16866 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL_ POINT PEN ONLY
-PERMIT NUMBER
BUILDINGBU I LDING PROJECT I IDENTIFICATION APPLICATION*& PERMIT
ADDPS
pp U�ZQ za ' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S ! / - PLAN CHECK VALIDATION
MAY � QTY. x . ELECTRIC PERMIT FEE
Zr� F � BHVNE
CAMEO .o/a.�s //J y UTLETS-SWITCHES-RECEP 10.00/1.00 '
NAME �H N`®/ 3�PPS
LIGHTING FIXTURES 10.00(1.00
( uc.No.
CONTRACTOR'S [�// pPLIANCES-RESIDENTIAL 4.00
AOOR S /[ l V✓� ��✓ 0 1,
, PHON PANELS 10100 DATE OF APPLICATION
ARCHITECT PLAN CHECK FEE P.C.No.
OR PANELS (OVER 200 AMP) 20.00
^^ - ENGINEER _
uc.No. SIGNS TRANS. _ l•3.00 '
moo iSSS era. SPECIAL CIRCUIT 5.0E PERMIT VALIDATION
.PIP TEMP.METER OR POLE INS. 20.00 _
APPLICANTS a MOTORS - SEE FEE SCH.
ADDaE
SERVICE CHANGE 20.00
,02
0o LICENSED CONTRACTORS DECLARATION
BE v U I hereby affirm tlnat I am licensed under provisions of Chapter 9 - PAID
ISSUANCE DATE
(commencing with Section 7000)of Division 3 of the Business and _ - DG. ELECT. PLO. MECH:
WD z Professions Code,' d my license is in full fore d --
0
-
O y License Class Lic.Number EJ JK E
E z r Date Contractor_l+yl+�p,',%�J
RATION / BUILOING.PERMIT
¢ ¢w o OWNER-BUILD
Iik DECLARATION INFORMATION
E
3 LL N I hereby'uffnrn that I am exempt from the Couloutor's License MISC.- VALUATION S/FT.
H .. O J Law for hire Following rcason.(Sn.7031.5,Busincssand Professions PERMIT ISSUANCE 10.00 ZQ'D
sP Code:Any city or county which requires a permit to construct,alter,
re
QUO improve, or repair any structure,prior to its issuance.also ELEC.CONTE_ LIC.NO. ELEC.
O¢ requires the applicant for such permit to file a signed statement that TOTAL J' +]
i
PERMIT TO
K
" he is(Chapter
pursuant to the provisions of 00L)ofDiet.(s License - ,
H i he
Q law.(Cha nd professions
Codeng with that
7s eseci t the eirorn and
- �•.
Business and Professions Code)or that he is exempt therefrom and ETV. PLUMBING PERMIT FEE EC.
¢ r the basis for the alleged exemption.Any violation otoaSection malty STORIES TYPE CONSTR.
� ; � by anyapplicantfor upquited Abject.the 0pplicanuoacivil penalty ALTER-DRAIN -WATER (EA.) 5.00
of not more,lhan five hundred dollars ISSOOIJ:
❑ I.as owner of the property.m 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,AREA,COND. 5.00
Code:The Contractor's License Law loos not apply to nowwner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself re through his own employees.provided that such imlrzwe-
mmselents fonotimmndedor offered fornemployee sale.provided
that r.such
cmprovg GAS-EA.SYSTEM-1INC.4OUTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 2.00 BUILDING USE
Builder will have the burden of proving that he did not build or im- RES IND CON PB Omer
prove for,purpose of sale.). INDUSTRIAL WASTE INTER. 30.00
, ❑ I,a owner of the property,am exclusively contracting with ❑ • ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044, Bushes LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO,
' and Professions Code: I'he 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].,such projects with a contractons)licensed pursuant to
the Contractor's License Law, SEWER-SANITARY-STORM EA.200ft/10.00 .TRACT NO. PARCEL NO.
-- - '❑ 1 am exempt under Sec. ,B.&P.C.tier this WATER HEATER W/VENT 6.00 -
reusmh
Owner Dare 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 ofeornsenl to self-insure. ZONING ENG.SITE NO.
ora certificate of Workers Ciuu,nsutioo Imumncc,or a certified
copy thereof(Sec.3800,Lab.C.). -
Policy No. Company
O ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z 2 ❑ Certified copy is. Filed with the city inspection division. MISC.- REFER TO ORD.
O Applicant _ Y❑ Is❑ Y ❑ N❑
CC CER'TFICA'I'1?OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.U.C.
L COMPENSA'fIUNINSURANCE PLG.CONTR. LIC.NO. PLG.
