APO
ZONING
ENG. SITE NO.
t7_1J pony-
❑ Certified copy is hereby furnished.
O Certified c py is file with the city Inspection Ivision.
Applicant '
FIRE SPRINK
Y ❑ N ❑
ENERGY T-24
Y ❑ N❑
MISC.- REFER TO ORD.
CIiNTIPICA'T. P E%IiMI'TION FROM WORKERS'
PERMIT ISSUANCE 10.00
FLOOD ZONE
A,LU.C.
PLG CONTR. LIC. NO.
TOTAL
COMPENSATION INSURANCE
(This Section need nal be completed if the permit is for one
Y❑ N❑
Y❑ No
OTY. MECHANICAL PERMIT FEE
FEE SUMMARY
hundred dollars(SI00) orless)
I certify that in the performance ol'the work for which this per.
mit is issued, I shall not employ any person in any mannerso as to
BUILDING
�S�
become subject to the Workers' Compensation Laws of California.
Date ApplicantALTER
OR ADD TO MECH. 5.00
NOTICE TO APPLICANT: If, after ...String this Certificate of Ex
eruption, you should become subject to the Workers Compensation
APPLIANCE 5.00
PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
such provisions or this permit shall be deemed revoked
FEE
AIR HANDLING UNIT (TO 10AWC.F.M.) 4.00
AIR HANDLING UNIT (OVER 1000C.F.M.) 6.00
SEISMIC FEE
a
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
EXHAUST HOOD (WITH DUCT) 5.00
the performance of to or for which this p mit is issued (Sec.
3097, CN.C.).
MICROFILM
HEATING UNIT (TO 100,000 B.T.U.) 8.00
HEATING UNIT (OVER 100,000 B.T.U.)9.50
'ELECTRIC
Lenders Name
Lender's Address
I certify that I h� sappl�,'yy6- -J state that the above
information is car e/ �t: 9-agieF to c6mp}ylMtlr all city and county
ordinances and slate laws relating to building construction, and
VENTILATION FAN (SINGLE) 4.00
PLUMBING
BOILER- COMP (3 H.P. or 100,000 B.T.U.) 6.00
BOILER -COMP (0., 100,000 BTU)SEE FEE SCH.
MECHANICAL
hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
MISC. - REFER TO ORD.
CONST. TAX
.(We) agree to save, indemnify and keep harmless the City of
Cupertino against liabilities, judgments, costs and expenses which
may in any way accrue against said City in cousequence,of the
PERMIT ISSUANCE 10.00
MECH. CONT. LIC: NO. MECH.
granting fthis permit.
MA .- 0-
TOTAL
TOTAL
Signature of pi nt Conlmctor
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
CITY41F CUPERTINO �;
INSPECTION DIVISION
JOB INSPECTION RECORD
Q}� /�
�s &6'
JOB ADDRESS L"�f O/ orm •'-6 UNIT# _LOT#
^ypV ��(� , ftl T rU
OWNER I lA I fu U CONTRACTOR W � ! l,iL
'
RMITNDMRE
91��}}. Cas
PERMIT EXPIRATION
' PERMIT. .EXPIRES IF WORK
IS NOT STARTED WITHIN
180 DAYS OF PERMIT ISSU-
ANCE ORA
AVS FROM
CALLS I SPECTION.
INSPECTION DATE INSPECTOR
INSPECTION RECORD
FOUNDATION
�j GG :;J�LAST
G_a OSS
LIFER -
PR EGUNITE
-
PERMIT NA arloN
-
ISSUANCE DATE
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND/SLAB
PLUMBING
-
ELECTRICAL
MECHANICAL
BLDG
ELECT.
❑ '
PLG. MECH.
❑ ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED
BUILDING PERMIT
INFORMATION
WOOD FLOOR
VALUATION
^�
SIFT.
PLUMBING.
MECHANICAL
ELECTRICAL, - -
PERMIT TO
T� t. -2m
c{� KGI,Wa
FRAMING
INSULATION
sroares
rrPE coesrR,
•,
"
OCC GROUP
RES. UNITS,
rPLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF
50. FL FLOOR AREP
TOTAL ACREAGE
DIAPHRAGM
G .
'BUILDING USE
HES IND : GOryPB Olner
E:l ID El • 1:1 El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED
ASSESSORS PARCEL NO,
'
ROUGH
PLUMBING
GAS TEST
TRACT NO.
PARCEL NO.
MECHANICAL
ELECTRICAL � jy - s
FINALS DATE INSP.
ACC. DATEACC.
-
FILE NO.
FRAMING yfA�Q•d . y
SAN #
•
INSULATION
PLUMBING
ZONING
ENG. SITE NO. '.
J
GAS
FIRE SPRINK
v N �•
ENERGY Tp
Y ❑ No
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
HEATING
FLOOD ZONE
Y ❑ N[]
A;L.0 c.
Y ❑ N❑
LATH -INTERIOR
ELECTRICAL
LATH -EXTERIOR
FIRE DEPT. A
SHEETROCK -
GRADE -
FEESUMMARY
SHEAR INTERIOR
BUILDING r,
BUILDING
SHEAR EXTERIOR
11
RY APPROVALS ;-^.
FIREWALLS
ELE
PLAN CHECK
FEE .
GAS '
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED
OCCUPANCY I I
SEISMIC FEE
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR.
MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505,
F ONE WORKING DAY BEFORE REQUIRED INSPECTION.
00 PLEASE GIVE JOB ADDRESS WHEN PHONING.
Z
-SEE PERMIT.FOR EXPIRATION DATE -
ELECTRIC
PLUMBING
MECHANICAL
CONST. TAX
•
IMPORTANT!
PLEASE READ.REVERSE SIDE BEFORE
CALLING FOR FINAL INSPECTION.
TOTAL
OFFICE COPY
r-