14753�l APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY _
BUILDING PROJECT IDENTIFICATION - PERMIT NUMBER
-
SWILLING APPLICATION & PERMIT q A I� �j
ADORES �� fe:29 I �} I J
L BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S - , PLAN CHECK VALI A ION
• NFME// /\///�/ /j (J J CITY. ELECTRIC PERMIT FEE
11 <'� /C PHONE Q✓/�
.om 7;c Rs ._ _ f9O/�7 OUTLETS-SWITCHES-RECEP .10.00/1.001 Y
NgME
LIGHTING FIXTURES 10.00/1.00
.IJT / LIL.NO.
CONTRACTOR
PPLIANCES-RESIDENTIAL4.00
AS G�0? - 7
D
L PANELS 10.00 DATE OF APPLICATION .
ARCHITECT ' PLAN CHECK FEE P.C.N0.
< OR PANELS (OVER 200 AMP) - 20.00
ENGINEER,(!// L�D_
U SIGNS TRANS. 3.00
ARCH.
CH E08 ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
EMP.METER OR POLE INS. '. 20.00 - -
APPucANT'S. MOTORS SEE FEE SCH. -
gooREss "(c /
SERVICE CHANGE 20.00 k9 Jc•tip ''/J`/f IAT/f' k`-r� i
wo o LICEN S IA)CONTRACTORS DECLA RA'I'I ONJ��-d
/ ;� _ (((
< u I hereby affirm that I am licensed under provisions ofChapter'J EL. Oil(_ o�=. ;) IS ANCE DATE '
y rt H (commencing with Section 7000)0l'Division 3 of the Business and - tat •- BLDG,p aELECT. PLG. MECH.
H H Z Professions CodeyylJ mrli}'.�nse is in full forcearyl,L 'c i ®v\ 21
Z O w - License Class-L�...?_L Lic.Number /_`L 1
A F Date Contract'),
a f - �-- ifadJ / - 1' BUILDING PERMIT
T Q w a OWNER-BUILDER DECLARAT
]ON - INFORMATION
A o A MISC.- REFER TO ORD
w U- I- I hereby affirm that I am exempt from lire Contractor's License VALUATION SIFT.
u 0 4 Law for the following reason.(Sec.7031.5.Business and Professions PERMIT ISSUANCE ' 10.00 , _
V,0 Code Any city or county whichregmresa permit to construct,alter. ,P
rc a o Improve,demolish n repair any structure,prior I its Issuance,also ELEC.CONTE, LIC.NO, ELEC. n../O�
n m¢ requires lite applicant for inch permit to file a 6 statement that - TOTAL P RMIT TOL
n w he Is licensed pursuant to the provisions of the Contractor',,Lfcvnsc
r z i Law(Chapter9(commencivg with Section 70001 of Division 3 of the '
a Business and Professions-Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE Q�
r o the basis for the alleged exemption.Any violation of Section 7031.5 1 STORIES' TYPE CONSTR.
ate _ by any applicant for a permit subjects the applicant lou civil penalty - ALTER-DRAIN -WATER (EA.) .5.00
of not more than five hundred dollars($500).1' -
❑ I,as than
of the property,or Iny employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and file structure is not
�. intended or offered for-sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:'ThC Contractor's License Law does not apply to an owner of
property who builds or Improves thereon,and who does such work - FIXTURES-PER TRAP 5.00 so.FT.rLOOR ARE TorAL ACREAGE
himself or throughdedis arn o".employees.fenprovided
e.If, dtin such improve-
Mr.
GAS-EA.SYSTEM-1 INC.4 OUTLETS 6.00
t rough h d rode sale. Hebridean Ll
.�Intlr.r 'men-,a,,,r within year of completion filen •. GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 - B ILmrvG USE
builder wil;ha a to burden of pro uty that h d not build or Int- RES IND CON PB Other
prove for purpose of,thee). ' INDUSTRIAL WASTE'INTER. 30.00 ❑' ❑ ❑ ❑
❑ d1.as owner is to construct he exclusively contracting with
- . licensed contractoR IO construct the project(Sec. 7094,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code The Contractor's Lice nw La dos not apply
to an owner of 1 rolierty who build, tr inaploves thercon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractons)licensed pinuanl to SEWER-SANITARY-STORM EA.200ft/10.00'. eager No. PARCEL NO.
the Co reactors LicenseLaw.
❑ I am exempt order Svc.:, TiPC.for the WATER HEATER W/VENT 6.00 - ry
reason
\\ Owner CS Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
\`� s woRKERs'coMPENsn'IION OrcLARA'r1oN WATER TREATING EQUIP. - 5.00
\` I hereby affirm that I have a c,,,jILcalc c f c,nwol to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensafipu Insurance, ,a certified
copy thereof(Sec3800,Lab.C. �' L3 (r �ti G�(�
Policy Comfort -
0 Ceni( decoy ixs tiled fwith n FwESPRIrvK ENERGY Ts9
Z Z nifted copy is tiled with the mty inq - un division. MISC.= REFER TO ORD.❑ p Ifanf--�_e Y ❑ N❑ Y ❑ N❑
F rn `^' I�)�"J� PERMIT ISSUANCE 10.00 ,vim FLooD zoNE A.L.U.C.
CERTIFICATE OF EXEMPTION PROM WO 'P '
LU > . COMPENSATION INSURANCE: - PLG.CONTR. LIG NO. PLG. 1/,f Y❑ N[] Y❑ NE]
Cl (This section need not be contoleled if the permit is for one - TOTAL /-"
Z hundred dollars(8100)or less-1
U O 1 certify that in the performmnce of the work for which this per. QTY. MECHANICAL PERMIT . FEE FEE SUMMARY
LL I- ,at is issued, 1 slmll not employ any person tylny-rwHHs rl us to
-
U becom'subject to the W0'.ors'Coyywn. I nLaws ol'California. BUILDING � �
O a Dat \ - I ALTER OR ADD TO MECH. 5.00
} w N0TICIi T�YrPPL"N T 1f,after making tb is Certificate of T.
