8468 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aUILDING APPLICATION & PERMIT - 84GS
ADDRESS
I ' r BUILDING - ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME
OTY. ELECTRIC PERMIT FEE
L I=_'f7d PHONE - Guy'
',NOMERAcroRs [OUTLETS-SWITCHES-RECEP 10.00/1.00
/, LIC.No. 6J94 LIGHTING FIXTURES 10.00/1.00
"}' ADDRESS ORS PPLIANCES-RESIDENTIAL 4.00
SIn Jv).7
[L/r; ",-T PHONE /II PANELS 10.00 DATE OF APPLICATION
ORCHITECr PANELS (OVER 200 AMP) 20.00 PLAN CHECKFEE P.C.NO.
ENGINEER
LIC.No, SIGNS TRANS. 3.00
ARCH OR END SPECIAL CIRCUIT . 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP.METER OR POLE INS. 20.00
APPLICANT SMOTORS SEE FEE SCH. f
ADDRESS
AooR
SERVICE CHANGE 20.00
'00 LICENSED CONTRACTORS DECLARATION TEMP.POLE 30.00
u v I hereby affirm that I am licensed under provisions of Chapter 9
ISSUANCE DATE
y a y (commencing with Section 7000)of Division 3 of the Business and BL ELECT. PLG. MECH.
H 7 i Professions Cod c I d licenxe is in full fort and ctice t. 9
2 o y - License Class_Q.� Lic.Number=
Z
rw Date ' g//74l,� Contractor , /�
a Y E 7 BUILDING PERMIT
w u OWNER-BUILDER DECLARATION
w 3 LL 1 hereby aRirnl that I am exempt from the Contractors License
MISC.- - REFER TO ORD INFORMATION
HLLoj Law for the lollowingteasm,(See.7031.5.Business and Professions PERMIT ISSUANCE VALUATION $/FT.
10.00
Code:Any city or county which requiresa permit to constn¢L al[eq a q 4 O
a, ¢¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC. 7
u w m, requires the applicant for such permit to file a signed statement that TOTAL PER TO
he i licensed pursuant to the provisions of tine Contractor's License
HiQ
Law(Chapter 9(commencingwith Section 7000)of Division 3 of the /
f E o Business and Professions Code)or that he is exempt therefrom and DTV. PLUMBING PERMIT FEE
H o the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPECONSTR.
dam by any applicant fora permit subjects the applicant toacivil penalty ALTER-DRAIN& VENT-WATER (EA.) 5.00 /
of not more than five hundred dollars(SS001.1:
Cl 1,as owner of tire property,or my enlployces 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,AREA,COND. 5.00
Code:The Contractor's License Law docs not apply to an owner of `
property who builds or improves thereon,and who docs such work FIXTURES-PER TRAP 5.00 SO.FT,FLOOR AREA TOTAL ACREAGE
.
himself are through his or offerloyecssle,It,ed however,
the
improve- GAS-EA.SYSTEM-11 NC.4 OUTLETS 6.00
mcmts um not it I, old or offered I'or sale.If,however the building
b improvement ill have
is sold within one year of completion, the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will hove the burden of proving that he did not build or int- BUILDING USE
prove for purpose of sale.). INDUSTRIAL WASTE INTER. 30.00 t❑ ❑N ❑ D❑r
❑ d as owner of the property,he exclusively contracting with
licensed contractor : construct the project(See. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
mol Professions Code The hontmets o 1impro,Law(toesit()(apply
to tr owner of property who builds tr improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects wish a contmetor(sl licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
❑ I am exempt under Sec.-,If&P.C.for this WATER HEATER W/VENT 6.00
lral al
Owner flat, WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORK ERS'COMPHNSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate oI'conseat is,self-insure,
or n certificate of Workers'Compensation Insurance,or,a certified ZONING ENG.SITE NO.
copy thcrcyl((v$-y _$QA.yb.CJ.
�.�.. ......ten y 511')'6
O ❑ Cetlified copy is hereby furnished. FIRE SPRINK ENERGY T 24
z Z � Cenifed Copy is filed with the city inspection division.