S O This section need not he completed it the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)U,less,
U O 1 certify that in the performance of the work for which this per, OTY. MECHANICAL PERMIT FEE FEE SUMMARY
L I- mil is issued,1 shall not employ any person in any manner so as to
U become subject to the Workers Compensation Laws of California.
y Dorn Applicam ALTER OR ADD TO MECH. 5.00 BUILDING
} m NOTICE: TO APPLICANT: If,after making this Certificate Of Ex-
? enhption,you should become subject to the Workers'C_ompensalion APPLIANCE 5.00 PLAN CHECK,
provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10,000C.F.M,) 4.00
- - - ,) coNs'1'ku(TION LENDING AG ENCY AIR HANDLING UNIT(OVER 10A00C.F.M.) 6.00 SEISMIC FEE -
i'1 hereby affirm that mere is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00 _
the performance of lire work for which this permit is issued(Sec. MICROFILM
3097,CIv.C,. - HEATING UNIT(TO 100,000B.T.U.) 8.00 -
Lender'sNam
Lender's,AAddr ess HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
ddr
1 certify that 1 have .it this xppliaati.n and state that the above VENTILATION FAN (SINGLE) 4.00
intormali.n is correct 1 agree to comply with all city and county PLUMBING
ordinances and slate laws.rela]ing.lo building construction, and BOILER-or) (3H.P.or100,000B.T.U.) 6.00
r hereby authorize representatives of this city to enter upon lire BOILER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL
II above-mentioned property for inspection porticoes
(We).agrce to save, indemnifyand kee'' harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities;judg....His. costs and expenus which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in consequence of tiro
mono,of this permit MECH.CONT. LIC.NO. MECH.
TOTAL TOTAL
Signature of Applicant/Contractor Date
OFFICE COPY �,
POST THIS CARD NEAR FRONT OF BUILDING BRNIIrNunIBER
CITY `OF CUPERTINO 16866
INSPECTION DIVISION
JOB INSPECTION'RECORD
• _ ( ` PERMIT'EXPIRATION
JOBADDRESS,_ 6 � _UNIT# LOT#
� U' �Jer ( O �y� SCAO�� , IS.
NOT EXPIRES IF'WO IN
owisER LJ c� coNTancroa �`I Fl�'p-t/ IS. NOT STARTED WITHIN
INSPECTION DATE INSPECTOR INSPECTION RECORD IBB DAYS OF PERMIT issu-
_ ANCE OR 100 DAYS FROM
FOUNDATION NOTE:' '
LAST CALLED INSPECTION.
UFER ALL GRADING AND DRAINAGE SHALL BE INSTALLED
PREGUNITE - - TO COMPLY WITH THE APPROVED PLANS AND CITY,OF reRnur VALIDATION, _
CUPERTINO STANDARDS'.
GARAGE SLABS r• l',r
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
UNDERGROUND /SLAB. ^ j/
PLUMBING
ELECTRICAL ISSUANCE UArE
MECHANICAL LIVING 'ELECT.I PLG. naecR
'• DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED - T BUILDING PERMIT
INFORMATION
WOOD.FLOOR. vALUnnoN
PLUMBING - ' -
MECHANICAL
FEW n TO
ELECTRICAL -
FRAMING
INSULATION 0ORIES rvnE comsrR.
• 1yD upe I L)CC.GROUP' RES UNITS
PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED
'' ROOF NOTE:NO'FINAL INSP.SHALL BE MADE BEFORE sG.Fr.Fl.00 Anon TOTAL ncnE GE
DIAPHRAGM THE CONSTRUCTION TAXIS PAID
BUILDING USE
ROOF SHEATHING ,RES IND. .CON PB
El
!APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS' DATE INSP. �" L
ASSESSORS PARCEL NO
ROUGH SAN.#
PLUMBING ELECT.ENERGY n+ncT rvo. PARCEL NG.
TUBS
PLUMBING SHOWER PAN PLUMBING ENERGY
MECHANICAL MECH.ENERGY
ELECTRICAL - ACC.DATE ACE FILE No
_ BUILDING ENERGY -
FRAMING .. ELECT.FINAL TEST..
ZONING ENG.SITE NO.
INSULATION PLUMBING ..
GAS TEST' - GAS '
FIRE SPRINK ENERGY T 2<
MECHANICAL '
_ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING _ I E] rrDDD LOU F, r LI ' N�
PL
EXTERIOR SHEAR- ELECTRICAL RELEASE ? n,L.u.c.
INTERIOR SHEAR - - FIRE DEPT. v c NL c L. NL
SHEETROCK .. GRADE - FEE SUMMARY
EXTERIOR LATH BUILDING
INTERIOR LATH TEMPORARY APPROVALS BUILDING
SCRATCH COAT ' " ELECTRIC - PLAN CHECK"
I - GAS FEE
if
iNO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE
OCCUPANCY OF BUI LDING IS NOT PERMITTED UNTIL BUI LDING FINAL IS SIGNED BY BUILDING.INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
LUL
F- ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
' 0'� PLEASE GIVE JOB ADDRESS.WHEN PHONING.
i
— SEE PERMIT FOR EXPIRATION DATE _ MECHANICAL'
IMPORTANT,! coNST.TAx
' PLEASE READ REVERSE SIDE BEFORE . .TOTAL,
CALLING FOR FINAL INSPECTION. .• "r`=
OFFICE COPY