11144/
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
k k
so APPLICATION & PERMIT 11144
55 BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
i' 'sCHECK VALIDATON
OTV. ELECTRIC PERMIT FEE Ike,_PHaryACTORS UTLETS•SWITCHES-RECEP 10.00/1.00 3 �j
W NAME
rIC,NO. LIGHTING FIXTURES 10.00/1.00
CONTRACTORS APPLIANCES-RESIDENTIAL 4.00
ADDRESS
PHONE IPANELS 10.00 DATE OF APPLICATION
ARCHITECTPANELS (OVER 200 AMP) 20,00 PLAN CHECK FEE P.C.NO.
OR
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ARCH.OR ENG. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT MOTORS SEE FEE SCH. ,�J
ADDRESS ///�_
SERVICECHANGE 20.00 / /
woo LICENSED CONTRACTORS DECLARATION tp�17 `(f Y
a v v I hereby affirm that I am licensed under provisions of Chapter 9 ISSUA CE DATE
N a .0 (commencing with Section 7000)of Division 3 of the Business and LDG. ELECT, PLG. MECH.
H D z Professions Code,and my license is in full force and effect. ❑ ❑ ❑
o z m W License Class Lic.Number
Dale Contractor
`a x E BUILDING PERMIT
¢ ¢ w OWNER-BUILDER DECLARATION INFORMATION
o a MISC.- REFER TO ORD
X R. N I hereby affirm that I am exempt from the Contractor's License Vn 'A/TII�ON/\) S/FT.
� u04 Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00
Code:Any city or county which requires a permit to construct,alter,
¢ 4a ¢ p improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
ii: O u requires the applicant for such permit to File a signed statement that TOTAL PERMIT TO
u w m y he is licensed pursuant to the provisions of the Contractor's License O
Hi>
Law(Chapter 9(commencing with Section 7000)of Division 3 of theVIP
a Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
at $ the basis for the alleged exemption.Any violation of Section 703 L5 STORIES TYPE CONSTR.
d ; by any applicant for a permit subjects the applicant to a civil penally ALTER-DRAIN -WATER (EA.) 5.00
of not more than five hundred doll."($5000.):
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00
their sole compensation,will do the work,and the structure is not OCC.GROUP RES.UNITS
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
p property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 sa.FT.FLOOR A A TOTAL ACREAGE
himself or through his own employees,provided that such improve.
1 marls are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
or improvement is sold within one year of completion, the owner GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that he did not build or im- /BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 RES I D CON PB oma,
Cl 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 contractor(s)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200tt/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&P.C.for[his WATER HEATER WIVENT 6.00
na
owneso
r Dale WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that I have a certificate of consent to self-insure.
or a certificate of Worker'Compensation Insurance,or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.). ,
Policy No. Company
0 ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant Y❑ N❑ Y ❑ N❑
= m CERTIFICATE OF EXEMPTION FROM WORKERS, PERMIT ISSUANCE 10.00
FLOOD ZONE A.L.U.C.
UJ > COMPENSATION INSURANCE PLG.CONTR. LIC.NO, PLD.
1 O (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y ❑ N❑
::) Z hundred dollars IS 100)or less,)
U O 1 certify that in tire performance of the work for which this per- CITY MECHANICAL PERMIT FEE FEE SUMMARY
L f mit is issued, I shall not employ any person in any manner so as 0
U become subject to the Workers'Compensation Laws of California.
U y Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} to NOTICE TO APPtLICAN'f: If,after making this Certificate of Ex-
L.. ? emption,you should become subject to the Workers'Court Reasalion APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10MC.F.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. - MICROFILM
3097,Civ.CJ. HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
Lender's Address
1 certify that I have read this application and stale that the ahova VENTILATION FAN (SINGLE) 4.00
information is correct. 1 agree to comply with all city and county PLUMBING
ordinances and state laws relating.to building construction, and BOILER-COMP(3H.P.Dr100,000B.T.U.) 6.00
l hereby authorize representativesof this city to enter upon the BOILER-COMP (over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify end keep harmless the City of MISC.• REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
may in any way accrue against said City in consequence of the PERMIT ISSUANCE 10.00
"-; rami" of this petmitn MECH,CONT. LIC,NO. MECH. �a
Ci/l/ G,�� TOTAL TOTAL ! 3 3�
�9 ��or - L
Signature oCAppllcant/Contractor Data
OFFICE COPY
POST THIS CARD NEAR FRONT OF BUILDING
♦.-� - PFRMIT NUMBER
CITY OF CUPERTINO 91144
INSPECTION DIVISION
X JOB INSP TION RECORD �.
' PERMIT EXPIRATION
JOB ADDRESS UNIT' LOT# PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPEC 10 DATEINSPECTOR INSPEV_IONECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - - ANCE OR 180 DAYS FROM
LIFER LASTCALLED INSPECTION.
PREGUNITE PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED /J J
UNDERGROUND /SLAB
PLUMBING w /off
ELECTRICAL ISSUANCE DATE
MECHANICAL BL=ELECT. MECH.
e ❑ ❑ ❑
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
INFORMATION
WOOD FLOOR VALUATION $IFT.
PLUMBING
MECHANICAL
ELECTRICAL +vERMlyio r 1
FRAMING
Si IE T PE CONS
INSULATION
� OCC.GROUP RES.UNITS
•r s
Y PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
sD FL FLOOR AREA TOTAL ACREAGE
ROOF
. 4-/
DIAPHRAGM BUILDING USE -
RES IND CON PB 00e '
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ❑ ❑ ❑ ❑•
ROUGH , ,
ASSE5SORSPARCEUNO.
"
PLUMBING r -
GAS TEST - TRACT NO. PARCEL NO,
MECHANICAL
ELECTRICAL —25� FINALS DATE INSP. Acc.DATE ACC.FaE No.
- FRAMINGSAN #
INSULATION PLUMBING
a3 8 ZONING ENG.SITE N0.
GAS
FIRE SPRINK ENERGY T@G
MECHANICAL Y [3 N[j Y ❑ NE]
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.U.C.
LATH—INTERIOR ELECTRICAL
LATH—EXTERIOR FIRE DEPT. Y❑ "(—] Y ❑ No
SHEETROCK — GRADE FEE SUMMARY
SHEARINTERIOR BUILDING
SHEAR EXTERIOR, Z TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUILDING IS NOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
T
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
LU ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
z PLEASE GIVE JOB ADDRESS WHEN PHONING.
' — SEE PERMIT FOR EXPIRATION DATE — MECHANICAL
IMPORTANT! CONST.TAX
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.,
OFFICE COPY