A p"plicant �/5f Misc.- REFER TO ORD.
F0 Y•''�''NI . Y N❑ Y ❑ N❑
-
jr -/ CERTI FICA117 OF EXEMPTION PROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
LUC041-NSATION INSURANCE PLG.CONTR, LIC.NO. PLG.
d O ('This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
::) Z hundred dolla(1(SIOOa Or less.)
U O I certify that in the performance of the work]Or 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 to
Uw become subject to the Workers''Coalictintion Laws of California-
0. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} N NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F Z emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
pr visions of the Labor Code, you must forthwith comply with FEE
U such.....visions m this permit shall be deenmd revoked. AIR HANDLING UNIT(TO 10)000C.F.M.) 4.00
CONST RUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10A000.EM.) 6.00 SEISMIC FEE `?>
I hereby affirm that there is a cfmstomliom,lending agency for EXHAUST HOOD(WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,CiveC). HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Name
Lenders Address H EATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
I certify that l have read this application and State that the above VENTILATION FAN (SINGLE) 4.00
information retail,is
correct. [-agreee oc comply with all city and county PLUMBING
farm.antis and State laws to building construction. and BOILER-COME(3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purpuses.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD. r
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 10.00 CONST.TAX
To in an ay accrue egp'nst sa'0 City in Consequence of the
gran is n is pcl'mit. / MECH.CONT. LIC NO. MECH.
✓ .,� ( � i/2 cE TOTAL TOTAL
yx Sig re of Applican t/ ntractor Data
/// INSPECTOR COPY
POST THIS CARD NEAR FRONT OF BUILDING
MIT NUMBER
CITY OF CUPERTINOss
INSPECTION DIVISION
JOB INSPECTION RECORD
�, �,/ �s„// •, PERMIT.EXPIRATION
JOB ADDRESS��7 ✓ •i / T/.�/L// # LOT# PERMIT EXPIRES IF WORK
OWNER CONTRACTOR i IS NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION 13ECORD 180 DAYS OF PERMIT ISSU-
FOUNDATION - ANCE OR 180 DAYS FROM
LIFER
} LAST CALL ED INSPECTION.
PR EGUNTE - - - PERMIT VALIDATION
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED /DA UNDERGROUND /SLABPLUMBINGELECTRICAL ISSUAN
MECHANICAL- 7 B ELECT. PLG. MECH.
DD NOT POUR FLOOR UNTIL,ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR INFORMATION
VALUATION SIFT. .
PLUMBING41
MECHANICAL -
ELECTRICAL PER MITT
FRAMING
INSULATION STo TVP ONSTTL
OCC,GROUP RES.UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
ROOF . • SQ,FT.FLOOR AREA _•TOTAL ACREAGE
DIAPHRAGM
BUILDING USE
RES IND CON . PB Ober
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED - ❑ cl ❑' ❑ 11 '
ROUGH.
ASSESSORS PARCEL NO.
,
PLUMBING -
GAS TEST TRACT NO. PARCEL No.
MECHANICAL -
ACC.DATE ACC.FILE N0.
ELECTRICAL - FINALS DATE INSP.
FRAMING - to 7-77 SAN n '
ZONING ENG.SITE NO.
INSULATION PLUMBING 1,( ,
GAS
MECHANICAL FIRE SPRINK ENERGY T"]4
COVER NO WORK UNTIL ABOVE HA4 BEEN SI NED HEATING ❑ "❑ ❑ "❑
LATH—INTERIOR ELECTRICAL FLOOD ZONE A.L.u.c,
LATH—EXTERIOR FIRE DEPT„ • Y❑ N❑ Y ❑ N❑
SHEETROCK GRADE FEE SUMMARY
SHEAR.INTERIOR BUILDING — Ll
SHEAR EXTERIOR TEMPORARY APPROVALS • BUILDING.
FIREWALLS IELECTRIC 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
'ARRANGE FOR INSPECTION BY PHONING 252.4505, ELECTRIC
Iu' 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 _ '