.r.Z emption,you should become subject to tire Workers'Compensation APPLIANCE 5.00 PLAN CHECK,
provisionsofthe Labor Code, you must Iitrthwifh comply wilh FEE
U such provisions or this li,omt shall he deemed invoked; AIR HANDLING UNIT(TO 10MC.F.M.) 4.00
CONS'I'RUCfION LENDING AGENCY AIR HANDLING UNIT(OVER 10pWC.F.M.) 6.00 SEISMIC FEE r t7
•I hereby affirm that mere is v'
Constru llou lending agency for EXHAUST HOOD(WITH DUCT) -- 5.00
the performanceof the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). - HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lenders Nam' HEATI NG UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC 3•
Lender's Addle
1 certify that I have read this application and stale that the above VENTILATION FAN (SINGLE) 4.00
information is correct.I agree..lo comply with all city and county PLUMBING (�
]Imes and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,000 B.T.U.) 6.001 ^
hdlf e• ,t ize representatives of this city to enter upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL K'
�
AcIve-inc onod property for inspection purpose.
(We) agree to save, indemnify and keep harmless the City of MISC.- 0 �.L REFER TO ORD.
Cupertino against liabilities;judgments, costs and expenses which CONST.TAX
ray in anywayaccrue agar id City in consequence of the PERM T.ISSUANCE 10.00 <T�
rat fthis pernl it. MECH.CONT. LIC.NO. MECH.
- - TOTAL 0�S: TOTAL
Signature of Applicant/Contractor Dec fP
- - OFFICE COPY -
POSTTHISCARD NEAR FRONT OF BUILDING
�. ♦ _ PERMIT NUNIHER
-`' CITY OF CUPERTINO .1
14753
; 'INSPECTION;DIVISION. �
JOB INSPECTION RECORD
PERMIT EXPIRATION
� OBJOBADDRESS �`J7L���G C7 UNIT# " -LOT# PERMIT EXPIRES IF WORK
/ /
ov/NER -, r . .ry- CONTE CTOR dp L. IS NOT STARTED WITHIN
INSPECTIO, . DATE INSPECTOR INSPECTIONRECORD 1BODAYS OFPERMIT ISSU''
F.OUNDATIO .O '
ANCE OR 180 DAYS FROM
• /�-. L FI ' C'7• NOTE . � ` LAST CALLED INSPECTION.
UFER - 'ALL GRADING AND DRAINAGE SHALL BE.INSTALLED
TO COMPLY WITH THE APPROVED PLANS AND CITY OF .TF.RMTT vnunATTON'
PR EGUNITE dS
CUPERTINO STANDARDS.
I GARAGE SLABS ' - - I .y -
' POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED ' , - '..>'�I. � ` j,_ •..,
UNDERGROUND /SLAB A
PLUMBING
ELECTRICAL - - �'� Is U Nce ua TE
1" MECHANICAL' S,', U 'RLDG: ELECT. PLG. MECR.
❑ ❑ -El ❑
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WOOD FLOOR
INFORMATION
VALUATION
PLUMBING _
MECHANICAL
I' . . ELECTRICAL . . M:.tJ .PERMII TOJs!�.
FRAMING A AA
INSULATION STORIES TYPE CONS".
1
1 - oCC.GROUP - RES.UNITS
'I 1PLA -E'LNO-SUBFLOOR-UNTIL ABOVE HAS BEEN SIGNED ) -
_ • SO FT.FI.00N AIILP TOTAL ACH FACIE
. ROOF NOTE:NO FINA INSP.SHALL BE MADE BEFOP.E �•'j 4 =
M -. THE CONSTRUCTION TAX IS PAID
't )C117F SHEAT �.D . ' em LDINc use ,.
Nil IND CON Pa
0 El
APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED FINALS I L
r .1 A SSESSORS P A R C E L NO
ROUGH SAN.#
�� PLUMBING - ELECT.ENERGY "An Na.. PARCEL No
TUBS&SHOWERPANPLUMBING ENERG Do
MECHANICAL. MECH.ENERGY
qTACC.DATE ACC FILE NO.
ELECTRICAL, _ U BUILDING ENERGY
FRAMING ELECT.FINAL TEST, ' "
ZONING ENG.SITE NO.
•_ INSULATION . PLUMBING
GAS TEST _ 144 - GAS
FIRE SPRINK ENERGY TQ4
MECHANICAL
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING ,Y-❑ '' N❑ ❑ NL�
A
EXTERIOR SHEAR � ELECTRICAL RELEASE � � FLOOD TONE Luc. `
INTERIOR SHEAR FIRE DEPT. - Y "� I "�'
SHEETROCK GRADE FEE SUMMARY
✓" EXTERIOR LATH.. BUILDING I.
BUILDING
.INTERIOR LATH � TEMPORARY APPROVALS
SCRATCH COAT ELECTRIC PLAN CHECK .
FEE
GAS
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY SEISMIC FEE ... r
OCCUPANCY OF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE 'FOR INSPECTION BY PHONING 252-4505, ECECTRIc .,
tW—, ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING.
PLEASE GIVE JOB ADDRESS WHEN PHONING.
MECHANICAL
—_SEE PERMIT FOR' EXPIRATION DATE-
- CONST.TAX
IMPORTANT!
- 11 PLEASE READ REVERSE SIDE BEFORE
1 "CALLING FOR FINAL INSPECTION , TOTAL •�.f: .%7
OFFICE COPY